Customer Service in your Medical Practice: Attitude Is Everything

There truly may not be enough words in the English language to sum up the importance of attitude at your medical practice. It is a topic so broad, that it will even be difficult to sum up in this post. To narrow this down, the easiest place to start is by working your attitude into your customer service model.

A great attitude in customer service can be very simple: Choose to be thankful for every patient that walks through your door, whether you are the receptionist, the nurse, the medical assistant, the doctor, office manager, or bill collector. You must thank every person that comes in for choosing your medical practice. Let them know that you are grateful that they are there.

This can be fairly easy to integrate into appointment scheduling, telephone answering check-in, and check out. Simply thanking a patient for calling, stopping by, and/or arriving on time should be habit from day one (and should be a part of an interview with a new staff member and orientation). A simple change of your greeting on the phone to “Thank you for calling XYZ Family Medicine, how may I help you?” can start the conversation off in a positive manner and begin laying the path for the patient (aka customer) to feel like they are in good hands.

Where things get tricky is thanking the patient that arrived late. A simple and sincere “Thank you for making it in” after they explain what happened or in the course of letting them know they will need to reschedule can help ease an otherwise uneasy situation. Sincerity is key in the delivery.

You can continue your attitude of gratitude and great customer service by having the staff member (usually the nurse/medical assistant) that brings the patient to their exam room and starts their assessment by phrasing their initial statement, “Thanks for coming in today, I understand you are here for …” and certainly in the instance of running off schedule — “Thank you for your patience Ms. Smith, I apologize we are running a little behind schedule.”

This same positive, smiling, thankful attitude should follow the patient all the way to the checkout desk where they make payment and schedule their appointment. You should thank patients again for coming in, thank them again for their patience if they have had to wait, and certainly thank them for making their payment and scheduling another appointment.

In your attitude adjustment to thankfulness, please don’t grovel or beg, and it can be a fine line. Desperation will make your patients uncomfortable; even if you are, is not the right attitude to project — it turns patients off and makes them uncomfortable.

Try these suggestions on for size in your practice. Attitude is contagious, so pass around your fantastic attitude to your co-workers, staff, and patients. Please understand the depth of attitude — you choose your attitude every moment, and the simple tool of choosing to change to an attitude of thankfulness, of gratitude, is life changing and will transform your business. Once you and your staff have mastered the art, there will be no stopping the successes personally and professionally that comes your way.

Approximately 7 out of 10 clinics I consult with aren’t saying thank you to their patients, at all. How does your clinic stack up?

Find out more about Audrey "Christie" McLaughlin and our other Practice Notes bloggers.

View the original article here

Avoiding Embezzlement at Your Medical Practice

Medical practices work hard to earn and collect payment for services. So physicians need to devote at least some energy to defending themselves from employee dishonesty. Developing an eye for potential embezzlers can be a good place to start.

Why does someone steal from an employer?

Some people steal because they are in desperate need of money. Others grab a little cash from the drawer because they need it for the weekend. Some are disgruntled and feel wronged — either by compensation they think is too low or what they perceive as unfair treatment. Their theft at least starts out as an attempt at equity. The hardest reason to understand is entertainment: It is just fun and exciting.

How does it start?

Embezzlement starts small. The thief identifies an opportunity and exploits it. With time and lack of detection, the aggregate amount of the theft grows, and the thief becomes bolder.

Experts say that employee theft is rarely, if ever, discovered before it has gone on for some time.

Red Flags

Here are a few strong indications that a physician needs to be concerned about possible embezzlement:

1. It is a medical office.

In 2010, the Medical Group Management Association published the results of a survey in which 83 percent of the respondents reported being a victim of employee theft. More than 18 percent of the respondents reported experiencing a theft in excess of $100,000.
Medical offices are prime targets because they are small and it is more difficult to separate duties related to financial transactions. The problem is exacerbated because physicians tend not to be familiar with or interested in standard financial practices that can mitigate the risk of employee theft.

2. Patients are complaining about errors in their accounts.

Numerous patient complaints that payments were not credited to their accounts is the most common symptom associated with embezzlement.

3. Some or all of the staff has been with the practice a long time. They are just like family.

Embezzlement requires trust. If a person is not trusted, the opportunities to steal are severely limited.

4. An employee is completely devoted. She does not want to inconvenience anyone, so she comes early, stays late, and continues to do some of her work even when she is on vacation.

There is a reason the FDIC recommends to banks that "active officers and employees be absent from their duties for an uninterrupted period of not less than two consecutive weeks" and the absent individual's duties performed by someone else. "Embezzlement of any substantial size usually requires the constant presence of the embezzler in order to manipulate records, respond to inquiries from customers or other employees, and otherwise prevent detection."

NOTE: Strictly enforced rotation of duties can achieve the same objective as the uninterrupted two-week absence from duties.

