Last Minute ICD-10 Thoughts

ICD-10 is upon us.

It is almost here, yes, there will not be a delay. I have had several providers ask that question even as of last week. CMS will go easy on denials and penalties if the first three digits (first one an alpha) are used with less specificity for the first 12 months. 

No guarantee what other payers will do – advice – DIRFT, do it right the first time anyhow!

By now all should have identified the top 20 ICD-9 codes from the billing software and done your cross walk. Recommend that you have a five column spreadsheet handy:

ICD-9   |   Description   |   ICD 10   |   Description   |   Considerations

The considerations are specifics that will help with the cross walk from 9 to 10. Use this in lieu of printing new super bills, laminate several copies and have them all over the office.

Plan on no money in November and December, October should be all right. Get a line of credit and plan on no bonus this year. That may sound extreme but you never know with 650,000+ providers, multiple insurance carriers, labs, imaging centers, pharmacies, etc. all involved something will go wrong. W e hope not too much but be on the safe side.

Cross walk existing patients, those scheduled after 10/1 (remember it’s date of service driven), and new patients with ICD-9 for current billing and then you are prepared for the first visit after 10/1. Some software programs will be a big help.

For authorizations, lab orders, imaging studies, procedures, etc. that will be done after 10/1 talk with the payers NOW about how to deal with them. See who will accept ICD-10 now or when they will accept and if you have to authorize with ICD-10 or if they will allow the ICD-9 authorization that you may already have slide. Not sure I trust anyone so checking is a good idea.

Plan on reviewing your cash picture around 10/20 for Medicare payments since you will be submitting claims on Thursday 10/1 and 10/2 and payments will be made in 14 – 17 days. Plan the same for 11/4 or 5 and 11/20 for your non-Medicare payers based upon payment sequences found in your contracts (check out payment terms, interest payments, etc.

You may do well and have all your testing done, laminated copies, systems in place, providers and staff trained, if so great. Not sure about all those outside of your direct control. Therefore, be cautious and prepared for the worst and hope for the best.

How About Getting Long-Timers Disease? ICD-10 and Cash Flow

The medical practice world is built on a cash basis accounting system. Cash comes it, it is recorded as income, cash goes out  it is recorded as an expense. At the end of the year we take all income out so we don’t have to pay corporate taxes. This creates a void in looking at new investments.

I hate to pay taxes like anyone else except for what I owe to make sure that I get the benefits that I need and deserve, I know we could get into a long discussion about this idea! But that’s not the point. The point is that things are changing and it may be beneficial to think about a long term strategy and long term investment into our business model.

An independent practice can consider switching to an accrual based accounting strategy. We book activities when they occur rather than when they are paid for. If we manage the revenue cycle well, we will know what is coming in and that it is coming in timely, e.g., our days in accounts receivable is less than 30 days. We effectively manage our inventory. Our tax burden is controllable.

Now is a great time to think about this strategy for 2016. Why? Because the ICD-10 conversion will occur in October! I suggest that cash planning for 2015 include NO bonus or significant cash out at year end! It’s not that you will have a problem with managing the change! Half a joke! It’s that the payer is on the other side. So the recommendation is to plan on normal cash in October, but very little in November and December. Plan on cash infusion in January.

Therefore, it you were to start a new program, purchase new equipment, renovate the office, or make some change it should occur in 2016. You may also then elect to move to an accrual based accounting strategy as of January 1, 2016. You then can consider the future with a solid long term investment strategy rather than a year-to-year model.

Chronic Care

In 2010 the chronic care disease state was responsible for 7 of every 10 deaths in the US and over 75% of the total health care costs. What is the percentage of patient visits – new and established that have a chronic care diagnosis? How do you treat them?

Today, the provider is so busy completing PQRS/VBPM and Meaningful Use requirements that it is estimated that only 55% of the providers day is actually involved in directly providing patient care. In addition, the overall care that is provided addresses the immediate need and may not address the on-going needs for managing the chronic care needs of the patient.

What can you do improve chronic care to patients in your office?

• Develop treatment plans and protocols around those key disease states. 
• Consider multiple chronic care states, e.g. 20% of Medicare patients have five or more chronic diseases and 10,000 US citizens become eligible for Medicare on a daily basis 
• Seek others to join the team or care process such as dietitians, certified diabetic educators, exercise physiologists, behavioral health professionals. These may be contracted or employees. There are key codes today in transition management of post hospital patients and chronic care codes for services covering 30-days. Now is a good time to look at the volume, team and see if there is anything that can be done to expand services. 
• The team can also be used during “shared medical visits”, SMV. An SMV brings around 15 patients together for a group visit. There is education, answering questions (the same one once rather than 15 times), and time set aside for individual visits, e.g., extract a patient for a few minutes from the group for an individual visit. Use established visit E & M codes 
• Consider the local market and assume some responsibility for population health management, broaden the perspective of patients needs, know the resources available in the community, and communicate healthier measures to the patient 
• Work closely as referred and referee of patients to insure the patient is receiving well coordinated care. 

The coming changes in reimbursement, less emphasis on fee for service and more on risk sharing, performance based approaches lead me to believe that managing these patients well will be a positive benefit maybe not today but certainly tomorrow. Now is the time to think about it.

