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.

Insight in Leadership in the Medical Practice

In the November issue of the Harvard Business Review an article by Sawhney and Khosla identify some interesting questions on where to look for new ideas. I believe that we should not only focus on the “problems” that we face but more importantly look at what opportunities there are for us to better serve patients. The glass is always half full. Here are some of their insightful questions:

• Is your market share or revenue abnormally low or high in a geographical market? 
• Are you having unusual success with a specific customer (e.g., patient) segment? 
• What’s most frustrating about your products, processes, or workplace? 
• What bothers you personally about your business (yes your practice is a business)? 
• What work-arounds do people use to get their jobs done? 
• What beliefs do you hold sacred? 
• Why do things have to be this way? 
• What opportunities would be opened up if we abandoned those assumptions and beliefs? 
• What are the social, cultural and environmental factors that affect your preferences and behaviors? 
• How can you create solutions that respond to those factors? 

Take a look at these questions at your next board or leadership meeting. Openly discuss them and develop strategies to transition your practice for a brighter future.

Maxwell at MGMA in Vegas

John Maxwell the leading expert on “Leadership” was the Monday morning keynote and what a great presentation. It was build around his 15 Invaluable Laws of Leadership.

One of his laws it that of INTENTIONALITY. Growth doesn’t just happen! We often talk about our experiences as part of our growth. Do you have twenty years of experience or one year of experience 20 times? You don’t automatically grow; it is a process an effort. The best teaching part of our experience though is the evaluation; do we stop to evaluate our experiences as we grow? We should.

When you wake up in the morning challenge yourself with a simple concept, whom am I going to add value to today! This will set a framework of a positive attitude.

Another key law is that of CONSISTENCY, which he highlighted as a boring concept. You always want to hear how good you are from other, hearing you being defined as consistent is one of your best compliments. Motivation gets you going but discipline gets you growing!

He has a rule of five citing a story of chopping a tree with an axe five swings today. Five swings tomorrow, the next and the next. This is to say that there are five things that you should do everyday related to your purpose. These five things will provide you with a focused result, success. They will also lead you to be consistent in your daily life. As an author his rule of five for each day is: read; think; file, ask questions; and write which he does each and every day including holidays and vacation days.

His final rule covered in the presentation was the rule of ENVIRONMENT – your surroundings must be conducive to growth. People are your most appreciable asset, what are you doing to grow them in your work place.

Consistent from what we heard from Lou Holtz – attitude, focus on the now, and grow. What a great set of principles and concepts from both. I hope my sharing this with you spreads the word and encourages you to identify your attitude, live in the now and consistently strive to grow. This will make you a better person and have a positive impact and all you come in contact with.

Lou Holtz and MGMA

At the MGMA Annual Conference, AC, Lou Holtz the hall of fame Football coach of schools such as Arkansas, Notre Dame, and South Carolina gave the Opening Key Note address. What a great presentation.

He talked about a five-part plan built around the idea that “titles are from above, leaders are from below!” What a concept!

His five-part plan:

• Attitude – have fun and add value to your self and your practice.
• Passion to succeed – to win in his world, your definition of success is yours but you must have a passion for it.
• Focus on your purpose – we are individuals but in the world we are a team, one that needs each other to achieve our purpose.
• Make sure you are growing and not dying, we need something to hope for.
• Make good choices, help your children make good choices (your fellow employees make good choices).

His acronym here was to WIN – what this stands for is

• What’s
• Important
• Now

His three rules:

• Do what’s right
• Do everything to the best of your ability
• Show people you care

Throughout his presentation he offered stories to support each of these key points – awesome for an 83 year old who was up and on TV until 3 AM Eastern time and spoke to us at 3 PM Pacific time!

Above all – in the football vernacular – do not attack the performer, attack the performance!

Very glad to have had the opportunity to hear him!

Passive Aggressive Physician Responses in the Medical Practice

A lot of comments lately on the fact that the doctor does not want to change, they don’t feel the “pain” or accept a reason for change. More importantly, we hear that the administration brings up an issue at the monthly board meeting. There is discussion about the issue and eventually there is a vote or consensus reached that the recommendation for change it accepted.

The next day however, the doctor does not change to the new way. Instead indicates that the decision does not apply to them, it is for others. Or I’m about to retire and I don’t have to change. Or I don’t like someone telling me how to run my practice.

