MGMA In Practice blog

Guest blog by Elizabeth W. Woodcock, MBA, FACMPE, CPC, healthcare speaker and author of Front Office Success: How to Satisfy Patients and Boost the Bottom Line.

It takes a few seconds to form a first impression, but that impression lasts a long time.

Your medical practice's front office staff maintains patient flow, collects cash and verifies insurance coverage and patient demographics while also answering phones and sending faxes. But there's another critical responsibility you entrust them with: Being directors of first impressions.

Medical practices with inexperienced, unmotivated and underpaid staff on these front lines often suffer the consequences: poor staff morale and eroding patient loyalty – the slow, quiet killers of many practice's bottom lines.

No matter how carefully you hire, today's multigenerational workforce brings with it multiple outlooks about good manners and good customer service. Some employees want to make every patient feel like a pampered guest of the finest first-class hotel; others, while competent in every other aspect of the job, seem to think that looking up after a minute or two to acknowledge the patient waiting at the counter is good enough. The gulf might not be that dramatic in your practice, but I've seen both sides in practices where I've consulted.

Make sure everyone is on the same page when it comes to the service quality your patients demand. Here are "10 Commandments of Good Service" for staff to follow – an MGMA blog-exclusive supplement to my new Front Office Success book.

1. Greet patients warmly and sincerely.
   Teach staff to personalize each encounter by greeting and acknowledging each patient. The patient's first impression – whether walking in the door or calling – should be, "I feel wanted here."
2. Listen to patients.
   Coach staff on the importance of  giving patients a chance to express their thoughts and feelings. Whether a simple request or a complaint, patients want to be treated as individuals and to know you care.
3. Use names.
   Encourage staff to always introduce themselves and call patients by their desired address (Mr., Ms., or Mrs.) and name. It makes the encounter memorable and personal.
4. Be prepared to help.
   Front office staff should act as the patient's guide and advocate through the administrative details.
5. Go the extra mile.
   Helping patients navigate the unfamiliar check-in process, a long wait or other events can make a lasting, positive impression. Encourage and reward employees who look for opportunities to show empathy and understanding.
6. Show respect.
   Staff members who keep patients informed about delays and apologize for them show respect for patients' time. Also, employees who speak to each other with civility help defuse the inevitable tensions of a busy medical practice. The same goes for administrators, supervisors, clinical personnel and physicians.
7. De-stress.
   Don't let staff skip lunch breaks or any other opportunities for short breaks that you offer during the day. Stress on the job without any let-up leads to lower performance, fatigue and a host of other problems that won't put people at their best.
8. Defuse office politics and gossip.
   Administrators and supervisors can't directly enforce this, but they can set the example. Steer clear of gossiping about patients, other staff and physicians. Keep an eye out for squabbles and mini power struggles between staff. Gossip and office politics destroy morale. An atmosphere of trust and respect makes the day run much smoother and everyone wins – patients, the physicians, your coworkers and, most of all, you as the successful administrator.
9. Teamwork works.
   Praise workers who jump in to help others. Provide opportunities for training and elicit employees' suggestions for improvements. This isn't just about being a nice boss; it's about getting people to give their best, which most will do when it is appreciated.
10. Communicate.
    Show employees that every interaction they have with patients, workers and physicians is an opportunity to get things done – and done right. Communication makes all types of businesses, including medical practices, run and serve their customers (patients) better.

Training and motivation are critical factors in getting workers to give their best every day. Patient loyalty is built on good first impressions, which is why there's no letting down for those who manage front office staff.

MGMA members frequently share interesting stories on the MGMA Member Community. Here are a few in the realm of patient antics – the quirky things patients actually have done in practices and how administrators recommend dealing with them.

Note: All names have been removed to protect privacy. The information provided here does not constitute legal advice and is intended only to share administrators’ experiences. Consult your attorney for legal advice.

If a patient or patient's relative records or videotapes the visit via cell phone

MGMA members offered these tips:

• Post a sign in the lobby and visit rooms that states: "Due to confidentiality reasons we strictly prohibit the use of any photographic equipment including cameras, video equipment and use of cell phone cameras."
• Add the policy to your employee handbook, too. For example: "Camera-equipped phones or phones equipped with recording devices are prohibited from all patient areas of the Clinic and unauthorized photos or recording are prohibited by staff or patients. If you notice patients taking pictures in the Clinic, please notify your manager. Pictures obtained of other patients without their permission can be a violation of HIPAA confidentiality rules, and we need to address this directly with the person taking the pictures."

