Covered in FPM Quiz

Sample code distributions Relatively simple graphs of each provider's code distribution (such as those shown here) can provide helpful feedback for any practice seeking to improve its coding. Physicians' patterns may not be identical because of individual practice styles and patient and payer mixes, but you can track each individual's coding patterns over time. This will help you judge whether coding practices are improving. Physician A Established patient visits Physician A New patient visits Physician B Established patient visits Physician B New patient visits

Doctors feel pinched on time with patients
BY MICHAEL D. SORKIN
05/12/2003

Dr. Mark Gregory works longer hours than he did 10 years ago - for less money - and sees more patients. He worries every day about how to spend enough time with the 4,000 patients who visit him each year. "I try to schedule 20-minute appointments," says the St. Louis internist, "which leaves me some slack to squeeze in someone in an emergency, or make a phone call."

A new study says a growing percentage of physicians report they aren't able to spend enough time with patients - even though they now work longer hours dealing with patient matters such as tests, diagnoses and paperwork.

The study also says patients wait longer for appointments and are more likely to see nurse practitioners or other doctor-substitutes.

The proportion of physicians reporting inadequate time with patients grew from 81 percent in 1997 to 86 percent in 2001, according to a national survey by the Center for Studying Health System Change. It's an independent health research group in Washington.

Patients are frustrated.

"Some come to waiting rooms prepared to knit or crochet - and prepared to be frustrated for a very long time," says Ellen Dirnberger of Webster Groves. She's an official with the Missouri AARP and often hears members' complaints.

Some doctors are so busy that patients have trouble just getting an appointment.

"Sometimes, you practically have to tell them that you're having heart palpitations," Dirnberger says.

Doctors are frustrated, too.

Nobody forces them to pile on patients until waiting rooms turn into knitting sessions. But doctors say they can't afford not to: they point to HMOs, which frequently pay them just $5 a patient per month.

"Most people think doctors make a gazillion dollars," says Gregory, who earns $6,000 less than when he opened his doors 10 years ago. He made six figures just once in that time.

He is in an office with five other doctors, each with about 3,000 patients. After hours, that means the rotating, on-call physician is responsible for all 18,000 of their patients.

Imagine, Gregory says, trying to sit for an evening Blues game at Savvis Center - as your pager and cell phone ring with patients' calls.

It's not that doctors don't want to hear from patients - it's just that they say they are overwhelmed.

"Physicians really want to spend time with patients," says Dr. Jeff Thomasson. "That's what we're trained to do."

He's a radiologist at St. John's Mercy Medical Center and president of the St. Louis Metropolitan Medical Society.

"I would like to say that it will get better," Thomasson says. "But it may get worse before it gets better."

"Physician extenders"

Other signs that doctors feel crunched for time include the survey's finding that fewer physicians will accept new patients.

The proportion of doctors accepting new Medicare patients fell from 73 percent in 1997 to 69 percent in 2001, after the government cut payments to doctors. The proportion of doctors accepting new, privately insured patients fell from 70.8 percent to 68.2 percent during the same period.

Meanwhile, more doctors employed physician assistants, nurse practitioners, nurse midwives, clinical nurse specialists and other so-called "physician extenders." That proportion jumped from 40 percent to 48 percent.

Dr. Norman Druck is an ear, nose and throat specialist in an office here with three other doctors. They are so busy at times, he says, that they just can't see another patient. They have one nurse practitioner - and are considering adding a second.

"They take a lot of pressure off the doctor," Druck says. "She is probably as good as a senior resident, at least for office material."

Dr. Gordon Goldman is an obstetrician at DePaul and St. Luke's hospitals. He works 70 to 80 hours a week, seeing more patients today than when he started 29 years ago.

He won't use physician-extenders.

"If I'm going to be responsible for that patient's care, then I'm going to do the examination," Goldman says. "Not that I don't trust anybody else - it's just that I don't trust anybody else."

He says doctors are busier today because they take better care of patients and keep them healthier, with tests and procedures that were unavailable 10 or 15 years ago. "And the paperwork hassle is just overwhelming," he adds.

Meanwhile, the work piles up.

"I do what I can," he says. "Things can get put off, and they're late. Patients don't get called back as promptly as they want. But it gets done."