So passive response = yes to the vote followed by aggressive = no I won’t change is the result. In my years, this is a very common situation.

How do you deal with it? A recent article in Psychology Today offers some suggestions:

• Don’t over react when you find out about the response, this may lead to even more of that behavior 
• Don’t force the change 
• Proactively deal with the situation 
• Get the doctor involved with what might work in their specific practice. Work with the supportive staff to help. Identify the problem and seek a solution that will work. 
• There may have to be direct consequences for the lack of acceptance of the change. This can be accomplished with peer pressure, e.g., comments at the next doctor meeting. It may also be accomplished by some form of monetary penalty if there is a tie to the lack of change in behavior to some risk to the practice. 

How does this fit in with the purpose of this blog? If you believe that improvements in care are necessary, there will have to be changes made. These changes will impact the physician practice directly. Even though many changes can and will be transparent, there are others that be direct.

The Medical Practice Front Desk Screwed Up Again

An insurance claim that results in non-payment due to a denial is a waste! Statistically we know that the cost of handling a denial is about $25. Costs start from input, maintenance of the account, receipt of the EOB, the RE-WORK, re-submission and the time value of money. If your practice has only 10 denials a week that’s $250 times 52 totaling $13,000. You’re not writing a check for that amount but you might as well.

The cost is in the re-work where staff can be doing something else with their time. Today’s cash flow has a greater percentage of patient payments than ever before.

The main source of denials is from demographic errors. Is that what your denial report shows? You do get and review a denial report at least weekly, right?!

Let’s assume it’s at the front desk. How about doing a Gemba and checking things out and you will find phone, patient questions, noise, copying, scanning, patient check in and check out and many other activities. Draw a process map and see what steps are there and who makes what decisions.

This simple step will create a picture, which should result in changes as to how this key area is handled. How about shifting staff from the denial management department to the front desk. You won’t need the staff in the back if the front is staffed correctly! This is an assumption and jumping to a conclusion. More importantly, it is intended to suggest that a look at your denials, making an effort to repair them by using Lean tools and determining that many activities can be changed.

Challenge one is to look at your denial report, identify the main source of denials, calculate the cost of processing them, evaluate the main source, use the time as a teachable moment, and things will improve.

photo credit: via photopin cc

Experience in an Emergency Department and Hospital Admission

The next series of posts will relate to recent experiences I have had while being a patient or involving personal experiences with family members as patients. The goal is to share ideas from the VOC – voice of the customer – perspective and encourage all to consider these as well as your own experiences. This is a “research” project on understanding the customer experience.

Recently, the EMS team was called to my home to take a family member to the Emergency Department of the closest hospital to our home. We had a very nice experience in the ED, staff worked well, kept us informed as to what was going on and what would happen while there. It was determined that an inpatient admission was in order. We were told that a “hospitalist” would see us either in the ED or shortly after arriving on the floor.

Practical and Gemba

Let’s get practical. Applications of some of the tools we have talked about have produced some interesting results.

• A three doctor practice in the Houston area looked at their patient cycle time, improved their scheduling process, shifted tasks between staff members and were able to increase patient visits by four per day.
• Tools used: flow chart, run chart (we will see one later), brainstorming.
• A large practice in the mid west was reviewing their cash flow. The CEO simply used the “5 why” technique and found out that there was an automatic hold of 14 days on the AR. The reason given finally was that there was a problem with the billing system several years ago and that became the policy.
• Key tools used was the 5 why which came in a brainstorming session.
• A large oncology group decided to track compliance with care plans, which were developed and agreed upon. They monitored the results and determined that peer pressure and consequences were the best way to see improvement. Compliance increased from 35% to greater than 50% within three months and as of now compliance continues to improve.
• Key tools used was cause and effect diagram (we will see one later), flow chart, brainstorming, session with EMR vendor.

There are many more. One of the keys here is the involvement of the staff through brainstorming. It is not possible for one person to fix or solve all your problems. Utilizing staff knowledge and encouraging them to be involved is essential to the success of an efficiency program.

Another key term and concept in Lean is “Gemba” which literally means “the real place”. We think of it as the place where the work is done. It is essential that those involved go to the Gemba to see how, what, why, and/or when things are done.