Medical bills aren’t always like other bills, many times they are not planned for and the bill is an unexpected surprise that some people cannot afford. If a patient doesn’t have insurance, this can be a real problem, especially in this economy where as more and more people lose their jobs they also lose their medical insurance.

As a doctor billing patients when they cannot pay in full at the time of service, you must have policies and procedures in place for your office staff to follow in order to successfully get paid for your services. You should look at it as part of your job to help your patients be able to pay your office. 

With that in mind here are my top five tips for helping your patients pay off a balance due.

1. Be realistic when talking with patients about payments. If you aren’t realistic, you won’t get paid. Ask them about their income and monthly bills and set a monthly payment they can realistically make, otherwise they won’t make any payment.
2. Get payments twice a month rather than once a month.  Even if the installment payment is less, if someone is paying twice a month it could be more than one monthly payment, resulting in the bill getting paid quicker.
3. Put it in writing. Whatever you decide with your patient in regards to their bill, put it in writing and send them a copy.
4. Follow up. Any collection efforts you put in go down the drain if you don’t follow up.
5. Offer your patients a couple of solutions. Many people are embarrassed to have a past due balance with you, and want to pay it off as quickly as possible. Offer them a couple of options so they can be part of the decision making process on how they will pay you.

Michelle Dunn, author of The Guide to Getting Paid, is an expert on the topics of credit and collections.  For more information on Michelle, visit www.credit-and-collections.com.  To read more articles like this, visit www.efficiencyinpractice.com and sign up for a complimentary subscription to our Efficiency in Practice enewsletter.

This article can be reprinted freely online, as long as the entire article and this resource box are included.

One of the biggest mistakes a medical practice can make when they receive a request for medical records from a payer, such as Medicare or Medicaid, is to quickly copy some records and throw them into an envelope. Most audits start with the payer, or their audit contractor, providing a list of names and dates of service for which they are requesting copies of medical records.

Here are a Baker’s Dozen worth of tips for those type audits:
1. Before submitting records to the payer or their audit contractor, make sure records are legible and that there are records for each date of service. Further, make sure the documents are well-organized so that auditors can easily find the pertinent records.
2. Designate one person to be responsible for responding to the audit and follow-up.
3. Allow plenty of time to respond. Pay close attention to the deadline for responding in the audit notice. Sometimes you may be granted an extension. Request an extension early, and request it in writing.
4. Read the audit request letter carefully. It usually lists the types of information the auditor expects. Don’t worry if the generic list you’re provided includes information that is not applicable to your patient or the services provided. Just make sure you send a copy of documentation in your records that supports each service billed.
5. Send only copies of the record, not the original, and number the pages.
6. Make at least one copy of the records you submit, exactly as submitted. It is more difficult to appeal an audit when you and your advisors are not sure what was sent to the auditors and used to render their initial decision.
7. Make sure to submit documentation for each date of service requested, but do not fabricate documentation if you do not have it.
8. If your office note for an Evaluation and Management (E/M) code refers to a prior history, you should include documentation related to those aspects. This is especially important for new patient visits where all three elements, History, Exam and Complexity of Medical Decision Making, will be reviewed.
9. If lab tests, x-rays or other diagnostic tests were ordered and billed by your medical practice for the date of service, make sure the report is in the record submission even if the report was not available for several days, after the encounter. Even if the tests were performed or billed by another physician or entity, include them because they may help justify higher levels of E & M services.
10. If you performed a consult, even if it is a payer such as Medicare that no longer recognizes consult codes, include a copy of the report to the referring physician. Again, that helps indicate the extent of work performed on the date of service.
11. If your handwriting is not legible, it may be best to have the records transcribed. Some auditors may deny a service if the records are not easy to read. At other times, auditors may miss important aspects and down code or deny the service. If you transcribe old records, make sure it is clear that the transcription is recent, with the current date prominently displayed. When you submit the record, place the handwritten copy behind the transcription. Usually, you should include a comment about the recently transcribed records in the cover letter you send with the audit submission.
12. Write a cover letter outlining the contents of the package. Provide the name of a contact person at your medical practice along with phone and email address in case the auditor needs additional information.
13. Use FedEx, UPS or mail with return receipt requested so that you have a record of delivery. Some payers allow electronic transfer of records.
Finally, the steps you take to comply with the request will make a difference in how the audit proceeds and how much time and effort it takes to appeal any adverse findings.

Hoyt Torras, MPA, MHA is a Senior Consultant Senior with InGauge Healthcare Solutions and a contributing author to Efficiency in Practice. For more information on Efficiency in Practice and to register for Hoyt’s tele-class, “Practical and Achievable Approaches to Compliance – Tips for Preventing Coding/Billing Audits, and What to Do If You Get Audited” click Here. First time attendees register at no charge.
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Traditional Faxing and HIPAA
We are often asked questions by physicians and practice managers regarding faxing and HIPAA compliance. One would assume following the logic that email containing PHI cannot be sent unsecure that FAXing is also a no-no. That’s not entirely true.
HIPAA states in the “Safeguards Principle”: Individually identifiable health information should be protected with reasonable administrative, technical, and physical safeguards to ensure its confidentiality, integrity, and availability and to prevent unauthorized or inappropriate access, use or disclosure.
As you can see from the above, HIPAA lays out rules and guidelines but doesn’t offer any solutions to get this implemented (especially in the case of FAXing). With email it’s quite simple to meet the above by using end to end encryption. However FAXing isn’t quite so “cut and dry”
What sensible steps can you take for HIPAA compliant FAXing?
1. Use a cover letter. This will help to avoid any casual or accidental reading of PHI.
2. Send only the necessary PHI, no more.
3. Use saved speed dial numbers for entities that your practice faxes often. This will help prevent dialing wrong numbers.
4. Verify any new fax numbers with a test fax.
5. Document in your “Policies and Procedures Manual” what to do if PHI is accidentally faxed to the wrong location.
6. Make sure your fax machine DOES NOT save copies of received faxes. This is a simple configuration on the machine.
7. Never leave PHI sitting on fax machine once received or sent.
8. Do not fax if there are other “more secure” ways to deliver PHI (i.e. encrypted email, by hand, etc.)