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Haggle with your doctor, cut your bill

Don't be cowed. Many consumers negotiate with physicians, hospitals and pharmacies to lower their bills. Here's how to do it successfully.

You may have negotiated a decent price on your new car or bargained for a great lamp at your neighbor's yard sale, but did you know that you can haggle with your doctor to lower your out-of-pocket expenses?

According to The Foundation for Taxpayer and Consumer Rights (FTCR), everything in health care is negotiable, even the bills from your doctor, pharmacist and hospital. FTCR's patient guide states: "You're paying the bills, not only as a consumer, but also as a taxpayer who helps fund the medical system." So don't be cowed by your doctor's sparkling white lab coat or by your hospital's credentials. Establish the price you believe is reasonable and go for it.

There's no harm in asking, says Larry Gelb, president and chief executive officer of Care Counsel, a provider of employer-sponsored health-care assistance and advocacy services in San Rafael, Calif. "There's nothing new about people asking for discounts on medical treatments," says Gelb. "There's a long history of patients negotiating with their providers for lower prices on elective procedures, such as laser vision surgery or psychotherapy."

How you can bargain

Many consumers successfully talk their doctors and hospitals into lowering their bills. Some 17% of consumers recently polled by Harris Interactive Health Care News say they have asked a pharmacist in the last year if they could pay a lower price. A smaller but growing number say they have done this with doctors (13%), dentists (12%), and hospitals (10%).

About half of all those who have tried to negotiate a lower price say they did so successfully, Harris says. This varies from 54% of those who spoke with their doctors to 48% who talked with their pharmacists, 47% of those who talked with their dentists, and 45% of those who talked with hospitals about their bills or prices.

There's both an art and science to haggling for lower health-care prices, according to Gelb. "Research indicates outspoken individuals have better health outcomes," he says. "But even I would think twice about creating bad feelings between me and my surgeon if I was about to have surgery."

The doctor/patient relationship is as delicately balanced as the employer/employee relationship, Gelb concedes. "You don't want to march up to your boss and demand a raise," he says. "You're probably much less likely to get the desired outcome by doing it that way than if you calmly explain the reasons why you need to make more money. Same thing goes for asking your doctor to lower his prices."

While there are no hard and fast rules for successfully lowering your out-of-pocket health care expenses, there are a few good guidelines:

• Find out what others are paying. This isn't as easy as it sounds because doctors and hospitals in different areas of the country charge widely varying amounts. The American Medical Association Web site now has an interactive tool that lists how much Medicare reimburses doctors for certain medical procedures. However, the AMA warns these are "bargain-basement prices" reserved for 39 million senior citizens and the disabled who need government assistance with their health insurance. Still, you should never pay your provider more than private insurers pay, says health-care attorney Deidre O'Reilly Marblestone. "Insurers never pay more than one-half to two-thirds of the total amount billed," she says. A note: You must register to use the AMA interactive tool for Medicare reimbursements. Registration is free, but you are limited to 10 searches annually.

• Cash talks (so do credit cards). Offer to pay your doctor the discounted amount you both deem reasonable in cash, immediately. If you don't have the cash, offer to put it on your credit card -- if you're financially able to do that. Says Marblestone, "It works. Just like Wimpy says in the Popeye cartoon: 'I'll gladly pay you Tuesday for a hamburger today.'"

• Plead your own case. Nine times out of 10, the telephone won't do the trick and neither will a written request. Arrange to get face time with your doctor, pharmacist or hospital billing officer and plead your own case for paying a lower amount. It also helps if you have an established relationship with your doctor or pharmacist.
  "It's much more compelling when a consumer speaks on his or her own behalf directly to the provider and explains the situation," says Gelb. It's also harder for the provider to turn you down in person.

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Healthcare Marketing

What you need to know about marketing to women

Any self-respecting healthcare marketer has long recognized that the single most-important segment of his or her audience shares one quality: they are female.

The influence of women in the healthcare decision-making process cannot be stressed enough. Women make between 70 and 90 percent of all healthcare decisions; they represent 60 percent of all physician visits; and they spend two out of every three healthcare dollars. Even when the husband's employer is providing the healthcare plan, surveys show that it's nearly always the wife who makes the selection.