Medical Practice Staff and Patients

There was a book published several years ago by Jan Carlson of Scandinavia Airlines entitled “Moment of Truth”. Basically his point is that every time a customer comes in contact with a business a moment of truth is formed. These moments of truth create an impression which leads to thoughts about whether or not they should continue to seek products or services. Negative impressions will lead to the customer seeking other alternatives.

If we realistically look at the patient visit to the medical practice most “moments of truth” have to do with staff and the environment and NOT the provider. This is not to say that the provider portion of the visit is not important, it is the reason to be there, but it is to say that the staff needs to always be at their best.

So think about a few scenarios and how you respond:

• Patient yells – do you yell back or allow the patient to “vent”, listen and once the complaint is out, respond in a cool manner. Utilize the reflective/deflective listening approach which means you repeat what the patient said and attempt to reach common ground and a resolution of the issue. 
• Patient cries – they have just gotten bad news, time to empathize and recognize their need. 
• Use common language – it is noted that patients don’t understand medical terminology, make sure your discussion is in common language. 
• Pay attention – listen to what they have to say 
• Patient is late – offer them alternatives such as rescheduling or waiting to be worked in. We have done a good job of training patients, they expect us to be late so they can be late as well 
• We are so busy – instead of stating to obvious about a stressful day, don’t and try to calm down, relax and treat the patient with care and respect. Don’t let them know you’re too busy to see them – they’ll become stressed! 
• Treat them like you want to be treated – the golden rule 

Then make sure the reception area is clean, maintained at a comfortable temperature, includes entertainment such as wi-fi, TV, recent and relevant periodicals.

Patient satisfaction is one of the key metrics in Medicare and payer programs and plans, it is essential that we all do our part.

Medical Practice Question: To Charge, or Not to Charge for No-shows

A question that I am often asked is whether or not there should be charge for no-shows. In most cases this creates bad vibes with patients and creates a lot of work on the back end with little results. A blanket response to a provider complaining at a board meeting about the fact that there are a lot of no-shows is not appropriate.

What is your percentage of no-shows per week? I am not aware of a good benchmark but in talking with practices, the goal of less than 3% seems reasonable.

Instead the root cause of no-shows should be considered. Here are a few questions that should be asked when the issue of no shows comes up:

• Is it one provider? 
• Is it one day of the week or time of that day? 
• Is it one payer type? 
• Is it one age group? 
• Is it new patients? 
• How long from the call to the appointment? 
• Is it established patients? 
• Repeat offenders that can and should be dealt with individually? 
• Others in your practice? 

The main point of this is that the administrator should have sufficient data in place to offer a well thought out plan. A blanket response implies unawareness, laziness, or reactionary decision making. This type of action often times causes more problems than offers solutions.

This does not mean that a no-show charge is not warranted, it may well be for certain patients, e.g., a behavioral health patient that has difficulty with responsibility may learn something from having to pay for that a mistake.

We may have done such a good job training our patients that we always run late that they can come in late or maybe not bother to show up since they are feeling better.

We may have a provider that needs help with bed side manner and efficiency.

We may have a scheduling issue and schema and protocols needs to be changed as a result of the analysis of data.

I am sure you can find many more reasons, come up with solid solutions and develop a well thought out transition plan to address those solutions!

Technology vs. Team Work in the Medical Practice

Team Work in the Medical Practice

A recent article published by the consulting firm McKenzie got me thinking. The premise made a very simple but profound point. A patient who experienced a doctor visit or hospitalization 20 years ago and then came back today would be amazed at the technological advances for their care. But they would still have to wait, be treated exactly as they remember as a patient.

Technology is great and we have adjusted, changed with the times to incorporate many wonderful tools. We have become more efficient (EMR discussions aside!) with diagnosis, results, and the use of technology.

Have we changed how we manage the patient experience? Sure we have nicer reception areas, we have kiosks to register and update information, we have coffee, the entertainment options while waiting are great. Does this meet the customer expectations or needs or are they basically treated on a personal basis the same way. They enter, sign in, are told to wait, and eventually are called to the triage area, wait again in the exam room and get the prescription, check out and go home. All in the same amount of time that it took 20 years ago. No wait – it takes longer now since we have to use the EMR!

My goal in posting this is to have you realistically ask the question how do we treat patients?

Put a team together, call is a patient experience and transition team. First assignment is for each member to relate a recent experience with another business – could be a doctor’s office, a trip to the grocery store or whatever. Think about it from what they remember from years ago to today. What changed and was that change for the better? Has their experience improved? Was it more efficient? Was it more pleasant? What was the measurement? It is possible to learn from others what you could do better!

Once the team shares their observations, what if anything can be done to improve the patient experience. Take those ideas and develop a transition plan.

After three months of this team observing and making improvements, thank them for their assistance and create a new team. Ask them to follow the same pattern. The ideas for improvement will come, employees will be recognized, and all will be more enthused about making some positive improvements because they were involved, their opinions mattered.

Medical Practice - We Need to Control Expenses.

Control Expenses Now!