5. An insurance company is withholding payment for an extended period of time and a significant sum of money.

A prospect once complained to me that an insurance company was holding up over $100,000 of payments for no good reason. The billing manager was in constant contact with them and could never get a better response than "The check is in the mail." I offered to look into the situation. The physician agreed. The billing manager initially agreed, but called me later to cancel. When I asked the physician, she told me the billing manager did not think I would be able to find anything. See #3 above.

6. An employee clearly does not need the money, but she is at work every day and is one of the best employees in the office.

Many people work for the sheer joy of it, but it is only prudent to be concerned about employees who appear to be living well above their means. It is also prudent to be somewhat skeptical about stories of "family money."

Next week, we will look at controls that can be put in place to discourage embezzlement in the first place and detect it more quickly if it does occur.

Find out more about Carol Stryker and our other Practice Notes bloggers.

View the original article here

The Impact of RACs on Your Medical Practice

Please sit down — this will not be an easy article to digest, no matter how carefully I parse my words. Life under the microscope of Recovery Audit Contractors is going to get tougher for physicians. Three recent developments may impact your practice in the next year.

I have written in the past on RACs and documented their growth from a twinkle in Uncle Sam's eye to the behemoths they have become. Much of the advice offered in prior articles (please see links at the bottom of this article) remains valid and should be heeded.

Audits of Level 5 E&M services

CMS has given approval to Connelly, the Region C RAC, to perform complex medical reviews on level 5, E&M services (e.g., 99215, 99205, and 99255). This is the first time CMS has given any RAC permission to target the coding and documentation of E&M services. One impetus for the focus on level 5 E&M services is a shift in providers' use of level 4 and 5 codes. According to the Center for Public Integrity, the percentage of Medicare services coded as level 4 or level 5 increased from 25 percent to 40 percent between 2001 and 2010. This, of course, has increased CMS's financial outlay for these services and made them a much larger budget item (i.e., target).

Connelly is the RAC for thirteen states: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia. Take note: the other three RACs are expected to follow suit.

Since early 2009, the Medical Group Management Association, AMA, and 101 state and specialty societies have actively opposed RAC audits. It is unfortunate for all of us that CMS has not heeded their advice.

There is yet another cause for concern with this initiative. Though it has not been officially confirmed, CMS apparently has given Connelly permission to extrapolate the results of their E&M audits. For instance, if a RAC audit determined that six of twenty (30 percent) level 5 services did not meet coding/documentation guidelines, the RAC would have authority to extrapolate this 30 percent failure rate across all level 5 services provided during the review period.

If you provide level 5 services, it is prudent to have several of them copiously reviewed by a certified professional coder.

9th Circuit Court of Appeals verdict

On September 11, 2012, the U.S. Court of Appeals for the Ninth Circuit rendered a dangerous opinion. It affirmed that RACs are not restricted by regulatory deadlines, statutes of limitations, or time limits. Lead plaintiff attorney Ronald S. Connelly, of Power Pyles Sutter & Verville PC, says "The decision leaves providers with absolutely no finality in their payments from the Medicare program. Contractors could reopen claims that are even 10 or 20 years old, and providers would have no right to challenge the timeliness of the audit."

Legal minds will weigh in on this opinion in the weeks and months to follow, but again, a scary precedent has been set. It may mean that Medicare patient and billing records should be maintained indefinitely. At a minimum, it means the past is neither safe nor sacred.

I recommend you contact your medical malpractice insurance carrier to determine if this circuit court opinion will change their recommendations for records retention.

EHR automated notes

Last but not least, the HHS's Office of Inspector General has set its focus on whether providers are using automated note generation appropriately in their EHRs. Also known as "cloned notes," automated notes and templates use copied and pasted data on multiple patients to record standard information such as a normal review of systems or physical exam.

An observer reviewing several such notes would find virtually identical documentation and very little patient-specific information. Herein lies the OIG's concern. They are concerned that cloned notes may lead to over-documentation or a lack of patient-specific information. From a medical malpractice liability perspective, the same concerns apply.

There is a place for structured notes, and many physicians used them prior to the advent of EHRs. These are acceptable, and EHR-generated notes that contain patient specific documentation should be good to go as well. Your risk lies in over-cloning identical text in your patient notes.

In summary

The United States Department of Justice (DOJ) has three top priorities:

• Terrorism
• Violent crimes
• Healthcare fraud

I wish healthcare fraud were not on this list, but it is, and it is not dropping off the list anytime soon. Government oversight and second-guessing are givens for anyone who practices medicine today; expect fraud identification and enforcement initiatives to grow.

To get a head start on audit-proofing your practice, read the following articles that offer advice and practical tips for protecting both yourself and your practice:

• Avoid Medicare Fraud Claims by Coding Correctly

• Medicare's Fraud and Abuse Program

• Nine Things to Know About RACs

Lucien W. Roberts, III, MHA, FACMPE, is vice president of Pulse Systems, Inc., and a former practice administrator. For the past 20 years, he has worked in and consulted with physician practices in areas such as compliance, physician compensation, negotiations, strategic planning, and billing/collections. He can be reached at lroberts@pulseinc.com.