That's why it is so important to consider the woman's perspective when marketing healthcare services. Turn them off and you're turning away your most important customer - the key to your healthcare organization's success.

My experience in speaking to women about health over the past several decades has taught me a few key lessons I can share.

1. Don't scold

Never, ever lecture or scold women. Many healthcare messages too easily focus on the things that people "should do but don't" when it comes to taking care of themselves. If women put off getting their mammograms, good marketers provide incentives. Motivate, don't blame. Women experience enough guilt already in their lives as they struggle to measure up to their own expectations in their many roles. If you provoke more guilt it will be difficult for you to establish a relationship with them.

The same applies for any patronizing tone. I personally remember speaking with a female patient who was enraged because her doctor shrugged off her symptoms and told her to "go home, put on your nightie, and have a good long rest." And haven't you heard the story about the worried mom whose pediatrician told her over the phone to follow these instructions after she reported her child's symptoms, "Take a glass, fill it with 2 ounces of scotch, now drink it and relax." Amusing, maybe. Insulting, definitely.

2. Women don't want to be defined by their ability to bear children

Don't segment the women's market by the reproductive events in their lives. Women don't want to be defined in this way. They don't think of themselves as "in the childbearing years," or "pre-menopausal." You risk alienating your audience if you assume that pregnancy and infertility issues are of interest simply because a woman falls into a particular age bracket. The same applies for menopause. In fact, the vast majority of health topics that interest women are not age-specific.

3. Watch your language

Be careful of negative stereotypes cropping up in your marketing copy, such as:

• "old wives' tales" - women's tales should be treated with respect - don't use these words to describe something to be discounted or ignored.

• "Pollyanna" or "Pandora's Box" - these terms convey negative images of women as weak in the first instance and responsible for evil in the world in the second.

• "What Mom told you" - a client of ours presented some new research findings in its newsletter copy as a corrective to Mom's advice. Fortunately, we were helped them edit their unintentional disrespect for this most important manager of the family's health. Even as men have stepped up to share more family responsibilities in recent years, healthcare management is still the woman's domain.

4. Recognize gender differences

In 1998, the U.S. Surgeon General predicted that gender would be the most important factor affecting health in the 21st century. Pay special attention to gender-specific information on illnesses that women share with men. By far, we've learned that the most attractive and compelling health and medical information for women is that which tells them that you know the difference between them and their husbands, brothers and fathers, and that you consider that incredibly important. Everyone is seeing lots of advertising for medications and treatments these days that point out that women are different when it comes to heart disease. Women in your market will respond positively when they recognize expertise in gender differences.

This opportunity to show women you understand their unique concerns goes far beyond heart disease, and smart marketers know it.

5. Get wired

Use the Internet when marketing healthcare services to women. They are going there in droves for information to manage their health and that of their families. Women represent the fastest-growing segment of new Internet users, and nearly three-quarters of them have sought medical information online, compared to just half of men.

Last year doctors dropped by 14 percent as a resource used for information on health topics and medical conditions, while the Internet jumped by 9 percent. As a source of information about what health services are available in the market, the Internet jumped from 7 percent to 20 percent over a two-year period.

So don't wait for women to come to you. Reach out with email to inform them, educate them and let them know what services and physicians you have to offer along with information about how to manage their family's health.

Years ago physicians resented it when their patients would bring up medical information that came from other sources. Women, in particular, who brought up things that they had read or heard often were chastised by their doctor. Today that attitude has changed. Physicians, for the most part, will work with the information a patient brings to the table, and that's a good thing, because women have become much more assertive in their relationships with physicians. They will no longer tolerate a non-collaborative approach.

So by recognizing that women need to be approached differently in your healthcare marketing efforts, you are accomplishing two worthy goals. Not only are you ensuring your organization's effectiveness, but you are also helping women better manage their health and that of their loved ones.

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What is Medicare's position on faxed signatures? Are they an official authorization of treatment plans?