Look who’s searching…

In today’s medicine, the web and social media are important and beneficial tools that should not be ignored.    According to an article from amednews Feb. 21, 2011, “New vital sign:  degree of patient’s online access” by Pamela Lewis Dolan, searching for health information is the third most common online activity behind checking e-mail and using a search engine, with women more likely than men doing healthcare research.   

A Harris survey conducted in January 2011 on behalf of Insider Pages, an online directory that has a “physician finder”; found that most people look for physicians based solely on their location.  Patients starting with a physician finder normally do a query on physicians in a particular geographic area, and once that is generated, the patients will click on the profiles of the physicians they are interested in.   This is then normally followed by the searching the profile page and then the physician’s personal web page if they wanted more information.  The survey also noted that even though not all adults go online, the percentage of online health information seekers is at 59% of the totalU.S.population.

Designed for Success…

In considering web design/medical website development, you should carefully consider what type of audience you want to attract.  You may want to attract a certain type of patient, specific to your specialty, which will dictate how your design and website should be promoted.  A plastic surgeon would certainly want to promote beautiful photos of before and after surgical procedure pictures, whereas a pediatrician may want to promote an “ask-a-nurse” component or brightly colored home page.  Another consideration is the actual design.   If you aren’t sure what type of design you would like to promote the practice, do some research and find other practices online in your same specialty. 

“Googling” the simple phrase “Family Practice” for instance, will provide hundreds of practices with an online presence.  Review them, making helpful notes to assist you in design.   What was the first thing that caught your eye on their site?  Did it seem professional?  Were there any “special” effects such as flash animation, special links or other features you would like to incorporate in your website?   Did the website allow patient interaction with the providers?  How were the physicians highlighted in the website?   Is it easy for the patients to navigate?  Did they have a pleasing home page, highlighting the practice with easy to read information?    Keeping a list of website links that contained special designs, features or undesirable attributes will help down the road when designing your home page or speaking to the web designers if you decide to use a professional service. 

In respect to website content, this is obviously going to be specific to your practice and specialty.  Some items to keep in mind globally would be using your practice name, address, phone number and any other means of contacting the office on each page.  If you can, include a map for patients to find your location and a link to such as “Mapquest” or “Googlemaps” that will allow the patient to print out directions to your practice. 

Keeping the content fresh and updated is also a good idea for visitors to return.  Information about sunburns isn’t really relative in theMidwestduring a February snowstorm.  If you are using a professional web design company, they will question you for interest in SEO or “search engine optimization” which is normally an additional fee to site design.  By using the design company, they will “promote” your website by SEO optimization, which is done by paying special attention to descriptions and keywords making sure that your scores rate higher in ranking in search results.

There are many free analysis tools to track your site’s SEO performance, such as Yahoo! Site Explorer, Google Webmaster Tools, Google Analytics, SEO Book and SEO Chat that will give you a wide range of options to follow your SEO campaigns.  

Legally Speaking…

Using a website for your practice is treated as advertising under the law, so any legal and ethical rules of advertising for physicians should be applied.  One should also take into consideration any patient-physician-practice contact and the legal ramifications under HIPAA (Health Insurance and Portability and Accountability Act) and ARRA (American Recovery and Reinvestment Act) standards. 

The AMA has guidelines available to help you develop your web presence and social media rules for the practice as well.   Your malpractice carrier should be aware that you are developing a practice website for risk management purposes.   Some malpractice carriers will have specific suggestions/guidelines for their clients to use with legal resources and documents.  A good resource for HIPAA, ARRA and social networking/media updates can be found at the AMAPracticeManagementCenterat www.ama-assn.org/go/pmc.  

In considering truth-of-advertising, if you list or mention your staff on websites, make sure that the written content matches their titles and credentials.  For example, if your office only employs medical assistants in the practice, you wouldn’t want to have a statement or content stating that “our nurses” or “the nurses” provide XYZ services to the patients.  This would be misleading to patients on the website and possibly make them believe they are speaking to a “nurse” in your practice when they are really speaking to a medical assistant.  Patients deserve to know who is providing their care.  The AMA also clarifies in H-405.968 code ethics “Clarification of the Term “Provider” in Advertising, Contracts and Other Communications”.

As mentioned previously, a website in a physicians’ practice is considered advertising under the law, so you would treat it no differently than an advertisement in the newspaper or telephone book, with the exception that the physician must also be aware of truth-in-advertising and testimonials. 