View the original article here

Using Positive Patient Reviews on Your Medical Practice Website

An online search for "reputation management" yields 62 million results, including a dozen paid ads for services.

The paid ads on Google point to the profitability and popularity of reputation management services.

Reputation management in 2012 involves monitoring the online presence of a company. This could mean looking at social networks, discussion forum comments, and generally tracking who’s saying what about your practice.

It also includes the more active function of responding to negative comments, posting content like blog posts, and managing patient reviews.

Actively soliciting reviews and ratings from patients is a vital function of these services. The good news is, you can do this yourself if you make a habit of it.

Whether you hire someone to get patients to review you online or you do it yourself, here are a few ways to further leverage positive reviews from satisfied patients.

1. Post them on your own website

Create a separate page on your practice website for patient comments. You can label the page "Patient Comments" or "What Patients Are Saying."

Whether you get the comments from online or offline sources, make sure you respect the level of privacy or anonymity of the patient’s review.

Some patients put their full name in their review; others leave it totally anonymously.

Use the whole comment, break it up into paragraphs, or just post an excerpt.

2. Ask permission for future use

Before you try the technique in number 1 above, it’s better to get permission from the patient.

Be explicit when you ask!

Ask if you can include their full name, city, state, occupation, and even a picture. You won’t know until you ask.

If patients are genuinely excited about their experience, they don’t mind sharing some or all of these things. Give patients some idea of how the comments will be used — in print ads, online, or in the office.

3. Ask patients for multiple reviews

One of my patients recently posted her comments and reviews on two separate ratings websites.

All I did was ask her to visit an extra site when she left the comments.

Another way to get reviews in multiple locations is to let patients know they can just leave a quick "star" rating, like at Healthgrades.com. This takes a few minutes and doesn’t require writing a paragraph of comments.

4. Mix reviews with patient education

Imagine you’re a patient looking for information on eczema treatments.

You look at a local dermatologist’s website and read patient education articles on the subject.

Wouldn’t it be powerful if you read a testimonial from an eczema patient in the body of the article? Of course!

Try putting excerpts of patient reviews in your patient education articles.

Even if that particular patient had some other problem, it helps patients to see that other people are happy with your office as they’re reading about conditions and problems they have.

5. Let your patient know what’s next

Finally, think of other ways you can get your happy patients involved in promoting your practice.

Patients who leave positive reviews, especially in multiple places, are bona fide raging fans. They are usually willing to spread the word about you in other ways, too.

After they’ve left a review, let them know you may ask them to do a video review in the future, contact them for a media interview, or let other patients call or e-mail them if they have questions.

If you’re just getting started, I’ve written some guidelines on how to pick patients to review and rate your practice.

Find out more about C. Noel Henley and our other Practice Notes bloggers.

View the original article here

Telemedicine: How It Can Work for Your Medical Practice

As a child, I never dreamed I would be able to communicate with a person several thousand miles away while looking at their face via video. Now, we can not only communicate via video with our family and friends, we can receive medical treatment from our providers.

Telemedicine is here and being utilized. Though there are some uncertainties regarding if, how, or when private payers are going to cover telemedicine, Medicare and Medicaid programs are utilizing the advances in technology to assist in treating our rural communities.

Medicaid coverage and eligibility varies by state. However, Medicare is clear on their coverage and position. Medicare does consider a telecommunications system to substitute for a face-to-face encounter in specifically allowed situations and areas.

Here's how it works:
• The Originating Site is considered to be the location of the Medicare beneficiary at the time the service is being furnished via telecommunications. This site must be located in a rural health professional shortage area (HPSA) or in a county outside of a Metropolitan Statistical Area (MSA).

• If you are located in an MSA, remember you can still participate by creating a relationship with a facility that is located outside of an MSA. These locations need qualified specialists to assist with their patients. Many times, patients living in rural communities need specialized care but do not have the means to travel. There are many opportunities for both sides.

• The Distant Site is considered to be the location where the practitioner is furnishing and receiving payments for the telehealth service. Eligible practitioners include:
o Physicians
o Nurse practitioners
o Physician assistants
o Nurse midwives
o Clinical nurse specialists
o Clinical psychologists/clinical social workers (cannot bill for CPT 90805, 90807, and 90809)
o Registered dietitians or nutrition professionals

• An interactive audio and video telecommunications system must be used that utilizes real-time communication (exceptions: Alaska and Hawaii).