Medicare does not generally accept faxed signatures as "official authorization" for initial prescriptions or authorization of treatment plans, says Nancy Beckley, MS, president of the Bloomingdale Consulting Group in Brandon, FL. However, the government gives you some latitude on the length of time you can take to acquire signatures. You can begin treatment for Medicare patients in the absence of a physician authorization on the plan of care, as long as the physician signs the form in a reasonable period (in other words, as soon as possible). After you receive a faxed authorization, continue to follow up and collect the original signature within the next week, says Beckley. Check with your local Medicare carrier or fiscal intermediary for further clarification. If you are having trouble finding a contact person, go to http://www.lmrp.net and search for the appropriate local medical review policy.

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RISK MANAGEMENT IN A CAPSULE

The "Big A" and the "25 C's"

A. The "Big A" is ANTICIPATE

Anticipate what could go wrong with medical therapy or an operation. Be sure the patient is informed and be prepared to take care of any complication. Avoid surprises and lack of preparation.

B. The "25 C's"

1. Competence

The sine qua non of quality medical care is a competent physician acting in the patient's best interest.

2. Communication

Effective communication skills enhance the doctor-patient relationship and decrease the risk of a suit if treatment results are not optimal. If the patient gets a complication, communication is especially important. Never let the patient believe he or she was abandoned even if the patient was referred to another physician for treatment of the complication.

3. Consent

"Alleged failure to obtain informed consent continues to occupy a high position on the medical-legal hit parade of recurrent themes that result in litigation. A very specific communication must occur between the physician and the patient before the physician can treat the patient. That communication must result in proper informed consent, namely, adequate disclosure, if the treatment is to start. MORE INFO>>>

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Patient Discount Programs: How To Make Sure They're Legal.
A clinic that's part of the Orlando (FL) Regional Health System offers patients a 40% discount when they pay in full at the time of service, and a 25% discount to patients who pay half on the date of service and agree to pay the rest over three months, according to Stuart Showalter, JD, MFS, director of compliance for the health system.

Here are four tips from Showalter on offering discounts in compliance with federal and state laws:

• Offer discounts to self-pay patients only.
• Don't offer cash discounts to insured patients without reducing the amount billed to the insurance company.
• If you offer discounts to privately insured patients, it may decrease the amount insurance companies will pay for services.
• The amount you can claim as a "customary charge" for a service might change if you offer discounts to a fixed number of patients. This will lower your revenues.

Late Again: Dealing with Employees Who Are Never on Time

Tardy employees can impact your business' overall productivity, delay and frustrate customers who wind up waiting for service, and even decrease the morale of on-time employees.

Yet besides watching the clock, what can you do to encourage habitually late employees to arrive on time and ready-to-go?

Is it really a problem?
"Many good, hardworking people have a tendency to be habitually late" say experts at Businesstown.com. So, "unless being precisely on time is crucially important, don't bring up the issue with an employee who is occasionally late."

To determine if an employee's tardiness is a problem, ask yourself the following questions:
Is the person more than five to ten minutes late several times a month? If you answer yes, tackle the problem.

By being late does this employee put your business or others at risk? If you answer yes, address the issue.

Have other employees brought the person's tardiness to your attention, saying they don't think it's fair that you have different, more lenient expectations of the tardy employee? If you answer yes, deal with the matter.

Does the person make up the time at the other end of the day by working late at night or at the end of the shift? If you answer yes to this question, you may choose to turn a blind eye to the employee's tardiness. Answering no, however, suggests that it's time to confront the situation.

Is the person an overall good employee who regularly meets deadlines, provides excellent customer service, and gets along well with other employees? If you answer yes to this question, you may decide to ignore the employee's late arrivals. However, the tardiness should be addressed if you answer no.

Addressing the issue
Start with a friendly, but firm chat. Remember if you ignore the person's tardiness, the employee may conclude that being punctual is neither important nor required.

During this talk, make it clear that you are generally pleased with the person's job performance, but starting immediately you need to see this person arriving on time. Also mention how the employee's lateness effects the business or the rest of the staff. "For example, explain how another worker was unable to get coverage for a break, or how fellow staff had to work extra hard unloading a truck because the employee wasn't there when expected."

Then, expect to see some immediate results. According to Businesstown.com, "virtually all tardiness problems will disappear after a gentle talk."

