Manage My Practice

HEALTHCARE BILL IMPACT ON INDIVIDUALS AND RAGE

A number of people asked me about the impact of health reform on them as individuals.  Here is a great story from the Atlanta Journal-Constitution that takes specific examples of individuals and families and speculates on how the new bill(s) will impact them.

For 2010, the changes are minimal:

• Dependent children may be covered by their parents’ health insurance policies until age 26.
• A high-risk insurance pool will open for people with pre-existing conditions who have been uninsured for six months.
• In 2011 Medicare will pay for an annual checkup, and deductibles and co-payments for many preventive services and screenings will be eliminated. The Medicare prescription drug doughnut hole will gradually narrow every year until it is eliminated in 2020. People in the  “doughnut hole” could receive a $250 rebate this year.

I have to say that I’ve been dumbfounded by the fury raised over the passage of the new healthcare legislation.  I realize that the bills separate people into winners (uninsured, providers with uncompensated charity care, patients with pre-existing conditions, Medicare patients, providers who see Medicaid patients, families with adult children, etc.) and losers (companies who have to pony up more money for their retired employees, insurance companies, illegal immigrants, high wage earners, etc.), but this story placed the fury into a different perspective for me.  It’s a good read.

CONCIERGE PRACTICES

What does healthcare reform mean for the physician practice?  Many are predicting the rise of concierge practices (also called boutique medicine, retainer practices, VIP medicine and cash practices) as physicians find they cannot survive if their patient population is predominantly Medicare, Medicaid and uninsured patients. Concierge practices fall into two categories:

• The first operates on an insurance+ model, which means that the practice accepts and files the insurance for the patient, but also requires an additional out-of-pocket fee of anywhere from $1500 to $1800 per year to be a patient of the practice.  The fee is to cover services that Medicare and commercial insurance do not, such as physicals, phone consultations, wellness counseling and patient education.
• The second operates on a strictly cash basis and the practice does not accept or file any insurance for the patient.  The patient pays a flat fee per year for care (usually in the $5,000 to $15,000 range) and all primary care is provided for that amount.  The patient still needs to carry insurance for prescriptions, hospital services and sub-specialist services.  Imagine being a manager in this type of practice – no pre-authorizations, no insurance department, no eligibility checking, no refunds…

Concierge medicine has not been around that long, but it is growing in popularity by leaps and bounds. The first acknowledged concierge practice was formed in 1996 in the Pacific Northwest.  In 2002, CMS (Centers for Medicare and Medicaid) published a memo stating that physicians may enter into retainer agreements with their patients as long as these agreements do not violate any Medicare requirements.  In 2003, the Department of Health and Human Services ruled that concierge medical practices are not illegal. Today, there are approximately 5,000 physicians using the concierge model in the United States today.

MEDICARE CUTS, MEDICARE CLAIMS AND DON BERWICK

Shortly after all the shouting and voting on healthcare reform was over, Congress recessed for two weeks leaving the controversy over the 21.5% cuts required by the SGR formula still unsettled.  CMS has advised the MACs to again hold claims for services provided from April 1 to April 10 to give Congress a chance to get back to work and back to voting for an additional delay (or not) for the cuts.  If the cuts are allowed to stand, many physicians will start making their own cuts by minimizing the number of Medicare and Medicaid patients they will see.

Amidst this craziness, a voice of sanity is heard and it is Donald Berwick, MD, current President of the Institute for Healthcare Improvement (IHI) and probable Obama pick for the head of CMS. If you don’t know Don Berwick or the IHI, click here to read an interview with him about the IHI’s “100,000 Lives Campaign” or watch the video below of him speaking about the dimensions of quality.  Good stuff!

As I write this Sunday night I am listening to the US House of Representatives’ discussion/posturing prior to a ‘yes” or “no” vote for the Senate’s healthcare reform bill H. R. 3590.  I don’t usually listen to CNN Live, but I want to remember this moment as I think it is the beginning of significant change in healthcare.

I’m not sure what this change will be, but many things that have been status quo for healthcare during my career might change almost beyond recognition by the time I retire. This, I think, is a good thing.  I don’t think the current system is bad, but I sure think it could be better.  As with any change, there will be good things, bad things, and unintended good and bad things.  It should be fascinating.

Discussion has now timed out and the representatives are voting;  216 votes are needed to pass.  The vote has just been announced (10:45 p.m.) and it is 219 Yeas to 210 Nays and the bill is passed!  The next step is for it to be signed into law by President Obama, which might happen tonight or tomorrow.