Many attorneys will advise clients to stay away from testimonials and deal with straight facts and information about the office.  Your site may describe to patients why they should choose your practice, as long as they aren’t legally false, deceptive or misleading, as judged by the state medical board.  The AMA has a code of ethics that states “Generalized statements of satisfaction with a physician’s services may be made if they are representative of the experience of that physician’s patients”.

Additionally, while social networking (Facebook, Twitter, MySpace, etc.) continues to be an undeniable presence with 35% of American adults using them in the online community, they are viewed in the medical community as a “minefield” of legal and professional hazards for the medical professionals who “friend” patients to communicate. 

In Summary…

Healthcare providers and physicians see the potential in online interactions with patients for improving access and quality of care.   Healthcare searches compose the third highest volume of online activity.  Patients search initially for physicians demographically then by profiles if interested in further information. 

Website design is specific to your audience and specialty.  A professional appearance with easy to navigate pages and current relevant site content will keep the patients returning to your site.  Women are more likely to be viewing and researching your online presence.  Website SEO optimization increases the likelihood of your site to be “noticed” online and moved higher on the search engines with key words and descriptions based on your site content. 

There are valid concerns to consider in regards to patient privacy, liability, risk management and the compromised situations the practice can be exposed to.   Social networking sites carry an additional legal & ethical concern for the employer-physician and should not be ignored when considering online communication with patients. 

Healthcare and the internet “society” will certainly increase and is destined to be a continuum.  The healthcare community can continue to use these tools to improve the quality of health care and patient outcomes, as well as practice enhancement and patient satisfaction, but should seriously consider how best to use electronic media to everyone’s advantage, by protecting the patients’ rights as well as using best practice techniques and effective risk management.  

© 2012 Efficiency in Practice

Rebecca Umberger, CMA(AAMA), CPM  is currently Vice President of Development at Family Care Centers of Ohio, and over the past 9 years served as part-time Adjunct Instructor in the Health Division/Medical Assisting Department at Stark State College North Canton, Ohio.   She has worked various positions both as a CMA and Practice Manager in an outpatient setting for over 26 years.  During this time, she has focused in clinic operations management, practice design, planning and development, marketing, recruiting, process improvement and workflow efficiency, supervisory training and leadership development with a special interest in medical law/ethics.  She can be contacted at Rsumberger@famcareohio.com or you can check out her company’s website at www.famcareohio.com

Does your practice receive patient complaints about long waits during the visit? Do you have a physician who is constantly behind schedule? Prolonged waiting times affect your practice in several ways. Patients can become dissatisfied to the point of leaving your practice. Physicians and staff become frustrated with delays that can result in long hours and patient complaints.

There are a variety of reasons for prolonged waiting times. Patients who arrive late, staff who take too much time with patients, providers who try to do too many things at once, and poor communication within the office are just a few of the many possible causes. Are you not sure where the problem lies in your practice? It might be time to measure your office visit cycle time.

According to the Institute for Healthcare Improvement (IHI),  office visit cycle time “… is the amount of time in minutes that a patient spends at an office visit. The cycle begins at the time of arrival and ends when the patient leaves the office.” Measuring the office visit cycle time can help you identify where the bottlenecks exist in your practice.

When measuring cycle time, you can measure as few or as many steps in the patient visit process as you wish. The fewer steps you measure, the easier it is – but you get less information. The more steps you measure, the more helpful your information will be – but it will also be more resource-intensive. The steps you will want to consider are:

• Patient appointment time
• Time patient checks in at desk
• Time patient is taken to exam room by staff
• Time staff leaves the room
• Time provider enters the room
• Time provider leaves the room
• Time patient leaves the room
• Time patient checks out at desk

IHI recommends that you measure a total of 15 patients in order to get a good average cycle time. The patients should also be measured on the same day of the week and at the same time of the day. Depending on your specialty – or where you think your bottlenecks are – you might also want to include lab, x-ray, or certain procedures in your cycle time measurement.

Cycle time can be measured manually or, depending on the sophistication of your electronic health record (EHR), automatically. The manual method can be done by staff or by patients. A sample form can be found at IHI’s web site, www.ihi.org. Patient Cycle Tool If you prefer to try to automate it, many EHRs are able to time-stamp several important steps in the cycle: patient check-in, staff logging in and out of the record, providers logging in and out of the record, and the end of the visit (closing the encounter).

Once you’ve identified where the bottleneck exists, focus on that step in the cycle and use basic process improvement tools (process mapping, plan-do-study-act cycle) to make changes that will improve your cycle time.

When measuring cycle time for the first time in your practice, you should consider doing several (if not all) of your providers. This will not only enable you to get an overall average for your practice, but you can also identify best performers within your practice and use them as a model for the others. As for a standard benchmark, IHI suggests that you take the amount of time that a patient spends with the provider and multiply that by 1.5. For example, if a patient spends 20 minutes with the provider, the ideal cycle time would be 30 minutes (20 x 1.5 = 30).

Improving patient cycle time can help reduce waiting times in your practice. It can become a valuable aspect of your practice’s quality program. It not only makes the practice more efficient, it is also a great satisfier to patients, staff and providers.

© 2011 Efficiency in Practice

Tom Ludwig is President and CEO of Forward Healthcare Solutions, LLC, a consulting firm that specializes in working with physician practices. Tom has worked in the physician practice setting for a variety of organizations for 35 years. He has extensive experience in clinic operations management with expertise in strategic and business planning, process improvement and workflow efficiency, advanced access, supervisory training and leadership development. Tom can be reached at tludwig@forwardhealthcaresolutions.com or http://forwardhealthcaresolutions.com/index.html

And for more medical practice management resources and information, visit www.efficiencyinpractice.com
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Healthcare practices often spend time looking at ways to improve patient satisfaction, but how often do they address communication as it relates to improved patient service? I would have to say, not often enough.