If the problem should resurface after several weeks or months of a turnaround, remind the employee of how important it is to be on time. Let the person know that his on-time arrivals have impressed you and that you'd like to see that punctuality again.

During these chats, ask the employee if there's anything that you can do to help prevent tardiness. Examples of how you might help include:

If the employee works shifts that change regularly, maybe you need to post the work schedule in a clearer fashion. Consider an erasable scheduling board, which allows you to make updates without cross-outs that make the schedule hard to read.

Maybe the employee has family issues and would like to discuss working a flexible schedule, such as 9:30 to 6 instead of 8:30 to 5.

Document the problem
If your gentle talk and reminders don't do the trick, begin documenting the employee's tardiness. If your staff punches in using a time clock, tracking the person's arrival time should be easy. Most time clocks print the date and the exact punch-in time, down to the minute (e.g. JAN 31 AM 9:42).

If your staff does not punch a clock, note what time the employee arrives each day and log it manually. This way, the next time you address the problem, you'll be able to say accurately, 'eight times this month you were more than 30 minutes late, five other times you were 15 minutes late.'

Consider using a log book. As these books have ruled pages, you can create one page per employee and takes notes all year. This system will help you track the tardy employee's arrival times. Plus, you'll have notes on all of your employees that will help you organize your thoughts during annual performance reviews.

Disciplining the employee
The tardiness may reach a point where you have no choice but to discipline the employee. You might choose to take away some of the employee's responsibilities, expect the employee to make up the lost time, require them to participate in a performance improvement program, or place them on probation. In some cases, depending on the person's job, labor laws, or union agreements, you may even be able to dock the employee's pay.

If done incorrectly, disciplining employees could have serious legal ramifications; consult a lawyer before reprimanding the employee or deducting missed time from the employee's paycheck.

Set a good example

Finally, remember that your employees will take their lead from you - if you routinely arrive late, they may follow suit.

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September 3, 2002 To: HBMA From: Bill Finerfrock & Joshua Beail-Farkas Capitol Associates Re: Office of Inspector General (OIG) special advisory bulletin on furnishing inducements to Medicare and Medicaid beneficiaries On August 30, the Office of Inspector General published guidelines for furnishing inducements to Medicare and Medicaid beneficiaries. In summary the memo states that the OIG will interpret section 1128A(a)(5) of HIPPA, which prohibits giving remuneration to Medicare and Medicaid patients in order to encourage them to select certain providers, in the following ways: 1. Medicare and Medicaid providers may provide to beneficiaries inexpensive gifts (value not to exceed $10 per gift and $50 annually per patient) as long as they are not cash or cash equivalents. 2. Providers may offer beneficiaries more expensive items or services that fit within one of the five statutory exceptions: waivers of cost-sharing amounts based on financial need; properly disclosed co-payment differentials in health plans; incentives to promote the delivery of certain preventive care services; any practice permitted under the federal anti-kickback statute; or waivers of hospital outpatient co-payments in excess of the minimum co-payment amounts. 3. The OIG is considering several additional regulatory exceptions. The OIG may solicit public comments on additional exceptions for complimentary local transportation and for free goods in connection with participation in certain clinical studies, particularly certain ones sponsored by the NIH . 4. The OIG will still entertain requests for advisory opinions related to the prohibition on inducements to beneficiaries, but suggests that they be limited to situations involving conduct that is very close to existing statutory or regulatory exception. Additionally the memo stresses that it is still acceptable for independent entities to provide valuable services or remuneration so long as the independent entity makes an independent determination of need and the beneficiary's receipt of remuneration does not depend, directly or indirectly, on the beneficiary's use of any particular provider. The special advisory bulletin itself can be accessed by clicking on the link below or copying and pasting the link to your browser address: http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=2002_register&docid=02-22124-filed

THERE'S NO CRYING IN TERMINATION

In rare instances, an employee may have done something so bad as to warrant immediate, unanticipated dismissal. Otherwise, your employees ought to be aware of their deficiencies by way of your organization's performance and disciplinary review procedures, according to Barbara Eberly, information technology manager for the Central Penn Management Group in south central Pennsylvania.