Now the representatives are voting on H.R. 4872 – “The Health Care and Education Affordability Reconciliation Act of 2010″ which contains fixes to H.R. 3590 that have been negotiated between the two chambers.  The bill has just passed (11:37 p.m.) with 220 Yeas and 211 Nays!  4872 will now go to the Senate for a vote which some are predicting will pass as early as Tuesday.

President Obama spoke from the White House after the votes and said “Tonight we answered the call of history.”  The passage of these bills has been compared to the passage of Medicare in 1965 and the passage of Social Security in 1935.

Here are details of both bills.

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Details on H.R. 3590 ‘‘Patient Protection and Affordable Care Act’’

Cost: $940 billion over ten years.

Deficit: Would reduce the deficit by $143 billion over the first ten years.   Would reduce the deficit by $1.2 trillion dollars in the second ten years.

Coverage: Would expand coverage to 32 million Americans who are currently uninsured.

Health Insurance Exchanges:

• The uninsured and self-employed would be able to purchase insurance through state-based exchanges with subsidies available to individuals and families with income between the 133 percent and 400 percent of poverty level.
• Separate exchanges would be created for small businesses to purchase coverage — effective 2014.
• Funding available to states to establish exchanges within one year of enactment and until January 1, 2015.

Subsidies: Individuals and families who make between 100 percent – 400 percent of the Federal Poverty Level (FPL) and want to purchase their own health insurance on an exchange are eligible for subsidies. They cannot be eligible for Medicare, Medicaid and cannot be covered by an employer. Eligible buyers receive premium credits and there is a cap for how much they have to contribute to their premiums on a sliding scale.  Federal Poverty Level for family of four is $22,050.

Paying for the Plan:

• Medicare Payroll tax on investment income — Starting in 2012, the Medicare Payroll Tax will be expanded to include unearned income. That will be a 3.8 percent tax on investment income for families making more than $250,000 per year ($200,000 for individuals).
• Excise Tax — Beginning in 2018, insurance companies will pay a 40 percent excise tax on so-called “Cadillac” high-end insurance plans worth over $27,500 for families ($10,200 for individuals). Dental and vision plans are exempt and will not be counted in the total cost of a family’s plan.
• Tanning Tax — 10 percent excise tax on indoor tanning services.

Medicare:

• Closes the Medicare prescription drug “donut hole” by 2020. Seniors who hit the donut hole by 2010 will receive a $250 rebate.
• Beginning in 2011, seniors in the gap will receive a 50 percent discount on brand name drugs. The bill also includes $500 billion in Medicare cuts over the next decade.

Medicaid: Expands Medicaid to include 133 percent of federal poverty level which is $29,327 for a family of four.

• Requires states to expand Medicaid to include childless adults starting in 2014.
• Federal Government pays 100 percent of costs for covering newly eligible individuals through 2016.
• Illegal immigrants are not eligible for Medicaid.

Insurance Reforms:

• Six months after enactment, insurance companies can no longer deny children coverage based on a preexisting condition.
• Starting in 2014, insurance companies cannot deny coverage to anyone with preexisting conditions.
• Insurance companies must allow children to stay on their parent’s insurance plans through age 26.

Abortion:

• The bill segregates private insurance premium funds from taxpayer funds. Individuals would have to pay for abortion coverage by making two separate payments, private funds would have to be kept in a separate account from federal and taxpayer funds.
• No health care plan would be required to offer abortion coverage. States could pass legislation choosing to opt out of offering abortion coverage through the exchange.

**Separately, anti-abortion Democrats worked out language with the White House on an executive order that would state that no federal funds can be used to pay for abortions except in the case of rape, incest or health of the mother. (Read more here)

Individual Mandate: In 2014, everyone must purchase health insurance or face a $695 annual fine. There are some exceptions for low-income people.

Employer Mandate: Technically, there is no employer mandate. Employers with more than 50 employees must provide health insurance or pay a fine of $2000 per worker each year if any worker receives federal subsidies to purchase health insurance. Fines applied to entire number of employees minus some allowances.

Immigration: Illegal immigrants will not be allowed to buy health insurance in the exchanges — even if they pay completely with their own money.

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Details on H.R. 4872 – “The Health Care and Education Affordability Reconciliation Act of 2010″ (fixes to 3590)

COST: $940 billion over 10 years, according to the Congressional Budget Office.

HOW MANY COVERED: 32 million uninsured. Major coverage expansion begins in 2014. When fully phased in, 95 percent of eligible Americans would have coverage, compared with 83 percent today.

INSURANCE MANDATE: Almost everyone is required to be insured or else pay a fine. There is an exemption for low-income people. Mandate takes effect in 2014.

