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.

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!

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.

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.