Give employees three reprimands before termination, except in rare circumstances. Describe in the first written reprimand notice how the employee has failed to meet expectations and do what you have asked. Base the expectations on the employee's job description. List the changes necessary for the employee to improve and give a deadline for accomplishing these goals, Eberly says. "Both the supervisor and the employee should sign the reprimand notice," she adds. "If the employee refuses to sign, the supervisor should sign the reprimand and indicate that the employee refused."
A supervisor may ask another supervisor, office administrator, or physician to witness these reprimand signings, according to the policy of an orthopedic clinic in Boston. Witnesses, adds Eberly, should mediate when necessary and provide additional evidence that you followed proper procedures. The witnesses should sign all documentation, as well.

GRIEVANCE PROCEDURES PREVENT COSTLY EMPLOYEE LAWSUITS

The grievance process allow s employees and managers to solve small problems before they mushroom into big ones. And by big, we mean employee lawsuits that have been on the rise since the late 1990s. Put your grievance procedure in writing so that employees have no reason to doubt the steps they can take when a problem arises, according to Barbara Eberly, information technologies manager at the Central Penn Management Group in Lancaster, PA. Create reporting procedures for employees who feel wronged, she says.

Encourage employees to resolve problems using these steps:

• Confront other staff members involved

• Report to first-line supervisor

• Report to practice manager

• Report to physician or director and compliance officer

Supervisors should do the following for each problem:

• Promptly, thoroughly, and confidentially investigate complaints

• Carefully document investigation findings

• Take appropriate actions to resolve complaints

• Implement measures to prevent future incidents

Include a statement in your procedure that indicates an employee does not risk termination for reporting alleged employment law violations, workplace safety hazards, harassment, and fraud and abuse issues, says Eberly. List the proper reporting entities, such as local police, in your employee and practice manuals.

CONTROLLING LEGAL RISK, Does Your Staff Know How to Prevent Lawsuits?

Malpractice Suits Often Start With Poor Communication

Really, asks Florida malpractice insurance agent Matt Gracey, Jr.,did listening to your umpteenth attorney presentation on malpractice risk inspire you to dramatically improve your clinical documentation? He suggests spending some time and effort on another -- often untapped -- resource for reducing your malpractice risk: educating your support staff.

Staffers Want to Know

Your employees want to know the proper way to handle difficult situations -- like negative patient encounters that could escalate to legal action. If you give your staffers a safe environment to discuss issues, Gracey says the depth and breadth of their questions will amaze you. First, educate your support team regarding four key issues:

Documentation

Insist that staffers keep track of their communication with patients, especially when things go wrong.[2] Provide them with tools and instructions about noting phone and personal conversations.

Confidentiality

More than just complying with new HIPAA regulations, stress your commitment to protecting the privacy and dignity of each patient

Positive Communication Techniques

Consider bringing in an expert in customer relations and communication to lead an in-house seminar on good phone and personal courtesy

Handling Disgruntled Patients

Again, an outside instructor can help your staff learn how to defuse a volatile situation.

Beyond the Basics

Set up clear protocols about taking messages from patients. Create a customized message form with blanks for the basic information needed to serve your patients well. Teach staffers to recognize indications requiring your immediate personal involvement. Help them distinguish real emergencies.
Encourage and empower staffers to handle situations -- but help them understand their limitations. Gracey points out that malpractice cases commonly evolve from an over-confident staffer acting out of turn. In fact, instruct your team to invoke your "presence" in nearly every patient contact. For example, have them pass along instructions to patients with a phrase like, "the doctor would like you to..." Language like that reminds patients of your personal care and concern. Besides, patients don't want to know what the receptionist or medical assistant thinks -- they've come to you for your authoritative knowledge and skills.

Help staffers understand how their attitudes and behaviors reflect directly on the physician(s). If your own employees criticize or disrespect you, it can erode patients' confidence in you and make it difficult for you to establish and maintain your authoritative advice and treatment.

Free Help

Teaching your staff how to communicate more effectively pays off double: Not only can you reduce your malpractice risk, but you also improve patient satisfaction. And you might realize yet another bonus in improved office morale. Well-trained staffers who feel they can act in a professional manner feel more pride in their work and in their employer.
Your malpractice carrier can help you by conducting a professional liability risk assessment in your office. Most likely it will have resources for training your staffers -- perhaps even providing in-office instruction in these key risk-management areas.