• A few of the services covered by Medicare telehealth include:
o Consultations
o Office or other outpatient visits
o Individual psychotherapy
o Psychiatric diagnostic interview
o Follow-up inpatient telehealth consultations

• The distant provider submits the claim utilizing the same CPT/HCPCS codes they would normally with a modifier "GT" which alerts Medicare that it was a service provided via telemedicine (Alaska and Hawaii utilize the modifier "GQ").

• The originating site is allowed to bill for the service by utilizing the HCPCS code Q3014. The allowed reimbursement amount is minimal, but the ability to treat patients with a specialist who would not normally be available raises the quality of care level higher than ever before.

If your practice is interested in tapping into the telemedicine market, here are a few things to investigate and consider:

• Equipment can vary from a few hundred dollars to several hundred thousands of dollars.
o Webcam, computer & Facetime/Skype – this is the most cost effective process. The investment would range between $200 and $500.
o Mobile unit – $20,000 to $50,000
o Room unit – approximately $100,000

• Internet Connection - The key is being sure you have high speed Internet that will allow you to effectively communicate in a live environment, as well as an appropriate router with security functionalities.

• Licensure and Credentialing - Providers would need to be credentialed for the facility they are providing services.
• Medicare requires an 855I & 855R if the provider is located in another state.
• Other payers vary, so be sure to check before providing services.
States vary on licensures and would need to be investigated.

Other Considerations:

• Malpractice does vary and should be investigated.
• Policies and procedures should be developed to cover telemedicine processes, along with appropriate forms and consents.
• Staff would need to be trained on all policies, procedures, and best practices.
• Market opportunities with FQHCs, RHCs, hospitals and other providers with needs.

Even though at times the concept is hard to grasp, providers such as radiologists have been utilizing telemedicine for years just not in a live video environment. The sky is the limit to where the advances in technology are going to take the medical field. After all, 10 years ago who would believe we would be utilizing e-mail and the Internet to the magnitude we do today.

Find out more about Chastity Werner and our other Practice Notes bloggers.

View the original article here

Negotiating the Sale of Your Medical Practice

The sale of physician practices to hospitals continues at a steady pace. For those physicians currently considering an offer to acquire their medical practice (or who may consider it in the future), today’s blog will talk about some issues that require attention when negotiating the sale of your practice.

1. Make sure all the important points of your deal are captured in the Letter of Intent (LOI). Too often, my physician clients fail to take the time to negotiate the terms which are “deal breakers” at the LOI stage, only to find the hospital is unwilling to stray from the LOI when it’s time to draft the final documents. The LOI is the most important piece in determining whether the parties have a deal that both sides can live with. Make sure you bring legal counsel into the negotiation process as soon as you are presented with an LOI that the practice is willing to consider. When my clients call me after the LOI is already signed, there is little I can do to improve the deal or correct misunderstandings.

2. An LOI will usually have a provision that does not allow you to negotiate with other parties after the LOI is signed until the final documents are executed or a certain date is reached (and the parties have failed to consummate the transaction by such date). Physicians who are trying to play different potential buyers against each other for the best deal must understand they may no longer be permitted to “shop” the practice once the LOI is signed.

3. If a practice wants its employees to be treated a certain way once the practice is acquired, this expectation must be made clear to the buyer. This includes protecting staff from being reassigned to a different position or location or from being terminated following the sale. In addition, be sure you are familiar with your existing employment contracts. Even if the practice is going to be sold, the practice must honor the notice provisions (and other promises) in its existing contracts, particularly for those employees not being retained. When it comes to informing employees about the sale of practice, be strategic. Informing staff too soon can lead to anxiety and the departure of those who feel uncertain of their future. A meeting with staff once it seems that a deal is likely is advisable. Sharing information and providing assurances can go a long way to preserve your best employees.

4. Electronic health records are an issue often overlooked at the LOI stage; however, if the practice acquired its own EHR which is still not fully paid for, and the practice will be unable to use it following the sale, this issue must be addressed. The hospital may be unwilling or unable to cover the additional cost of the unusable EHR and the debt must be addressed with counsel to see if it impacts the ability to complete the transaction.

A related issue can arise if the EHR is tied to a hospital/system other than the one which has made the offer to acquire the practice. It may be necessary to coordinate the transfer of electronic information from the old EHR to the hospital-buyer and avoid potential gaps in access to information. Not surprisingly, cooperation from the non-purchasing hospital is often not forthcoming.

5. If your practice will collect its own accounts receivable following closing, be sure you understand how this will be accomplished. Most hospitals are not willing to allow their staff (your old employees) to collect the old accounts receivable during work hours. Often a hospital buyer will agree to collect accounts receivable on behalf of the practice (based on a percentage of collections) or will allow the practice to pay hourly for use of the staff. This is something that should be discussed at the LOI stage.

In my next blog I will cover some of the compensation, covenant, and termination issues that should be addressed in negotiating to sell your practice. If you have particular questions about the process that you would like to see answered, please let me know!

Find out more about Ericka Adler and our other Practice Notes bloggers.