If a patient harasses one of your employees via a social network

True story: One MGMA member's employee told her that a 17-year-old patient of the practice was stating via Facebook that the patient would call the practice's management and try to get her fired. Here's what administrators in the MGMA Member Community recommended:

• Consider this a personal, not a work issue. Because of the patient's age, advise the employee to be careful when associating with the patient outside the workplace. Also, if the patient is a Facebook friend of the employee's, recommend "unfriending" the patient or reporting the harassment to Facebook.
• If the employee is involved directly in patient care, ensure that the next time the patient visits, the employee has no interaction with the patient. If that's not possible, have another employee stand witness.
• Attempt to understand both sides of the story. One member said that if you consider this a work issue, call the patient's parent(s) and find out what the parent(s) knows. 

If a patient complains about administrative fees for medical record copies or other forms requiring doctor authorization, such as disability, Social Security and Family and Medical Leave Act forms

Administrators and patients have strong opinions about this issue (which we've blogged about before). MGMA members on the community examine both sides of the story:

• "Completion of forms is part of doing business, as long as it is not in excess," says one administrator. Consider limiting forms to three per calendar year, then charging a nominal fee for extra forms. If a patient complains, you could adjust the fee so you won't lose a patient. Odds are you spend much more in marketing to attract one patient than the cost of filling out the form.
• Unfortunately, many small practices cannot afford increasing overhead costs. "When faced with reducing the quality of care or service," says another administrator, "an admin fee can be a very reasonable response to an unreasonable circumstance for many practices." Explaining "why" to patients is often sufficient to get them on board with the fees.
• No matter how you handle the situation, charging for forms isn't just about the bottom line – it's about managing expectations. "We charge for forms because [they have] value," says an administrator in the community. "We charge for no-shows because ultimately it is our time you are paying for. A nurse answers the phone because it is cost effective and your in-depth questions require a visit which, yes, will require you to pay your copay. If we don't value our services, the patients never will."

Have you dealt with any of these in your practice? Tell us how you solved a sticky patient situation.

By Nick Fabrizio, PhD, FACMPE, FACHE
Principal, MGMA Health Care Consulting Group

With the trend toward integrated care continuing, perhaps a health system is eyeing your medical practice for partnership or ownership. There are several reasons why physician practices might want to form a collaborative relationship with a health system. But before your practice does, you'll want to be prepared.

If your practice hasn't yet integrated or is on the path to integration, here are 21 questions you should answer:

1. Why do you (your medical group and the hospital) want to integrate?
2. How many other physicians has the health system already approached in your specialty and other specialties?
3. How many physicians does the health system already employ or have a financial or legal relationship with?
4. How many physicians does the health system have a relationship with in your specialty?
5. How many months/years has the health system worked with those physicians?
6. What does the health system's medical staff plan look like: the number of physicians that work in the hospital, their specialties and specialties they're trying to recruit?
7. Is the health system successful operationally and financially? At physician recruitment and retention?
8. What is the scope of my power and authority as a medical practice administrator should we form a relationship with the health system?
9. How does the health system's administrative structure support medical group management? (Look at the organizational structure and the number of full-time-equivalent staff (FTE) members dedicated to medical group management.)
10. Does the hospital support several EHRs or practice management systems, or will the practice have to migrate to new systems?
11. How will the EHR be supported? Is there a hospital information technology (IT) staff dedicated to the medical group?
12. Who will handle billing and collections for the practice and how is their performance?
13. What do the financial and productivity reports generated by the hospital/billing company look like?
14. How will hospital staff support the practice (IT, billing, human resources, etc.)?
15. Will the medical group be charged overhead, for example, a percentage of collections or allocated FTEs?
16. Who will be the main administrative contact at the hospital? What is his or her level of decision making and other responsibilities?
17. Who will be the spokesperson for your group and the key negotiator? 
18. Is everyone in your medical group committed to proceeding with a negotiation and data exchange?
19. After integration, who will take care of the medical group's office (cleaning, maintenance, supplies, etc.)?
20. What is your medical group's plan for telling staff about the integration?
21. Do you know what will change right away in your practice vs. what will change in phases? (This includes benefits, compensation, total number of staff support, etc.)

As you can see, we have not even discussed compensation. Unfortunately, compensation is where most groups start. However, failure to address these issues will negatively affect compensation regardless of what the first year's integration looks like.