Every aspect of patient care involves communication. Whether it is in person, on the telephone or using technology, what you say is as important as how you say it. It is so easy for a patient to misinterpret what is being conveyed. For this reason, practices should look at their communication as a way of improving “the patient experience.”

When a patient is face to face with the front receptionist, does that receptionist look the patient in the eye? Does she address the patient by name and offer her the same respect and consideration that she herself would want? For that matter, every person in the office, from the clinical staff to billing person should treat patients with respect and dignity. Starting with the patient, there is a definite link between a patient’s understanding and patient satisfaction. In improving the relationship between the practice and the patient, it is important to:

• Include the pleasantries. Whether it’s greeting a person by name, offering them a seat or shaking hands, pleasantries and greetings are important.
• Create a rapport with the patient. This includes an understanding of the patient’s concerns, issues and needs.
• Understand the patient’s perspective and what he/she wants out of the visit to the office. This can include areas of scheduling, billing and education as well as the physician visits with the patient.
• Be empathetic and sympathetic to the patient’s concerns. They need to know that you care about them as a person. RESPECT and SUPPORT are essential.
• Do not appear rushed even if you are. Let the patient feel that they are important and you are giving them the time they need.
• Keep the conversation on track.
• Listen without interrupting. Look at the patient so they know you are listening. Hear what your patients are saying. If needed, repeat what they said; “if I understand you, you are saying….”
• Involve the patient in his/her care. Whether it’s educating the patient of his diagnosis, explaining a bill, or discussing insurance, the patient needs to be aware and understand what is happening. Build on the relationship and make the patient and family members PARTNERS in their care.
• Manage patient expectations. Try coaching your patients as to what reasonable expectations are.

Telephone encounters with the patient need to be equally respectful and considerate. Reaching a live person should be easy and telephone hold time should be kept to a minimum. Staff should try and establish why a patient is calling prior to transferring the call and should share the reason with the person they are transferring the call to. There is nothing more aggravating than having to explain the purpose of your call several times during the encounter.

Communication is more than just the spoken word. It is the little things that we do that remind the patient of their importance to the practice.

Some things a practice may want to consider doing are to:
• Send all patients a welcome letter
• Make special efforts to meet the patient’s needs
• Educate your staff on working with patients
• Listen
• Follow up
• Do the unexpected
• Exceed their expectations.

It is the body language we use to make a point and the gestures we make. It is going above and beyond the expectation of the patient to insure that the patient understands what he is being told and recognizes his value to the practice.

Every encounter we share with a patient, whether on the telephone, in person, on the internet or using advanced technology is a means of communicating. Practices should value all forms of communication and look for ways to improve them. Effective communication is customer service at its best.

© 2011 Efficiency in Practice

Donna Weinstock is a Senior Consultant at InHealth, and the President of Office Management Solution. She consults with healthcare practices to perform workflow analysis, improve processes, and increase profits as well as select and implement electronic health records. She can be reached at donna.weinstock@inhealthconsulting.com
This article can be reprinted freely online, as long as the entire article and this resource box are included.

Annual preventive exams have been a standard of care in the medical industry for many years.  CPT describes these services as a periodic comprehensive preventive medicine evaluation (or reevaluation) and management of an individual.  CPT codes 99381-99387 are the codes used to represent these services and their selection is based on whether the patient is new or established as well as the patient’s age.  CPT goes on to describe the services to include an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures.

Unlike other evaluation and management services in the CPT book, annual preventive exams do not have specific documentation guidelines required to support the service that is being provided.  A preventive medicine service is considered to be of a comprehensive nature however the “comprehensive” nature of these services is not synonymous with the comprehensive examination required in other evaluation and management codes.  So the age old question, what constitutes a comprehensive history and exam in relation to a preventive medicine service?

Here at Indianapolis Medical Management (IMM) this topic has brought much debate.  Some of the many services that we offer include chart reviews and provider education.  When these functions are performed around preventive services, the question of how these services should be documented comes up.  What types of information should we expect to see to constitute a comprehensive history?  What equates to an age and gender appropriate examination?  What types of counseling, anticipatory guidance and risk factor reductions should be addressed?  What laboratory and diagnostic procedures would be relevant to a preventive service?  What should we be educating  physicians and non-physician practitioners (NPPs) to document in a patient’s medical record to support the billing of a preventive medicine evaluation and management service? 

Again, there are no official, specific documentation guidelines, so in an effort to help streamline this process for both our team of billing and coding consultants and our clients, we have done extensive research and come up with best practice guidelines based on recommendations from the American Medical Association (AMA), the American Academy of Family Physicians (AAFP), the U.S. Preventive Services Task Force (USPSTF), the American College of Physicians (ACP) Internal Medicine and the American College of Obstetrics and Gynecology (ACOG).  These guidelines will be used to evaluate these services.  The following breaks down the information that we would expect to see documented in the review of a preventive medicine service based on the patient’s age and gender.