ARE YOUR INJECTION PRICES TOO HIGH?

1. You are probably not charging enough if your carrier accepts your full fee.

2. Check the codes and units if you're making what you suspect could be an unfair amount on injections. "You may be filing fraudulent claims,"

3. Determine injectibles by multiplying the cost of the drug according to the following figures:

When the drug costs * less than $5, charge four times the amount *

$5 to $10, charge three times the amount *

$11 to $20, charge two times the amount *

$20 plus, charge one-and-a-half times the amount

An example: A shot costs the physician $2.40. Multiply that times four; the charge is $9.60. "It comes down to what is a fair amount, and what seems fishy," says Sandra Stiles, a private health care consultant in Chicago. Never determine your fees on what you think Medicare will allow, she says. "Every single time that I've seen practices do this it's because the doctor didn't want a bunch of write-offs." Doctors, he says, often undercharge, and get much less than what the carrier is willing to pay. The Centers for Medicare & Medicaid Services (CMS) may look into limiting physician profits on Lupon, according to Barbara Cobuzzi, CPC, president of Cash Flow Solutions, Inc. in northern New Jersey. She says Medicare set Lupron's reimbursement level too high. Registered nurse William Criteser, supervisor at an Oregon clinical review company, says oncologists and urologists will get burned on chemotherapy drugs now that Medicare has identified the pricing problems. "Entire oncologist practices have been supported by the markup on chemo drugs," Criteser says. "Markups over 1000% in some cases. These practices have hurt the process."

PHYSICIAN GROUPS CALL FOR END TO HIPAA'S BIZ ASSOCIATE RULES

Doctors' offices and other providers should not have to clean up the mess left by their business associates, according to one of several proposals a group of physician organizations outlined in a March 5 letter to Department of Health and Human Services (HHS) Secretary Tommy Thompson. If
the agency is not willing to eliminate the business associate provisions from the final privacy rule, it should amend them, the letter said.

Go to http://www.hipaapro.com/content.cfm?content_id=20681 to read the letter.

Letter authors urged HHS to limit a provider's responsibility when its business associates violate contract rules. According to Michigan law firm Wachler & Associates, ask your business associates these questions before you rework your contracts:

• How do you plan to limit the use and disclosure of protected health information by your subcontractors and agents?

• Do you have an education program for the privacy and security regulations? Who is giving it, when, and what is the substance of the training?

Making Your Practice's First Impression a Positive One

Debra C. Cascardo [Medscape Money & Medicine, 2000. © 2000 Medscape, Inc.]

Don't overlook the importance of a friendly, efficient check-in and check-out system.

Checking patients in and out of their appointments in a friendly and efficient way is a complex process that leaves a deep impression - for better or worse - of your medical practice. Because first impressions are often lasting ones, leaving this process up to chance is not a risk you want to take.

This column will review the key steps you and your staff should take to ensure that all patients get courteous and efficient service from the moment they walk in the door until they pay for their services.

When patients enter your office, are they seeing the image of your practice you want to convey?

If not, educate your staff about the specific image you want to convey and provide the standards to support it. By establishing high standards, you eliminate mixed messages patients might get if they see another patient getting more personal attention or courteous, discrete service. While all office staff has a role to pay in achieving high standards, the office receptionist is the first contact a patient makes when he walks through the door. Her efforts to maintain those standards need to be supported by the rest of the office team.

Best Foot Forward

A clean, well-organized front desk and reception area will go a long way toward creating a positive impression and making patients feel comfortable. Make sure the area is clean and comfortable, with small amenities such as those described in last month's column.

Desks and work areas visible to patients should be neat and organized. Establish rules about eating and drinking in the reception area. Ensure that confidential phone calls to insurance companies by your billing personnel be made outside of earshot of the waiting room.

The front desk should be configured to help the receptionist efficiently perform her duties. For example, have a copy machine available to copy insurance cards, driver's licenses, and referral or pre-authorization information. Some practices let receptionists lose valuable time by requiring them to walk to the back office to perform these simple tasks.