INSURANCE MARKET REFORMS: Major consumer safeguards take effect in 2014. Insurers prohibited from denying coverage to people with medical problems or charging them more. Higher premiums for women would be banned. Starting this year, insurers would be forbidden from placing lifetime dollar limits on policies, and from denying coverage to children because of pre-existing medical problems. Parents would be able to keep older kids on their policies up to age 26. A new high-risk pool would offer coverage to uninsured people with medical problems until 2014, when the coverage expansion goes into high gear.

MEDICAID: Expands the federal-state Medicaid insurance program for the poor to cover people with incomes up to 133 percent of the federal poverty level, $29,327 a year for a family of four. Childless adults would be covered for the first time, starting in 2014. The federal government would pay 100 percent of the tab for covering newly eligible individuals through 2016. A special deal that would have given Nebraska 100 percent federal financing for newly eligible Medicaid recipients in perpetuity is eliminated. A different, one-time deal negotiated by Democratic Sen. Mary Landrieu for her state, Louisiana, worth as much as $300 million, remains.

TAXES: Dramatically scales back a Senate-passed tax on high-cost insurance plans that was opposed by House Democrats and labor unions. The tax would be delayed until 2018, and the thresholds at which it is imposed would be $10,200 for individuals and $27,500 for families. To make up for the lost revenue, the bill applies an increased Medicare payroll tax to investment income as well as wages for individuals making more than $200,000, or married couples above $250,000. The tax on investment income would be 3.8 percent.

PRESCRIPTION DRUGS: Gradually closes the “doughnut hole” coverage gap in the Medicare prescription drug benefit that seniors fall into once they have spent $2,830. Seniors who hit the gap this year will receive a $250 rebate. Beginning in 2011, seniors in the gap receive a discount on brand name drugs, initially 50 percent off. When the gap is completely eliminated in 2020, seniors will still be responsible for 25 percent of the cost of their medications until Medicare’s catastrophic coverage kicks in.

EMPLOYER RESPONSIBILITY: As in the Senate bill, businesses are not required to offer coverage. Instead, employers are hit with a fee if the government subsidizes their workers’ coverage. The $2,000-per-employee fee would be assessed on the company’s entire workforce, minus an allowance. Companies with 50 or fewer workers are exempt from the requirement. Part-time workers are included in the calculations, counting two part-timers as one full-time worker.

SUBSIDIES: The proposal provides more generous tax credits for purchasing insurance than the original Senate bill did. The aid is available on a sliding scale for households making up to four times the federal poverty level, $88,200 for a family of four. Premiums for a family of four making $44,000 would be capped at around 6 percent of income.

HOW YOU CHOOSE YOUR HEALTH INSURANCE: Small businesses, the self-employed and the uninsured could pick a plan offered through new state-based purchasing pools called exchanges, opening for business in 2014. The exchanges would offer the same kind of purchasing power that employees of big companies benefit from. People working for medium-to-large firms would not see major changes. But if they lose their jobs or strike out on their own, they may be eligible for subsidized coverage through the exchange.

GOVERNMENT-RUN PLAN: No government-run insurance plan. People purchasing coverage through the new insurance exchanges would have the option of signing up for national plans overseen by the federal office that manages the health plans available to members of Congress. Those plans would be private, but one would have to be nonprofit.

ABORTION: The proposal keeps the abortion provision in the Senate bill. Abortion opponents disagree on whether restrictions on taxpayer funding go far enough. The bill tries to maintain a strict separation between taxpayer dollars and private premiums that would pay for abortion coverage. No health plan would be required to cover abortion. In plans that do cover abortion, policyholders would have to pay for it separately, and that money would have to be kept in a separate account from taxpayer money. States could ban abortion coverage in plans offered through the exchange. Exceptions would be made for cases of rape, incest and danger to the life of the mother.

STUDENT LOAN OVERHAUL: Requires the government to originate student loans, closing out a role for banks and other private lenders who charge a fee. The savings – projected to be more than $60 billion over a decade – are plowed into higher Pell Grants for needy college students and increased support for historically black colleges.

MEDICARE: Extends Medicare’s solvency by at least nine years and reduces the rate of its growth by 1.4 percent, while closing the doughnut hole for seniors, meaning there will no longer be a gap in coverage of medication.