Well Baby Visits – Birth to 2 Years

History:  Past illnesses, surgeries, medications, allergies, pregnancy/birth history, family history and social history

Exam:  Hearing for newborns, weight, length, head circumference, head, chest, abdomen, genitalia, neck, extremities, eyes, ENT, cardiovascular, respiratory, skin, neurological

Counseling/Anticipatory Guidance:  Safety, health, nutrition, development, immunizations

Risk Factors:  Age appropriate developmental and behavioral assessments

Lab/Diagnostic Services:  Hemoglobin or hematocrit once between 9-12 months, lead testing at 1year and 2 years if uncertain about lead exposure, PKU screening

Well Child Visits – 3 to 10 Years

History:  Past illnesses, surgeries, medications, allergies, family history and social history

Exam:  Blood pressure, vision screen, hearing screen, height, weight, BMI, w/percentiles for age, eyes, ENT, cardiovascular, respiratory, GI, GU, musculoskeletal, skin, neurological, psychological

Counseling/Anticipatory Guidance: safety, injury prevention, health, nutrition, development, immunization, screenings

Risk Factors:  Age appropriate developmental and behavioral assessments

 Lab/Diagnostic Services:  Any warranted based on risk factors

Well Child Visits – 11 to 18 Years

History:  Past illnesses, surgeries, medications, allergies, family history and social history, status of chronic conditions

Exam:  Blood pressure, vision screen, hearing screen, height, weight, BMI, eyes, ENT, cardiovascular, respiratory, GI, GU, musculoskeletal, skin, neurological, psychological, hematological

Counseling/Anticipatory Guidance:  Nutrition, physical activity, healthy weight, injury prevention, avoidance of tobacco, alcohol and drugs, sexual behavior and STDs, dental health, mental health, immunization, screenings

Risk Factors:  hypertension, hyperlipidemia, coronary heart disease, depression, eating disorders, emotional, physical, or sexual abuse, problems with learning and school

Lab/Diagnostic Services:  Chlamydia screening for sexually active females,

Adult Visits – 19 to 39 Years

History:  Past illnesses, surgeries, medications, allergies, family history and social history, status of chronic conditions

Exam:  Blood pressure, height, weight, BMI, breast exam for women, depression screen, eyes, ENT, cardiovascular, respiratory, GI, GU, musculoskeletal, skin, neurological, psychological, hematological

Counseling/Anticipatory Guidance:  nutrition, family planning/contraception, physical activity, healthy weight, injury prevention, misuse of tobacco, alcohol and drugs, sexual behavior and STDs, dental health, mental health, immunizations, screenings

For Women:  Breast cancer and self breast exams

Lab/Diagnostic Services:  Cholesterol every 5 years beginning at 20 years, Chlamydia for sexually active women under 25, cervical cancer

Adult Visits – 40 to 64 Years

History:  Past illnesses, surgeries, medications, allergies, family history and social history, status of chronic conditions

Exam:  Blood pressure, height, weight, BMI, depression screen, eyes, ENT, cardiovascular, respiratory, GI, GU, musculoskeletal, skin, neurological, psychological, hematological

Counseling/Anticipatory Guidance:  Nutrition, physical activity, healthy weight, injury prevention, misuse of tobacco, alcohol and drugs, sexual behavior and STDs, contraception, dental health, mental health, immunizations, screenings

Lab/Diagnostic Services:  Cholesterol, diabetes, colorectal cancer beginning at 50 years

            For Women:  Breast cancer, cervical cancer

            For Men:  Prostate cancer beginning at 50 years

Adult Visits – 65 Years and Older

History:  Past illnesses, surgeries, medications, allergies, family history and social history, status of chronic conditions

Exam:  Blood pressure, height, weight, BMI, hearing screening, depression screen, eyes, ENT, cardiovascular, respiratory, GI, GU, musculoskeletal, skin, neurological, psychological, hematological

Counseling/Anticipatory Guidance:  Nutrition, physical activity, healthy weight, injury prevention, misuse of tobacco, alcohol and drugs, sexual behavior, dental health, mental health, immunizations, screenings

Lab/Diagnostic Services:  Cholesterol, diabetes, colorectal cancer

            For Women:  Breast cancer, cervical cancer, osteoporosis beginning at 65

            For Men:  Abnormal Aortic Aneurysm one time for men 65-75 years with history of smoking, prostate cancer

It is important to note that checking the status of chronic conditions and refilling on-going prescriptions is expected during the course of an Annual Preventive Exam and thus would not warrant the billing of a separate Problem Oriented Evaluation and Management service.  However, if a chronic condition is not being well controlled and decisions are being made as to how to treat the patient to improve control, changing the dosage of medications, changing to a new medication etc, this may substantiate a separate Problem Oriented Evaluation and Management service if more work is done (and documented) than what would normally be performed in the course of an Annual Preventive Exam.

In closing, please keep in mind, the above recommendations are just that, recommendations.  The individual needs of the patient and their history and risk factors will determine the extent to which counseling, anticipatory guidance and screening services should be performed.  For example, a female with a family history of breast cancer may need a screening at an earlier age than typically recommended.  What is important to remember is the documentation should include what counseling and anticipatory guidance was provided to each patient as well as the screenings that were discussed and ordered or offered, should the patient decline.    The documentation should very clearly show that the elements of the Annual Preventive service were met.  At IMM, it is our hope to provide information and education that will help our clients improve on documentation and thus help ensure that the services performed are supported by that documentation.  Hopefully this article will help you in your documentation of Preventive visits.