View the original article here

Avoiding Embezzlement at Your Medical Practice

Medical practices work hard to earn and collect payment for services. So physicians need to devote at least some energy to defending themselves from employee dishonesty. Developing an eye for potential embezzlers can be a good place to start.

Why does someone steal from an employer?

Some people steal because they are in desperate need of money. Others grab a little cash from the drawer because they need it for the weekend. Some are disgruntled and feel wronged — either by compensation they think is too low or what they perceive as unfair treatment. Their theft at least starts out as an attempt at equity. The hardest reason to understand is entertainment: It is just fun and exciting.

How does it start?

Embezzlement starts small. The thief identifies an opportunity and exploits it. With time and lack of detection, the aggregate amount of the theft grows, and the thief becomes bolder.

Experts say that employee theft is rarely, if ever, discovered before it has gone on for some time.

Red Flags

Here are a few strong indications that a physician needs to be concerned about possible embezzlement:

1. It is a medical office.

In 2010, the Medical Group Management Association published the results of a survey in which 83 percent of the respondents reported being a victim of employee theft. More than 18 percent of the respondents reported experiencing a theft in excess of $100,000.
Medical offices are prime targets because they are small and it is more difficult to separate duties related to financial transactions. The problem is exacerbated because physicians tend not to be familiar with or interested in standard financial practices that can mitigate the risk of employee theft.

2. Patients are complaining about errors in their accounts.

Numerous patient complaints that payments were not credited to their accounts is the most common symptom associated with embezzlement.

3. Some or all of the staff has been with the practice a long time. They are just like family.

Embezzlement requires trust. If a person is not trusted, the opportunities to steal are severely limited.

4. An employee is completely devoted. She does not want to inconvenience anyone, so she comes early, stays late, and continues to do some of her work even when she is on vacation.

There is a reason the FDIC recommends to banks that "active officers and employees be absent from their duties for an uninterrupted period of not less than two consecutive weeks" and the absent individual's duties performed by someone else. "Embezzlement of any substantial size usually requires the constant presence of the embezzler in order to manipulate records, respond to inquiries from customers or other employees, and otherwise prevent detection."

NOTE: Strictly enforced rotation of duties can achieve the same objective as the uninterrupted two-week absence from duties.

5. An insurance company is withholding payment for an extended period of time and a significant sum of money.

A prospect once complained to me that an insurance company was holding up over $100,000 of payments for no good reason. The billing manager was in constant contact with them and could never get a better response than "The check is in the mail." I offered to look into the situation. The physician agreed. The billing manager initially agreed, but called me later to cancel. When I asked the physician, she told me the billing manager did not think I would be able to find anything. See #3 above.

6. An employee clearly does not need the money, but she is at work every day and is one of the best employees in the office.

Many people work for the sheer joy of it, but it is only prudent to be concerned about employees who appear to be living well above their means. It is also prudent to be somewhat skeptical about stories of "family money."

Next week, we will look at controls that can be put in place to discourage embezzlement in the first place and detect it more quickly if it does occur.

Find out more about Carol Stryker and our other Practice Notes bloggers.

View the original article here

Negotiating the Sale of Your Medical Practice

The sale of physician practices to hospitals continues at a steady pace. For those physicians currently considering an offer to acquire their medical practice (or who may consider it in the future), today’s blog will talk about some issues that require attention when negotiating the sale of your practice.

1. Make sure all the important points of your deal are captured in the Letter of Intent (LOI). Too often, my physician clients fail to take the time to negotiate the terms which are “deal breakers” at the LOI stage, only to find the hospital is unwilling to stray from the LOI when it’s time to draft the final documents. The LOI is the most important piece in determining whether the parties have a deal that both sides can live with. Make sure you bring legal counsel into the negotiation process as soon as you are presented with an LOI that the practice is willing to consider. When my clients call me after the LOI is already signed, there is little I can do to improve the deal or correct misunderstandings.

2. An LOI will usually have a provision that does not allow you to negotiate with other parties after the LOI is signed until the final documents are executed or a certain date is reached (and the parties have failed to consummate the transaction by such date). Physicians who are trying to play different potential buyers against each other for the best deal must understand they may no longer be permitted to “shop” the practice once the LOI is signed.

3. If a practice wants its employees to be treated a certain way once the practice is acquired, this expectation must be made clear to the buyer. This includes protecting staff from being reassigned to a different position or location or from being terminated following the sale. In addition, be sure you are familiar with your existing employment contracts. Even if the practice is going to be sold, the practice must honor the notice provisions (and other promises) in its existing contracts, particularly for those employees not being retained. When it comes to informing employees about the sale of practice, be strategic. Informing staff too soon can lead to anxiety and the departure of those who feel uncertain of their future. A meeting with staff once it seems that a deal is likely is advisable. Sharing information and providing assurances can go a long way to preserve your best employees.