Medicare is a federal health insurance program created in 1965 for:

• people age 65 or older,
• people under age 65 with certain disabilities, and
• people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant)

Medicare Part A - 99% of patients don’t pay a premium for Part A (hospital insurance) because they or a spouse already paid for it through their payroll taxes while working. The $1,100 deductible for 2010, paid by the beneficiary when admitted as a hospital inpatient, is an increase from 2009.   Part A helps cover:

• inpatient care in hospitals (excluding the physician fees), including critical access hospitals
• skilled nursing facilities (not custodial or long-term care)
• some hospice care
• some home health care

Medicare Part B – Part B (outpatient/doctor insurance) base premium for 2010: $96.40/month (no change from 2009.)  Premiums are higher for single people over 65 making more than $85K per year and for couples making over $170K.  Part B premiums cover approximately one-fourth of the average cost of Part B services incurred by beneficiaries aged 65 and over.  The remaining Part B costs are financed by Federal general revenues.  In 2010, the Part B deductible is $155.  Part B helps cover:

• physician fees in the hospital
• physician fees in their offices and other outpatient locations
• other outpatient services (x-rays, lab services)
• some services of physical and occupational therapists
• some home health care

Medicare Part C – Medicare now offers beneficiaries the option to have care paid for through private insurance plans.  These private insurance options are part of Medicare Part C, which was previously known as Medicare+Choice, and is now called Medicare Advantage. Medicare Advantage expands options for receiving Medicare coverage through a variety of private insurance plans, including private fee-for-service (PFFS) plans, local health maintenance organizations (HMOs) and regional preferred provider organizations (PPOs), and through new mechanisms such as medical savings accounts (MSAs), as well as adding payment for additional services not covered under Part A or B. Here is a great article by Maria Todd on how Medicare Advantage plans get paid.
Medicare Part D -  Starting January 1, 2006, Medicare prescription drug coverage became available to everyone with Medicare.  The so-called “doughnut hole” is the amount the patient pays between the initial coverage limit of $2,830 and the out-of-pocket threshold of $4,550 – a total of $1720 that the patient is responsible for.

• Initial Deductible: $310
• Initial Coverage Limit: $2,830
• Out-of-Pocket Threshold: $4,550

COMPARISON OF MEDICARE PLANS

Original Medicare Plan

WHAT? The traditional pay-per-visit (also called fee-for-service) arrangement available nationwide.

HOW? Providers can choose to participate (“par”) or not participate (“non-par”.)  Participating providers accept the Medicare allowable and collect co-insurance (20% of the allowable.) Reimbursement comes to the providers.  Non-participating providers may charge 15% more (called the “limiting” charge) than the Medicare allowable schedule, but the patient will receive the check, which is why some non-par practices require payment at time of service for Medicare patients. To be able to charge patients for non-covered services, patients must sign an ABN before the service is provided.

Original Medicare Plan With Supplemental Medigap Policy

WHAT? The Original Medicare Plan plus one of up to ten standardized Medicare supplemental insurance policies (also called Medigap insurance) available through private companies.

HOW? Medigap plans may cover Medicare deductibles and co-insurance, but typically will not cover anything Medicare will not.  Medicare primary claims will “cross-over” to many Medigap secondary claims so the practice does not have to file the secondary Medigap claim.  Patients may still have a small balance that is cost-prohibitive to bill for.

Medicare Coordinated Care Plan

WHAT? A Medicare approved network of doctors, hospitals, and other health care providers that agrees to give care in return for a set monthly payment from Medicare. A coordinated care plan may be any of the following: a Health Maintenance Organization (HMO), Provider Sponsored Organization (PSO), local or regional Preferred Provider Organization (PPO), or a Health Maintenance Organization (HMO) with a Point of Service Option (POS).

HOW? You have to have signed a contract or be grandfathered in (called an “all-products” clause) under an existing contract to see patients and get paid. Primary care providers may have to provide referrals and/or authorization for specialty services and providers. A PPO or a POS plan usually provides out of network benefits for patients for an extra out-of pocket cost.

Private Fee-For-Service Plan (PFFS)

WHAT? A Medicare-approved private insurance plan. Medicare pays the plan a premium for Medicare-covered services. A PFFS Plan provides all Medicare benefits. Note: This is not the same as Medigap.

HOW? Most PFFS plans allow patients to be seen by any provider who will see them. PFFS plans do not have to pay providers according to the prevailing Medicare fee schedule or pay in 15 days for clean claims.  Providers may bill patients more than the plan pays, up to a limit. It would be a good thing to notify patients if your practice intends to bill above the plan payment.

Need more?  Click on CMS (provider-oriented) or Medicare (patient-oriented.)

I’ve had lots of questions about financial policies since I did a webinar on patient collections last year.  Here’s a short course on developing a new financial policy for your practice.  The topic is addressed more comprehensively in my book.

I dislike financial policies that are long and wordy.  I prefer a simple format that everyone can understand and use.

The format I recommend is one with three columns titled:

1. Your Plan
2. What You Do
3. What We Do

Here’s an example of how the three columns would read:

Your Plan

Medicare

What You Do

Pay your deductible ($155 for 2010) and co-insurance (20% of the allowable.)

What We Do

We will file Medicare for you.