© 2011 Efficiency in Practice

Ellen Risotti, CPC, CEMC, CFPC is a billing and coding consultant for Indianapolis Medical Management and a contributing author to Efficiency in Practice.  Efficiency in Practice is the free eNewsletter for medical practice managers who want to save time, money and reduce risk . To read more articles like this, visit www.efficiencyinpractice.com and subscribe free of charge. This article can be reprinted freely online, as long as the entire article and this resource box are included.

Many hospitals and health systems have Physician Liaison and/or Physician Relations Representatives that have the responsibility of visiting physician practices to promote the service lines of the hospital. Similarly many physician practices, in particular   specialty practices, have initiated or have considered initiating such a program as a vehicle to carry their message(s) to the field and ultimately grow their referrals. Some consulting organizations provide the option of outsourcing this role to them (Practice-Reps) while others will provide a Physician Liaison training program for your new hire (Healthcare Success Strategies, Practice Builders).

If you decide that you want to start a Physician Liaison program on your own, where do you start? Let’s examine some of the areas you need to consider:

      Job Description for a Physician Liaison

Many practices are at a loss regarding defining a job description because this is a new, unexplored role for them. The following is a general example of the role and responsibilities of a Physician Liaison:

The Physician Liaison will support the practice by representing and promoting our clinical services, physicians and programs in order to increase referrals from existing providers and secure new business from current low volume and non-referring physicians.

ESSENTIAL JOB DUTIES AND RESPONSIBILITIES:

• Functions as the primary sales and marketing contact for referring physician offices
• Interfaces with both physicians and their staffs to improve communication and understanding of the needs and wants of the referring practices
• Develops a sales plan for physician practices with measurable goals and objectives
• Conducts personal visits to referral sources on a daily basis 
• Identify issues and concerns from referring offices and communicates them back to the practice 
• Facilitates meetings for our physicians with referral sources and coordinates “lunch and learns” to discuss new clinical offerings
• Documents daily contact with referring physician offices
• Develops referral trend reports
• Facilitates community outreach, speaking and education opportunities for the practice.

MINIMUM QUALIFICATIONS:

Education:  BA in marketing or business.

Experience:  Three to five years in healthcare sales, preferably in a physician services environment.

      Finding the Right Candidate

Practices need to understand that if you are going to have a successful Physician Liaison it takes more than finding someone with an outgoing personality. That is certainly an important trait but there needs to be more. Your Physician Liaison needs to have the ability to listen and understand what the client is truly saying. They should have great attention to detail and excellent organization and follow up skills. They need to be problem-solvers and be able to facilitate solutions, calling upon resources within your practice. And they need to have “conceptual” selling skills so they can be your communication eyes and ears.

Can you get this from an entry-level hire? Perhaps, but it is going to take time, training and personal management, which in many cases practices cannot devote. Ideally you should be looking for someone that has been in a sales capacity in a physician services environment and has already been through a variety of sales training programs. To hire a “Marketing” versus a “Sales” person or move a clinical person into a Physician Liaison role is often a difficult transition for them due to their lack of experience making sales calls and “cold call fear”.

Potential sources to identify candidates can be online job posting websites along with recommendations from your vendors and hospital Physician Relations Department.

Finding the right, experienced person will put you further ahead on their road to productivity.

      Setting Objectives for Your Physician Liaison

One of the challenges for a Physician Liaison role, particularly if it is new to a practice, is staying focused on the job responsibilities. Inevitably what happens is that if something even has the slightest orientation to a sales and/or marketing responsibility, most people in the practice will direct it to the Physician Liaison. As this continues over time, the Physician Liaison becomes engulfed in day-to-day “stuff” and is not able to get into the field, fulfilling what they were hired to do i.e. calling on referral sources. To avoid this all too common situation, it is important to set clear, measurable and quantifiable objectives for your Physician Liaison so that they know, and your practice knows, what is expected of them. The following are some of the many measurable goals that can be established for a Physician Liaison:

• # of visits per week to referring physician offices
• # of meetings facilitated for practice MDs with referring physicians
• # of lunch and learns coordinated with referring practices
• # of social events scheduled with your practice and referring practices
• # of referral coordinator lunches scheduled
• # of meetings with ER physicians and Hospitalists
• # of speaking engagements coordinated
• Development of quarterly sales plan and rotational call schedule
• Submission of weekly sales activity report

 Mentoring Your Physician Liaison

A challenge for many practices is what do you do with this person? For practices that have no experience with a Physician Liaison, the short answer is that you need to mentor them, provide them with an opportunity to succeed, give them clear direction, and monitor their activities not only through their reports but also by spending time with them in the field making calls on your referral sources. Giving them a list of your referring physicians and telling them to make calls and deliver referral pads is potentially a recipe for disappointment.

On a weekly basis you should meet with your Physician Liaison and review the planned activities for the week. Questions that you and the Physician Liaison should discuss include: What are the objectives of your calls? Who are you going to call on in the practices? Who in the practices determine where referrals are sent? What do you want to accomplish with the calls? What have been their referral trends? Have there been any problems expressed by these practices? In other words, you need to strategize with the Physician Liaison on their calls. Leaving them on their own to do this will likely not yield the results that you are looking for.

 Tracking Physician Liaison Sales Activities

On a weekly basis the Physician Liaison should submit an activity report to the Practice Administrator. The Physician Liaison should document what practices they visited, who they spoke to, what information they left with the practice, and any issues that were identified and follow up that may be required.