4. Electronic health records are an issue often overlooked at the LOI stage; however, if the practice acquired its own EHR which is still not fully paid for, and the practice will be unable to use it following the sale, this issue must be addressed. The hospital may be unwilling or unable to cover the additional cost of the unusable EHR and the debt must be addressed with counsel to see if it impacts the ability to complete the transaction.

A related issue can arise if the EHR is tied to a hospital/system other than the one which has made the offer to acquire the practice. It may be necessary to coordinate the transfer of electronic information from the old EHR to the hospital-buyer and avoid potential gaps in access to information. Not surprisingly, cooperation from the non-purchasing hospital is often not forthcoming.

5. If your practice will collect its own accounts receivable following closing, be sure you understand how this will be accomplished. Most hospitals are not willing to allow their staff (your old employees) to collect the old accounts receivable during work hours. Often a hospital buyer will agree to collect accounts receivable on behalf of the practice (based on a percentage of collections) or will allow the practice to pay hourly for use of the staff. This is something that should be discussed at the LOI stage.

In my next blog I will cover some of the compensation, covenant, and termination issues that should be addressed in negotiating to sell your practice. If you have particular questions about the process that you would like to see answered, please let me know!

Find out more about Ericka Adler and our other Practice Notes bloggers.

View the original article here

Customer Service in your Medical Practice: Attitude Is Everything

There truly may not be enough words in the English language to sum up the importance of attitude at your medical practice. It is a topic so broad, that it will even be difficult to sum up in this post. To narrow this down, the easiest place to start is by working your attitude into your customer service model.

A great attitude in customer service can be very simple: Choose to be thankful for every patient that walks through your door, whether you are the receptionist, the nurse, the medical assistant, the doctor, office manager, or bill collector. You must thank every person that comes in for choosing your medical practice. Let them know that you are grateful that they are there.

This can be fairly easy to integrate into appointment scheduling, telephone answering check-in, and check out. Simply thanking a patient for calling, stopping by, and/or arriving on time should be habit from day one (and should be a part of an interview with a new staff member and orientation). A simple change of your greeting on the phone to “Thank you for calling XYZ Family Medicine, how may I help you?” can start the conversation off in a positive manner and begin laying the path for the patient (aka customer) to feel like they are in good hands.

Where things get tricky is thanking the patient that arrived late. A simple and sincere “Thank you for making it in” after they explain what happened or in the course of letting them know they will need to reschedule can help ease an otherwise uneasy situation. Sincerity is key in the delivery.

You can continue your attitude of gratitude and great customer service by having the staff member (usually the nurse/medical assistant) that brings the patient to their exam room and starts their assessment by phrasing their initial statement, “Thanks for coming in today, I understand you are here for …” and certainly in the instance of running off schedule — “Thank you for your patience Ms. Smith, I apologize we are running a little behind schedule.”

This same positive, smiling, thankful attitude should follow the patient all the way to the checkout desk where they make payment and schedule their appointment. You should thank patients again for coming in, thank them again for their patience if they have had to wait, and certainly thank them for making their payment and scheduling another appointment.

In your attitude adjustment to thankfulness, please don’t grovel or beg, and it can be a fine line. Desperation will make your patients uncomfortable; even if you are, is not the right attitude to project — it turns patients off and makes them uncomfortable.

Try these suggestions on for size in your practice. Attitude is contagious, so pass around your fantastic attitude to your co-workers, staff, and patients. Please understand the depth of attitude — you choose your attitude every moment, and the simple tool of choosing to change to an attitude of thankfulness, of gratitude, is life changing and will transform your business. Once you and your staff have mastered the art, there will be no stopping the successes personally and professionally that comes your way.

Approximately 7 out of 10 clinics I consult with aren’t saying thank you to their patients, at all. How does your clinic stack up?

Find out more about Audrey "Christie" McLaughlin and our other Practice Notes bloggers.

View the original article here

The Impact of RACs on Your Medical Practice

Please sit down — this will not be an easy article to digest, no matter how carefully I parse my words. Life under the microscope of Recovery Audit Contractors is going to get tougher for physicians. Three recent developments may impact your practice in the next year.

I have written in the past on RACs and documented their growth from a twinkle in Uncle Sam's eye to the behemoths they have become. Much of the advice offered in prior articles (please see links at the bottom of this article) remains valid and should be heeded.

Audits of Level 5 E&M services

CMS has given approval to Connelly, the Region C RAC, to perform complex medical reviews on level 5, E&M services (e.g., 99215, 99205, and 99255). This is the first time CMS has given any RAC permission to target the coding and documentation of E&M services. One impetus for the focus on level 5 E&M services is a shift in providers' use of level 4 and 5 codes. According to the Center for Public Integrity, the percentage of Medicare services coded as level 4 or level 5 increased from 25 percent to 40 percent between 2001 and 2010. This, of course, has increased CMS's financial outlay for these services and made them a much larger budget item (i.e., target).