I use the front of the financial policy to list all the variations of plans that the practice accepts.  For instance, the Medicares might include:

• Medicare
• Medicare/Medicaid
• Medicare/supplemental policy
• Medicare Advantage Plan (HMO/PPO)
• Medicare Advantage Plan (PFFS)
• Medicare secondary (MSP)
• Railroad Medicare

Lump together any like plans that you will treat the same.  Then decide what you will expect from the patient at time of service or after, and what the practice commits to doing. Don’t forget to address patients being seen out-of-network and self-pay patients.

I use the back of the policy to cover everything that you would like the patient to sign off on. This could include:

• Receipt of Notice of Privacy Policies
• Receipt of Advance Directives/Living Will info
• Agreement to Financial Policy
• Assignment of Benefits to Practice
• Guarantee of Payment

When you put a new policy in place, you have a number of options to educate patients. Here are some:

• Put the policy on your website.
• Send a copy of the policy to all new patients.
• Discuss the policy when you call patients to remind them of their appointment.
• Discuss the new policy at check-in and/or check-out and let patients know it will be in effect at their next visit.
• Circle the patient’s plan on the front, have the patient sign the financial policy on the back, and give them a copy to take with them.

How you decide to educate the patients will depend on how much time you have between making the appointment and seeing the patient and the type of practice you have – primary care versus sub-specialty.

Also, don’t forget to educate your staff.  If they have not had to discuss money before, they will need some coaching and some practice.

If you’d like a free copy of my sample financial policy, shoot me an email at marypatwhaley@gmail.com.

I took last week off to complete a project I’ve been working on since early this year – my first book!

It’s really a workbook and it guides the reader through a program to move their practice from a back-end collection process to a front-end collection process.  What is the difference?  A back-end program collects the majority of patient-owed balances after the payer has adjudicated the claim and has submitted payment to the practice.  A front-end program takes all the available information about the payer/plan and collects payment or arranges future electronic payments with the patient at the time of service.

The book has step-by-step instructions for implementing the program in any practice, and more than a dozen worksheets and templates are included.  Some examples are:

1. Patient Collections Benchmarks
2. 30-Day Project Calendar
3. Responsibility Assignment Worksheet
4. Budget Template
5. Sample Job Description and Hiring Worksheet
6. Product Evaluation Forms
7. Sample Financial Policy and Financial Policy Template
8. Patient Frequently Asked Questions (FAQ)

You really can implement a program like this in your practice.  It’s hard work, but well worth the effort.

Click here to view “The Smart Manager’s Guide to Collecting at Check-Out.”

I invited readers of MMP, colleagues on LinkedIn, and Tweeps (friends on Twitter) to comment on my post “101 ideas for Increasing Revenue and Decreasing Expenses.” I’ve listed their ideas below and hope you’ll chime in on the comments with even more ideas!  Thanks to everyone for contributing.

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David Kirkup

Partner at B2B CFO® – Experienced CFO for Rent. Fast, Effective, Affordable.

Consider adding a part-time CFO to the mix. Many medical offices have very weak financial capability or understanding. Assistance can range from better financial reports, capital expenditure analysis, budgeting and exit plans.

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Bobby Jones

Eastern Region Sales Manager – Billing Tree

1) Build a relationship with the patient before he/she leaves the practice.
2) Make sure they know you are expecting payment on the portion they owe, and when you are expecting that payment.
3) Let them know what your process is for collecting, and when they will go to an outside agency.
4) Enable a web site to take payments 24 hours a day.
5) Set up an IVR system to take phone payments after hours.
6) Communicate your available payment acceptance methods in writing, on the phone and every time you speak with your patients.
7) Send the invoice or statement when you intend to send it.
Re-inforce the payment acceptance methods on the first and any subsequent invoices.
9) Adopt a plan for following up with any patients that don’t pay after 10 days.
10) Get email addresses from all of your patients and their permission to contact them in that manner.

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Sukrit Tripathy

Sr. Product/Process Trainer and EDI Implementation Consultant

One suggestion would be to integrate the revenue cycle mangement function with your clearinghouse {for electronic billing} with integrated solutions like Coding database and Updates, Industry Broadcast, Performance and Audit reports for Claim Edits, Transmission and Rejects. Also, better training resources for billing staff actively into the practice management system.

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Barbara Rotter

Consultant at Pacific Women’s Medical Group

I would add effective cash management (even if interest rates are so low).

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Michael Glass

Medical and Business Consultant at Transworld Systems

Utilize a Flat Fee Collections Agency for Non-responsive Patient Pay concerns.

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Randall Shulkin

Principal Consultant – Culbert Healthcare Solutions

- Do you collect co-payments on the way in rather than on the way out?
- Does your PM/Scheduling system show the patient co-payment and outstanding patient balance in the appointment screen? If not, then can you download a listing for your front desk staff?