Also, consider using "cheat sheets" to assist staff in answering questions about insurance co-pays, hospital/lab phone numbers or directions to your office. The station responsible for collecting payments should have a cash drawer and credit card machine available.

A good receptionist has a demanding position that requires she courteously deal with difficult patients, scheduling delays and other problems. Making small improvements in the working conditions lets her know her skills are valued. For instance, consider providing a telephone headset that allows her to handle calls and appointment changes without getting a crick in the neck.

Getting Ready for the Day

Staff should arrive at the office before the first scheduled appointment. This is a good time to hold an informal staff meeting to discuss the upcoming day's appointments, open slots, potential problems, special meetings, as well as reviewing the previous night's hospital admissions and emergency calls.

Charts should have been pulled or created for new patients the night before or prior to the day's first appointment. A list of the scheduled patients and appointment times should be prepared and ready for the receptionist as each patient arrives.

All staff should be at their desks 15 minutes before the first scheduled appointment. The front desk staff should be ready to turn their undivided attention to the first patient as he or she opens the door.

Greeting and Preparing Patients

A friendly, attentive receptionist can reduce the anxiety of a doctor's appointment. Does your receptionist make eye contact when speaking with patients? Does she listen and respond rather than spout rote phrases? Standard scripts can be helpful in ensuring that office policies are followed, but they must be flexible to accommodate individual situations.

Assuming a list of the day's patients has been prepared, the receptionist should know who is expected and be able to greet each patient by name. For new patients, an appropriate greeting could be: "Hello, you must be Mrs. Smith. I'm Debra; we spoke on the phone. It's a pleasure to meet you. The doctor will be with you in a few minutes. Please make yourself comfortable in the reception area." Greeting the patient personally is preferable to a sign that says, "Sign in Please. "

To assure confidentiality, patients should be signed in on a list that's kept next to the receptionist instead of on the counter. Patients requiring special assistance should be escorted to a seat in the reception area and then to the examination room.

New patients should be pre-qualified during the appointment scheduling and reminder calls. Before the patient arrives at the office, you should know what type of insurance coverage he has; whether you are a participating provider in that plan, and if your practice provides the services needed. All such information should be in the patient's chart and verified upon arrival.

For established patients, the receptionist should verify the patient's address, employer and insurance plan. It is better to ask the patient to provide this information to assure they don't assume that "everything is the same." Check-in is the best time to update a patient's account. This is also the last opportunity for specialists to obtain the patient's referral and/or authorization form.

Whether a practice collects co-payments and deductibles at check-in and check-out depends on the practice's philosophy and type of services offered. For all practices, however, it is important that the patient be aware that payments for which the patient is responsible are expected at the time of the visit

The Last Impression

Checking out also provides an important impression for patients. Naturally, you want them to leave your office with a favorable impression of the practice.

If a follow-up appointment or referral letter is needed, handle it immediately. If the patient will be sent to the hospital or lab for tests, provide directions and a phone number as well as the appropriate form. If necessary, make the appointment for the patient.

The receptionist should know the co-payment, deductible and other fees due for the visit and politely request that payment. Here's a courteous way to phrase that request: "Mrs. Smith, your co-payment for today's visit is $20 -- $10 for the visit and $10 for the strep test. Will you be paying by cash, check or credit card today?" If the patient has forgotten her checkbook, provide a stamped, self-addressed envelope so that the check can be mailed as soon as she arrives home. By not expecting appropriate payment for your services, you are implying to the patient that your knowledge, skill and care are not worth the fee you are charging.

Before the patient leaves, ask if there is anything else you can do. Conclude the visit by thanking the patient and, if appropriate, relaying your concern for his or her well-being. ("Thank you. I hope you'll be feeling better soon.")

Because the check-in and check-out process have so many components, you will need to modify your procedures from time to time. Regularly schedule discussions at your staff meeting about how to handle a difficult patient; resolve scheduling problems, adapt to changes in insurance information; physician delays, and the like. As new problems arise, the entire staff can work on providing a solution.

My upcoming column will address the federal government's new guidelines to help solo and small group practices stay clear of Medicare fraud and abuse. Contact me at the address below with questions or suggestions for future column topics.

Debra C. Cascardo, MA, MPA, is the principal of the Cascardo Consulting Group in New York.

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