Connelly is the RAC for thirteen states: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia. Take note: the other three RACs are expected to follow suit.

Since early 2009, the Medical Group Management Association, AMA, and 101 state and specialty societies have actively opposed RAC audits. It is unfortunate for all of us that CMS has not heeded their advice.

There is yet another cause for concern with this initiative. Though it has not been officially confirmed, CMS apparently has given Connelly permission to extrapolate the results of their E&M audits. For instance, if a RAC audit determined that six of twenty (30 percent) level 5 services did not meet coding/documentation guidelines, the RAC would have authority to extrapolate this 30 percent failure rate across all level 5 services provided during the review period.

If you provide level 5 services, it is prudent to have several of them copiously reviewed by a certified professional coder.

9th Circuit Court of Appeals verdict

On September 11, 2012, the U.S. Court of Appeals for the Ninth Circuit rendered a dangerous opinion. It affirmed that RACs are not restricted by regulatory deadlines, statutes of limitations, or time limits. Lead plaintiff attorney Ronald S. Connelly, of Power Pyles Sutter & Verville PC, says "The decision leaves providers with absolutely no finality in their payments from the Medicare program. Contractors could reopen claims that are even 10 or 20 years old, and providers would have no right to challenge the timeliness of the audit."

Legal minds will weigh in on this opinion in the weeks and months to follow, but again, a scary precedent has been set. It may mean that Medicare patient and billing records should be maintained indefinitely. At a minimum, it means the past is neither safe nor sacred.

I recommend you contact your medical malpractice insurance carrier to determine if this circuit court opinion will change their recommendations for records retention.

EHR automated notes

Last but not least, the HHS's Office of Inspector General has set its focus on whether providers are using automated note generation appropriately in their EHRs. Also known as "cloned notes," automated notes and templates use copied and pasted data on multiple patients to record standard information such as a normal review of systems or physical exam.

An observer reviewing several such notes would find virtually identical documentation and very little patient-specific information. Herein lies the OIG's concern. They are concerned that cloned notes may lead to over-documentation or a lack of patient-specific information. From a medical malpractice liability perspective, the same concerns apply.

There is a place for structured notes, and many physicians used them prior to the advent of EHRs. These are acceptable, and EHR-generated notes that contain patient specific documentation should be good to go as well. Your risk lies in over-cloning identical text in your patient notes.

In summary

The United States Department of Justice (DOJ) has three top priorities:

• Terrorism
• Violent crimes
• Healthcare fraud

I wish healthcare fraud were not on this list, but it is, and it is not dropping off the list anytime soon. Government oversight and second-guessing are givens for anyone who practices medicine today; expect fraud identification and enforcement initiatives to grow.

To get a head start on audit-proofing your practice, read the following articles that offer advice and practical tips for protecting both yourself and your practice:

• Avoid Medicare Fraud Claims by Coding Correctly

• Medicare's Fraud and Abuse Program

• Nine Things to Know About RACs

Lucien W. Roberts, III, MHA, FACMPE, is vice president of Pulse Systems, Inc., and a former practice administrator. For the past 20 years, he has worked in and consulted with physician practices in areas such as compliance, physician compensation, negotiations, strategic planning, and billing/collections. He can be reached at lroberts@pulseinc.com.

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Telemedicine: How It Can Work for Your Medical Practice

As a child, I never dreamed I would be able to communicate with a person several thousand miles away while looking at their face via video. Now, we can not only communicate via video with our family and friends, we can receive medical treatment from our providers.

Telemedicine is here and being utilized. Though there are some uncertainties regarding if, how, or when private payers are going to cover telemedicine, Medicare and Medicaid programs are utilizing the advances in technology to assist in treating our rural communities.

Medicaid coverage and eligibility varies by state. However, Medicare is clear on their coverage and position. Medicare does consider a telecommunications system to substitute for a face-to-face encounter in specifically allowed situations and areas.

Here's how it works:
• The Originating Site is considered to be the location of the Medicare beneficiary at the time the service is being furnished via telecommunications. This site must be located in a rural health professional shortage area (HPSA) or in a county outside of a Metropolitan Statistical Area (MSA).

• If you are located in an MSA, remember you can still participate by creating a relationship with a facility that is located outside of an MSA. These locations need qualified specialists to assist with their patients. Many times, patients living in rural communities need specialized care but do not have the means to travel. There are many opportunities for both sides.

• The Distant Site is considered to be the location where the practitioner is furnishing and receiving payments for the telehealth service. Eligible practitioners include:
o Physicians
o Nurse practitioners
o Physician assistants
o Nurse midwives
o Clinical nurse specialists
o Clinical psychologists/clinical social workers (cannot bill for CPT 90805, 90807, and 90809)
o Registered dietitians or nutrition professionals

• An interactive audio and video telecommunications system must be used that utilizes real-time communication (exceptions: Alaska and Hawaii).