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Denise Price Thomas

DPT Healthcare Consulting & Training

I’d like to add “acknowledge the patient with eye contact” and offer “polished customer service” and they will WANT to return = return on your $ $

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Stacy Mays

Managing Partner, Dynamic Grape Companies

One other thought… don’t be afraid to try new technology. For example, one of my clients has developed a kiosk that allows patients to take their own weight and bp and electronically feeds the data into their EMR. The whole set up costs about $3500 and can save a ton of staff time. Tele-health in general should also be considered.

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Angela Short

VP at Operations

If you select a reasonably priced EMR and you implement enhancements then you more than save on staff cost. Keep in mind that my practice rolled out the EMR five years ago, so we have had time to get it right. Here are some of the savings/revenue opportunities:1. We utilize our electronic technology to send text messages and emails to our patients to remind them of their appointments. This function alone saves my practice one FTE. Not only do we save with staff time we improve patient satisfaction, as our Blackberry users loves the email or text that they can directly add to their calendars. The revenue enhancement to this function, we decrease no shows and lag time in our physician’s schedules.

2. The robust reporting within the EMR allows the organization to assemble important quality measures that we use in contract negotiations. Without the EMR this would be a labor intensive task.

3. We are able to push a secure message to our patients regarding their pathology results saving staff time on the telephone and increasing patient satisfaction by eliminating a visit just to obtain a normal result.

4. No more chasing charts for a phone message. My call center takes ALL clinical messages. This is attached to the patient’s electronic chart and routed to either a nurse to respond or a physician. This process greatly reduces staff time, decreases the time it takes to respond to the patient’s issue and provides a legal record of the telephone call which is often missed in a paper environment.

5. We receive a discount on our mal-practice insurance because in an electronic environment it is guarantee that your notes are legible.

6. The formulary function built into most EMR’s provides the physician will a real time snapshot if a prescription that he/she is about to write is covered by the patient’s health plan and provides alternatives if available.

I have just highlighted only a couple examples of the administrative benefits. There are many more. It is tough to imagine going back to a paper chart.

I have done the math and we could cover our current EMR with the incentives offered through the government initiative.

I will comment that physicians need to be trained on how to use the EMR. You can lose site of the patient and focus the entire visit on the computer versus the patient, however, we teach our physicians that the patient first and then chart completion. We conduct patient satisfaction surveys and I rarely receive a complaint regarding the physician’s time at the computer. I do however, receive praises from patients regarding the ePrescribe as it decreases their wait times when the arrive at the pharmacy, the prescription is ready.

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Okay Readers, it’s your turn – what’s your secret weapon for increasing revenue or decreasing expenses?

Mary Pat

BUILD ON WHAT YOU’RE CURRENTLY DOING:

1.  Add physician hours – add evening or weekend hours; start your office hours earlier and end hours later.

2.  Reduce physician time off – decrease vacation or change weekly days off to 1/2 days off.

3.  Set a minimum number of providers to be in the office seeing patients at all times the office is open.

4.  Have each provider add one new patient visit to his/her schedule weekly.

5.  Add ePrescribing to recoup additional Medicare revenue and streamline prescribing (there are free ePrescribing software packages available, but evaluate them carefully so they don’t add more complexity to the system instead of less.)

6.  Report PQRI measures to recoup additional Medicare revenue.

7.  Charge patients an out-of-pocket fee for completing patient forms – disability forms, etc. and reserve office visits for treating patients.

8.  Choose an EMR that qualifies your practice for the ARRA money (although it has been widely promoted that in a larger practice, an EMR and its associated work will cost more than you will get from the government.)

9.  If you are in an underserved or rural area, check to see if there might be grants or funds available locally, in the state or federally, for adding a service to your practice.

10.  If your practice does Independent Medical Exams (IMEs), reviews records or depositions, make sure that your fee schedule for such services is current and that the fees are collected before the physician provides the service.

ADD TO YOUR CURRENT SERVICES:

11.  Allergy testing & treatment

12.  Dispensing pharmaceuticals

13.  Dispensing nutriceuticals

14.  Dispensing Durable Medical Equipment

15.  Group patient visits

16.  Coumadin Clinic

17.  Heart Failure Clinic

18.  Diabetes Education Classes

19.  Add primary care to specialty care practices

20.  Add specialty care to primary care practices

21.  Research

22.  Joint Ventures with other practices or hospital

23.  Lease space to other entities

24.  eVisits (virtual visits or email visits)

25.  Elective procedures or services

26.  Mid-level providers

27.  Walk-in clinic

28.  Occupational medicine: drug screens, employment physicals, etc.

29.  Hospitalists

30.  Medical Director of local nursing homes

31.  Complementary & alternative medicine (CAM)

32.  Aging in Place services

33.  Social worker

34.  Concierge practice

35.  School team physician

EVALUATE YOUR REVENUE CYCLE MANAGEMENT:

36.  Are you renegotiating payer contracts regularly?

37.  Do your scheduling staff know how to educate patients about what payers you have contracts with and are in network with and what the patient’s financial responsibility will be?