             Targeting the Referral Influencer

While private practices are physician owned and controlled, the bottom line is that the physicians don’t necessarily always influence where the patient is sent for additional testing or consults. More often than not a referral coordinator, check out person or mid-level will play a key role in where the patient is referred. As part of the Physician Liaison’s role, they need to determine who coordinates referrals within these practices and then target them from a relationship building standpoint.

In meeting with the referral influencer your Physician Liaison should try to integrate   questions such as the following into their discussion to get valuable feedback for your practice:

• What’s the most important factor in determining where to send your patients for ________________ care?
• How’s your experience been with scheduling and with reports at our practice?
• Have your referrals to our practice changed over the last year? (If they’re down, why?)
• Have you been satisfied with our care of your patients and service to your office?
• What feedback do you receive from your patients regarding our practice?
• Can I answer any questions about the services we offer?
• How can we improve our service to your practice?
• Are there any issues or problems we should be aware of

Involving Your Physicians in the “Sales” Process

One of the most effective marketing initiatives is getting your physicians face-to-face, developing relationships with your referring physicians. Your Physician Liaison should be a conduit to facilitate these encounters. Primary Care physicians are often overloaded with patients so it is difficult to bring your physicians into their office for a “lunch and learn” or breakfast or lunch meeting. What can be very effective however is to bring your physicians to the PCP office for a “check in” with the physicians and staff regarding how your practice is performing on behalf of their patients. It does not need to be a formal, sit-down meeting but the fact that you are showing them that you value your relationship will end up paying dividends.

 Report Generation

As part of your Physician Liaison’s responsibilities, they should be the “go-to” person for collecting, analyzing and disseminating reports related to referral activity. Some examples of tracking reports include:

• Monthly referrals by referring physician
• Monthly new consults by referring physician
• Monthly referrals, new consults and total visits per office location
• Referring physician monthly ancillary services referrals
• Monthly ancillary services volumes by office location
• Source of self-referred patients by month (e.g. friend, television commercial, etc.)
• New patients generated as a result of community screening programs
• Referrals by your practice physicians to internal programs (e.g. exercise, nutrition, etc.)

Considerations

Implementing a Physicians Liaison program is a very viable initiative to enhance relationships, increase visibility and grow referrals for your practice. However, to have a successful Physician Liaison program and an overall effective marketing strategy, you first need to have a plan before you can “work the plan”.  

Marketing is a process rather than an event. To position yourself to “market”, you need to develop a plan, looking both internally to evaluate the current state of your practice and externally to analyze your market and define specific goals, tactics and action plans.

To help you understand the elements of marketing planning, register for the December 15th Efficiency in Practice tele-conference, Marketing Your Medical Practice: You Need To Have A Plan Before You Can “Work The Plan”.  

This tele-conference will provide you with the building blocks to develop a systematic and comprehensive marketing plan to promote your practice.

Our discussion will review:

• How to evaluate your practice from a marketing perspective
• The key elements of a strategic marketing plan
• Potential PR and marketing tactics to consider

Click HERE for more information and to Register

In approximately 24 months the most significant change to the diagnosis coding system will happen.  The Department of Health and Human Services released the final regulation in 2009 to move from the current diagnosis ICD-9 coding system to the ICD-10 coding system beginning October 1, 2013.  If your professional options do not include imminent retirement or a drastic career change, surviving the transition from ICD-9-CM to ICD-10-CM will require a strong foundation. 

ICD-10 is not just a routine annual diagnosis update.  This is a much bigger transition that requires attention devoted to physician and staff education, workflow alterations, clinical documentation, practice management operations and claims management processes and systems which must be reconfigured for ICD-10.  Failure to transition to ICD-10 on October 1, 2013 will result in delayed or denied reimbursement.  Reconfiguring your systems to be ready for implementation is required January 1, 2012 with the conversion to 5010.  While 5010 is a technical conversion where vendors will do most of the heavy lifting, the same is not true for ICD-10. The ICD-10 code set will require action from you and your practice.

Studies conducted by The Advisory Board (www.advisory.com) estimate the incremental impact on net revenue for a 250 bed hospital one year following implementation to be $1.0-2.5M with a three year impact of $2.5-7.1M. The reasons for such significant loss include:

• lack of clean mapping to the new code set
• claim denials as a result of unfamiliarity with newly revised policies regarding medical necessity from payers
• under-coding due to documentation specificity that was insufficient for accurate coding
• over-coding driven by coder inexperience
• payment errors due to IT issues

Of serious concern is the loss in productivity as coders query physicians for more information.  Successful use of ICD-10-CM begins with the physician or provider who is documenting the service.  Staff cannot pick a code if they do not have enough detail in the documentation.  It is critical that physicians engage now in education to improve current documentation habits in preparation for greater specificity requirements in ICD-10.  If you don’t start by making changes in your documentation now, you will be overwhelmed when it is time to implement the new codes.

While ICD-10-CM is similar to ICD-9-CM in that some terminology, conventions, classifications, and other features are the same, there are also many differences in terminology, categories, chapters, guidelines and code structure.  Advances in medicine and medical terminology and how we report quality data cannot be accommodated in the current ICD-9 system. 

Some of the category changes will include additional chapters in ICD-10-CM and the moving of some diseases to a different category. 