• A few of the services covered by Medicare telehealth include:
o Consultations
o Office or other outpatient visits
o Individual psychotherapy
o Psychiatric diagnostic interview
o Follow-up inpatient telehealth consultations

• The distant provider submits the claim utilizing the same CPT/HCPCS codes they would normally with a modifier "GT" which alerts Medicare that it was a service provided via telemedicine (Alaska and Hawaii utilize the modifier "GQ").

• The originating site is allowed to bill for the service by utilizing the HCPCS code Q3014. The allowed reimbursement amount is minimal, but the ability to treat patients with a specialist who would not normally be available raises the quality of care level higher than ever before.

If your practice is interested in tapping into the telemedicine market, here are a few things to investigate and consider:

• Equipment can vary from a few hundred dollars to several hundred thousands of dollars.
o Webcam, computer & Facetime/Skype – this is the most cost effective process. The investment would range between $200 and $500.
o Mobile unit – $20,000 to $50,000
o Room unit – approximately $100,000

• Internet Connection - The key is being sure you have high speed Internet that will allow you to effectively communicate in a live environment, as well as an appropriate router with security functionalities.

• Licensure and Credentialing - Providers would need to be credentialed for the facility they are providing services.
• Medicare requires an 855I & 855R if the provider is located in another state.
• Other payers vary, so be sure to check before providing services.
States vary on licensures and would need to be investigated.

Other Considerations:

• Malpractice does vary and should be investigated.
• Policies and procedures should be developed to cover telemedicine processes, along with appropriate forms and consents.
• Staff would need to be trained on all policies, procedures, and best practices.
• Market opportunities with FQHCs, RHCs, hospitals and other providers with needs.

Even though at times the concept is hard to grasp, providers such as radiologists have been utilizing telemedicine for years just not in a live video environment. The sky is the limit to where the advances in technology are going to take the medical field. After all, 10 years ago who would believe we would be utilizing e-mail and the Internet to the magnitude we do today.

Find out more about Chastity Werner and our other Practice Notes bloggers.

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Using Positive Patient Reviews on Your Medical Practice Website

An online search for "reputation management" yields 62 million results, including a dozen paid ads for services.

The paid ads on Google point to the profitability and popularity of reputation management services.

Reputation management in 2012 involves monitoring the online presence of a company. This could mean looking at social networks, discussion forum comments, and generally tracking who’s saying what about your practice.

It also includes the more active function of responding to negative comments, posting content like blog posts, and managing patient reviews.

Actively soliciting reviews and ratings from patients is a vital function of these services. The good news is, you can do this yourself if you make a habit of it.

Whether you hire someone to get patients to review you online or you do it yourself, here are a few ways to further leverage positive reviews from satisfied patients.

1. Post them on your own website

Create a separate page on your practice website for patient comments. You can label the page "Patient Comments" or "What Patients Are Saying."

Whether you get the comments from online or offline sources, make sure you respect the level of privacy or anonymity of the patient’s review.

Some patients put their full name in their review; others leave it totally anonymously.

Use the whole comment, break it up into paragraphs, or just post an excerpt.

2. Ask permission for future use

Before you try the technique in number 1 above, it’s better to get permission from the patient.

Be explicit when you ask!

Ask if you can include their full name, city, state, occupation, and even a picture. You won’t know until you ask.

If patients are genuinely excited about their experience, they don’t mind sharing some or all of these things. Give patients some idea of how the comments will be used — in print ads, online, or in the office.

3. Ask patients for multiple reviews

One of my patients recently posted her comments and reviews on two separate ratings websites.

All I did was ask her to visit an extra site when she left the comments.

Another way to get reviews in multiple locations is to let patients know they can just leave a quick "star" rating, like at Healthgrades.com. This takes a few minutes and doesn’t require writing a paragraph of comments.

4. Mix reviews with patient education

Imagine you’re a patient looking for information on eczema treatments.

You look at a local dermatologist’s website and read patient education articles on the subject.

Wouldn’t it be powerful if you read a testimonial from an eczema patient in the body of the article? Of course!

Try putting excerpts of patient reviews in your patient education articles.

Even if that particular patient had some other problem, it helps patients to see that other people are happy with your office as they’re reading about conditions and problems they have.

5. Let your patient know what’s next

Finally, think of other ways you can get your happy patients involved in promoting your practice.

Patients who leave positive reviews, especially in multiple places, are bona fide raging fans. They are usually willing to spread the word about you in other ways, too.

After they’ve left a review, let them know you may ask them to do a video review in the future, contact them for a media interview, or let other patients call or e-mail them if they have questions.

If you’re just getting started, I’ve written some guidelines on how to pick patients to review and rate your practice.

Find out more about C. Noel Henley and our other Practice Notes bloggers.

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