38.  Do staff know what typical new patient charges are to tell the patient?

39.  Do you check every patient’s eligibility for insurance benefits immediately prior to every service?

40.  Do you have patients sign a financial policy to acknowledge what they are responsible for based on their payer type?

41.  Do you copy the patient’s insurance cards at every visit, or at least compare their current card to the card you have on file?  Are you able to scan patient insurance cards and driver’s licenses into your practice management (PM) system?

42.  Is your PM system able to download the information from the scan into the patient registration screen?  If not, do you have a way to confirm that demographic and insurance information has been entered correctly from the cards?

43.  Are your charges being posted daily?

44.  Does the person who provides the service, or a documentation coding specialist, choose the CPT and ICD9 code?

45.  Is the documentation for the charges being completed within 24 hours of the service?

46.  Is your encounter form up-to-date with current CPT and ICD9 codes; do you order smaller batches of them so you can change the codes as new services are added in the practice?

47.  Do you check the CPT and ICDD9 matching to make sure the codes are valid for the year, the codes adhere to NCCI and LCD edits before you finalize the charges?

48.  Do you regularly audit medical records for coding and documentation and give providers feedback on where coding could be improved?

49.  Are you using ABNs for Medicare patients who want services that Medicare might not pay for?

50.  Do you file claims daily?

51.  Do you correct claims daily when they are rejected at the practice management, claims clearinghouse or payer level?

52.  Do you correct claims daily when they are rejected at the claim level and are not paid for for reasons that can be corrected?

53.  Do you have your contract allowables in your PM system so you know when you are not being paid correctly by contract?

54.  Do you appeal unpaid or underpaid claims?

55.  Do you check recoupments or requests for refunds from payers and make sure they truly should be refunded?

56.  Do you send insurance and patient payments to a lockbox to be scanned and stored digitally for your staff to post from?

57.  Do you make payment arrangements in the office for balances after insurance has paid, or payment plans by drafting credit or debit cards?

58.  Do you have a policy of not sending statements?

59.  Do you collect the patient’s portion of the service at the time of service?

60.  Do you collect fees for elective services prior to providing these services?

61.  Can your patients make payments online through your website?

62.  Do you file a claim with a patient’s estate if they have died?

63.  Do you accept cash only from patients who have passed bad checks?

64. Do you accept cash only from patients who have filed bankruptcy with your practice?

65.  Do you inadvertently see patients who have been dismissed from your practice?

66.  When adding a physician to the practice, do you timeline the credentialing appropriately so the physician can see patients with insurance as well as those without?

67.  If your new physician is only partially credentialed with payers, do you have him/her see the patients with payers they are credentialed with and add payers to their schedule load as the credentialing comes through?

68.  Do you meet with representatives from your largest payers monthly to establish relationships and bring problems to their attention? (the squeeky wheel theory of payer relations)

69.  Are you pre-certing everything that needs pre-certification or pre-authorization or pre-notification to be sure the service will be paid?

70.  Are you receiving payments via electronic funds transfer (EFT)?

71.  Are you receiving explanation of benefits (EOBs) or remittance advice (RA) electronically?

72.  Are you posting your RA electronically?

73.  Are you protecting your practice from embezzlement? (see my post on this here.)

74.  Is someone in the practice responsible for staying current on changing coding requirements for Medicare, Medicaid, Tricare and commercial payers?

DECREASE EXPENSES:

75.  Eliminate overtime. Evaluate the need for additional staff (part-time?) vs. overtime.

76.  Send some staff home (sometimes called “low census”) when there are no patients to be seen.

77.  Use volunteers. Tap into the local hospital volunteers, or recruit and train your own.

78.  Hire an after-school student employee to do routine jobs.

79. Discontinue paying staff for inclement weather closings when the practice is not open.

80.  Shop everything. Negotiate existing service contracts.  Do not assume anything is non-negotiable.  Negotiate the rent.

81.  Get rid of yellow pages advertising. It rarely brings you new patients and is primarily a place to look up phone numbers.  You will still get your white pages listing free with your phone service.