For example currently in ICD-9-CM, Chapter 3 Endocrine, Nutritional and Metabolic Diseases and Immunity (240-279) physicians would choose category 274 Gout and select one of 15 different codes to describe the encounter.   In ICD-10-CM, this chapter has been renamed and moved to Chapter 4, Endocrine, Nutritional and Metabolic Diseases (E00-E89). Gout has been removed from this category and placed in Chapter 13 Diseases of Musculoskeletal System and Connective Tissue.  In ICD-10-CM, physicians will choose from the category M10 Gout, and select a code from 162 choices.  In order to select the appropriate choice, your documentation will need to describe all of the following elements that most accurately describe the encounter:

• anatomical area affected
• laterality
• idiopathic
• lead-induced (also identify the toxic effects of lead and its compounds)
• drug induced (also identify the drug)
• renal impairment (also code the associated renal disease)
• other secondary diagnoses (coding first the associated condition)
• an additional code to identify certain diseases and/or disorders classified elsewhere

ICD-10 is so much more than coding and IT.  The transition to ICD-10 will have a significant impact on provider operations in almost every area.  Are you ready for ICD-10?  The time to begin preparation for transition to ICD-10 is now.

© 2011 Efficiency in Practice

Pat Schmitter, CPC, CPC-I is a Billing, Coding and Credentialing Consultant with Indianapolis Medical Management.

With almost 40 years of experience, Pat has a strong background in government payer regulations.  She provides billing and coding consulting services and is responsible for various audits; education on billing, coding and government regulations; and solvinf payor-related problems.

To reach Pat, email her at pat.schmitter@inhealthconsulting.com

Many physician practices often take a reactionary, shot-gun approach when it comes to marketing initiatives. For example, a competitor starts running ads in a local paper so the practice decides they need to do the same. This leads to careless spending and no integration of what you want to accomplish from a branding and messaging perspective.

While practices consistently plan and budget annually for operational expenditures and activities, the same thought process and attention needs to be devoted to marketing. To be successful, efficient and cost-conscious, developing a marketing plan is a necessary and critical element of a practice’s overall strategic process. The marketing plan will serve as a road map to guide your internal and external activities, define your budget and detail your planned strategies and tactics for a twelve month period.

Developing an effective marketing plan requires that you take both an “inside” and “outside” look at your practice.  As a first step in the marketing planning process you need to conduct an internal marketing assessment. This assessment should evaluate the current state of your practice from a marketing perspective, the effectiveness of past marketing initiatives, referral trends that exist and how you are perceived by your patients and referral sources.

In beginning your internal evaluation, as a first step, it is beneficial to “interview” each of your physician providers, mid-levels and management team members to gain their perspective of your practice. The interviews will allow you to get their view on your unique differentiators, SWOT (Strengths, Weaknesses, Opportunities and Threats), key messages, the competitive environment, marketing opportunities, relationships with referring physicians and any barriers to referrals that might exist.

The information they provide will not only be useful to you but it will also give them a feeling of ownership in shaping the future message, positioning and plans for the practice. It is recommended that you send them in advance a questionnaire to consider and then conduct individual face-to-face meetings to gather their input.

Click HERE for a sample Internal Interview Questionnaire  and SWOT Analysis

An important outcome of the internal marketing assessment is the development of a SWOT Analysis which will serve as a key component of the marketing plan. The SWOT Analysis is a subjective, yet useful, strategic look at your practice. The physician and management team interviews will provide the detail for this exercise. The information from the SWOT will help to drive your key messages and define your marketing tactics to help your practice achieve its objectives.

The SWOT Analysis identifies those internal and external factors affecting your practice:

• Strengths- internal practice aspects that provide a competitive advantage. Examples of strengths might include clinical outcomes in relation to national standards, same day consults, on-site prescription dispensing, bi-lingual staff…
• Weaknesses- the lack of strengths in certain areas may be considered an internal weakness. Weaknesses could include poor staff customer service skills, scheduling difficulties, not being a provider for a major insurance carrier, office location…
• Opportunities- external factors which provide growth and differentiation possibilities. Opportunities could include new clinical services not being offered in the community, new physicians and office locations, research initiatives and clinical trials…
• Threats- market and competitive activity which might negatively impact the practice. Threats could include declining outpatient reimbursement, growth and expansion of other providers, health system integration of our specialty…

In defining your goals which will be elaborated on in the marketing plan, the practice should attempt to capitalize on its strengths in relation to the identified opportunities and attempt to minimize weaknesses or threats or, conversely, develop strategies to transform these areas into strengths and opportunities.

Marketing should be approached as an ongoing process. To position yourself to “market”, you need to develop a plan, looking both internally to evaluate the current state of your practice and externally to analyze your market and define specific goals, tactics and action plans.

The following link  (http://mdpracticemarketing.blogspot.com/2011/08/conducting-marketing-assessment-of-your.html) will provide a guide for conducting an internal marketing assessment of your practice. The assessment will serve as the foundation from which you will be able to develop a systematic and comprehensive marketing plan.

© 2011 Efficiency in Practice

Bob Healy, Managing Partner of MD Practice Marketing, and author of the Physician Practice Marketing Tips blog, has over twenty-five years of healthcare experience helping physician practices to implement programs to grow revenue, referrals and new patient consults.

For assistance in conducting an internal marketing assessment, developing a marketing plan or implementing the plan, contact Bob at mdstrategies@gmail.com or visit http://mdpracticemarketing.com/