At the monthly board meeting the financial statement is reviewed and payroll costs are higher than expected based on either the budget or a comparison to same period last year. Doctor A asks about overtime and you acknowledge that there has been a lot of overtime recently. A motion is passed and all agree that no overtime, if necessary it must be approved by the employees supervisor.

How many times has this scenario played out in your practice? Maybe a better question is how many times a year is this question asked!

This change required a decision and discussion as well as a monitoring plan. All went well for how long? One pay period, two pay periods, two months?

The better approach would be to ask the question why was their overtime in the first place, in other words looking at the root cause(s) and developing a plan to change/transition related to the root cause makes more sense. Simply telling the staff no more overtime changes nothing except creating an awareness. Staff has heard this before and reacts like OK I’ll just keep on doing things. Some may not report their time, others may develop an attitude that says I won’t get things done until the next day.

Root cause analysis as to why there is overtime is a very helpful approach. One simple way is to use the “5 why” approach, ask the employee why they had overtime up to 5 times. It could be scheduling, doctor being late, consult reports not received, denials, refunds, or who knows. The 5 why approach drills down a little deeper to find out exactly what the root cause is. Once identified a transition plan can be developed and implemented.

Then in six months the board report can indicate that changes have been made to cut overtime, not by demanding but by improving how things have been done differently to improve care provided to the patient.

This may seem simplistic, it is not. This requires you to ask questions, take the time necessary to drill down and to work closely with your providers and team to achieve the goal.

Change vs. Transition

Change vs. Transition

We will do a series of posts on the concept of change! Change is a word we hate – maybe it’s not the word but what it stands for. There are three things that are certain in life: taxes, death, and change. We deal with it on a daily basis. Most people think of it as NO WAY and continue or revert back to doing it the way they know.

Let’s think in terms of transition rather than change. Perhaps using a different word will help put a different spin on what you are trying to do. Perhaps even this won’t work and it falls back on your shoulders as a practice manager or leader. Let’s look at this more fully.

Change is easy to announce, we want to do things differently. You get together with your team, talk about how things are done and everyone agrees to try something different. The meeting is adjourned and everyone goes to their work area and talks to their staff about the change. All listen and agree that it is a good idea. So you think it is done and all will be better. A week later nothing has happened, things are being done the way they always have been done.

Transition on the other hand requires a “PLAN” which means the acceptance of the new way is not enough. It is necessary to develop a way to implement it. This will mean a commitment. This will mean training or re-training. This will mean communication. And communication means talking, demonstrating, writing memos, etc. and doing it over and over again to reinforce the idea of changing how things are done.

We are so busy in our world that we do not take the time to effectively implement what was agreed upon as a way of improving patient care.

So here are the two questions to ponder:

1. What did you do wrong and how could you have done things better to make the transition to the new and better way of doing things? 
2. Why did you waste time having a meeting about the issue in the first place? Remember, we know that we waste 25% of our day, a meeting with several team members that accomplishes nothing is a good example of waste!

Time to Transition Away from, "We've Always Done it That Way"

“We’ve always done it that way!” “That’s the way I was told to do it!” These statements have served you well over the years because the business (your practice) has been successful and new patients have come. I believe that now is the time to set your intentions to “transition” to the future. I recently re-read a book by Clayton M. Christensen, The Innovator’s Dilemma (Harper Collins Publishers, Inc., 2003), in which he suggests that any innovation is based upon the business’ resources, processes, and values, which are all related but should be looked at as a ladder, with resources as the base.

One of his main points is that resources can be improved; processes (how and why we do things) are a lot harder to change and are where bottlenecks in improvement programs stop. Therefore, this might be a good time to look at your resources, one of the most important being employees. Do you have employees who buy into your practice purpose? Do your employees have the right skills for today and tomorrow? It has been proved over and over again that an employee problem is 85% the “fault” of the business (manager) by not selecting, training, and developing the staff. So whether your answer is yes or no, there are some things that should be done now to prepare this valuable resource for the future. First, do you have a training program? Is there time for orientation of new employees, which includes the “compliance” (OSHA, HIPAA) and the practice mission, values, benefits, etc.?

Set aside an hour or more monthly or at least quarterly for a formal training session, involve physicians and all staff, make it mandatory. Make reviewing the purpose, sharing ideas, and learning new things part of the program. Second, communicate well. This is not only about e-mail; it involves face-to-face interaction in group sessions as noted above and also individual or department discussions. Share the plans for the year, discuss what happened in the past, challenge everyone to be aware of the industry—healthcare is in the news almost daily. Any group meeting should include an agenda to prepare the participants as well as to help ensure maximum benefit in the time allowed. Minutes should be taken and made available (posted or on intranet) for all to see and review. The employee who understands, is involved, and is asked for suggestions will contribute. Third, involve employees by acknowledging their skills and ability. An employee who understands the business’ purpose will be more committed to becoming involved. As practice leaders, you can not only develop (train! communicate!) employees but you can delegate tasks. This will expand the use of resources but also may help lead to improvements in processes. The employee who understands, is involved, and is asked for suggestions will contribute. Developing and utilizing your employees will go a long way in preparing you to be proactive rather than reactive to future change.