82.  Utilize pre-employment testing to make sure job applicants have the skills you need.

83.  Shop postage machines or look into stamps.com.

84.  Join a group purchasing entity (hospital, professional association, etc.)

85.  Improve your accounting cycle. Invoices and statements are matched up with packing slips and negotiated prices.  Use purchase order numbers.

86.  Get the payment discount by paying on time or early – ask vendors for an on-time or early payment discount.

87.  Make sure office supplies are not going home with the employees.  Make sure office supplies that are ordered are “really need” and not “sure would be nice.”

88.  Remind patients of their appointments to decrease no-shows.  Call patients who no-show and attempt to reschedule (unless they feel better!)  Track no-shows and evaluate the reasons for them.

89.  Consider charging for no-shows or dismissing patients for no-shows.

90.  Have a good recall system in place.  If patients leave without scheduling a needed follow-up, make sure that they are called if they have not scheduled within a certain amount of time.  Keep track of annual wellness visits and remind patients to schedule them.

91.  Take advantage of any discounts offered by your malpractice carrier by completing risk management surveys and having speakers give annual updates on decreasing malpractice claims.  Some carriers give discounts for managers who are members of MGMA or Fellows in the ACMPE.

92.  Evaluate any discounts on services or products offered by your physicians’ professional associations and societies.

93.  Evaluate your leases - are those big old copiers and faxes worth paying for a service contract?

94.  Consider speech recognition/voice recognition and eliminate transcription.

95.  Review your computer maintenance contracts. Are you paying for maintenance on equipment or software that is no longer being used?

96.  Take advantage of online CME for physicians, midlevel providers, clinical staff and managers.

97.  Make plans to attend face-to-face seminars well in advance to take advantage of early enrollment discounts and good flight deals.

98.  Evaluate outsourcing. Think about outsourcing transcription, coding, billing, pre-authorizations, credentialing, switchboard, payroll, accounting and medical records copying.

99.  Replace your answering service with an answering machine educating patients on the limited reasons for calling after hours and giving the number of the physician on call.

100. Destroy archived financial and medical records that you are paying to store, once you have ascertained that they exceed the required time limit.

101.  Hold a brainstorming session with the staff and ask for their ideas for increasing revenue and reducing expenses.  The people on the front lines will have excellent ideas.  In return, do not nickle and dime the staff to death by charging for coffee, reducing parking stipends or eliminating uniform allowances.  Keep in mind that for your rank and file staff, having to pay for their own uniforms or paying more for parking might be a deal-breaker that causes them to search for work elsewhere.  Try to focus on the bigger items for savings and make sure the staff know you are trying to keep their small benefits in place in appreciation for their work.

Recent news stories about manager embezzlement give us all a black eye.  What can managers do to limit their liability, and how can physicians protect the practice without managing the day-to-day operations themselves?

Here are nine suggestions:

1. Perform a thorough background check before hiring a manager, and have your manager bonded.
2. Have your bank statements sent to the physician’s home address and/or make sure the physician has the master access to the bank accounts online.  Physicians, have a personal relationship with your practice banker and make time for a short meeting with them quarterly.
3. Have the physician sign your practice checks. Each check should be attached to an invoice that lists the goods or service purchased.  Do not order a rubber stamp of the doctor’s signature.
4. Insist on a duplicate, numbered receipt book for staff to give receipts to patients for all over the counter payments.
5. Have your insurance and patient checks sent to a lockbox.
6. Make sure the manager takes time off – at least several weeks a year. Managers who are “too busy” or “can’t ever get away” are a red flag.  The physician should review all mail during the manager’s vacation.
7. Check the monthly credit card statement carefully before making the payment.  Keep the card restricted to a relatively low limit to manage your liability.  Do not pay practice bills routinely on the card to build frequent flyer miles as this makes it much easier for an employee to hide non-approved expenditures.
8. Have a budget and make sure variances can be explained.
9. Hire a CPA to review the books quarterly.  Even if you do not need the services of a CPA for your statement reconciliation, taxes or partners distribution, hire one to review the expenses and receipts, and ensure that the retirement plan is being funded appropriately.

A qualified, ethical manager has nothing to hide and will thank you for following these nine rules.  The rules protect the manager as well as the practice.

Photo credit: © Yuyang | Dreamstime.com

A typical standard operating procedure in many practices when adding a new physician is to phase in his/her schedule  as s/he becomes credentialed by each payer.  Traditionally, new physicians have been able to see Medicare patients immediately due to the Medicare guideline that allowed for a practice to retro-bill for Medicare patients seen before (up to 27 months, actually) the doctor was officially credentialed.

Now all that has changed, and starting April 1, 2009, practices can only retro-bill for Medicare patients seen 30 days prior to the date the credentialing form was filed (if it was ultimately approved.)  What are the implications of this? (more…)