In addition to these questions, you can use this checklist I developed to ensure that you address the factors that contribute to long-term IDS success.

Is your practice pursuing integration? Leave a comment and share your experience.

You've heard every excuse in the book from your patients on why they can't pay their medical bills. But have you considered that your medical practice employees may be contributing to the problem?

In healthcare, if you want to make money, you have to ask for it. For some physicians and employees, this can be an unwelcome aspect of their jobs. Compassionate staff may be reluctant to ask, or not know how to ask for payment during patient check-in.

Thankfully, this culture is reversible. MGMA member Annette Hai, RN, RNFA, CPC, ACS-UR and practice administrator for  Affiliates in Urology in Westland, Mich., successfully transformed the practice's collection culture. In three years, she increased upfront collections to 98 percent. When employees and patients understand that the practice has to cover its costs (or go out of business) both parties can become more eager to do their part.

MGMA members can log in and read the article about Hai's methods in the MGMA Connexion magazine to find out how she did it. Enjoy this excerpt, featuring some sample scripts that will make your front office staff more comfortable when faced with financial questions.

Sample scripts

Patient: "I didn't know I owed this."

Response: "Your insurance company and our office sends statements informing you of your obligation. We call all patients with balances and remind them that payments are due. We called you on _______. The doctor has performed a service and should be paid for it."

P: "I don't have any money with me."

R: "We accept all major credit and debit cards. We do require patients to pay for the services the day they receive them, and did inform you of our office financial policy. It is your responsibility to know your insurance and pay for the portion that is not covered. Would you like to go and make the payment or reschedule your appointment?"

P: "I forgot my checkbook."

R: "We accept all major credit and debit cards. I can swipe your card today and preauthorize any future payments so you won't have to worry."

P: "I mailed a payment just yesterday."

R: "Oh, you should have saved the stamp since you had a scheduled appointment and brought the payment with you. That way we would have no questions about a payment being due. I can swipe your credit card and preauthorize a payment. We won't charge your credit card unless we don't receive the payment."

P: "I just lost my job."

R: "I am so sorry. This is affecting so many people. Unfortunately, we are being affected by this economic downturn as well, and unless we collect what is owed, we can't pay our bills here and then we are at risk of losing our jobs. I can offer you a payment plan or refer you to a subsidized clinic."

P: "I'll pay you after the doctor sees me."

R: "I understand your frustration and know that this may seem unusual, but we are bound by our contracts with the insurance company to collect from patients before they are seen. We don't make these rules but are forced to follow them and pride ourselves on running an ethical and legal practice."

P: "I never had to do this before. No other doctor's office does this."

R: "I can't speak for other offices, but we are following our contract requirements with insurance companies or our office policy. I am sure you will start seeing this more in the future. We pride ourselves on being recognized as one of the top 10 urology practices in the country for our administrative procedures since we really try to do everything to the letter of the recommended practices."

Do you use sample scripts in your practice? Share in the comments.

By Jeff Milburn, MBA, CMPE
Independently contracted consultant, MGMA Healthcare Consulting Group

Lately, there's been a lot of discussion about the relatively new healthcare delivery concept called accountable care organizations (ACOs). ACO are networks of providers (physicians and hospitals) working together to provide a higher level of care at a reduced cost under the banner of coordinated care. And healthcare reform legislation passed earlier this year authorized Medicare to contract with ACOs.

The theory behind ACOs is that existing or soon-to-be formed integrated delivery systems and physician hospital organizations will come together to coordinate medical services to a discrete population of patients. The ACO will receive funding in amounts and methods yet to be determined, which raises at least three questions:

• Will the amounts be adequate?
• How will the funding be divided among providers?
• Who will decide how the amounts are divided?

These questions are especially important for independent physician practices that are not part of an ACO but offer services the ACO doesn't to that organization's patients. If you're a practice administrator who works for a smaller practice, it's critical that you understand how the funds will flow when dealing with an ACO. 

Ensure adequate funding

Will the funding be adequate to pay all of the providers inside and outside of the ACO at a level that will cover basic costs and be comparable to reimbursement from other sources? Keep in mind that the cost of providing care to ACO patients may be higher due to case management and reporting aspects.

What happens if funding is inadequate over a period of time? Is your reimbursement guaranteed? Will you be required to share the losses? Are there limitations, or floors, on the amount you could lose? It may be necessary to get actuarial assistance to answer some of these questions.

Know how funds are allocated  

This is a two-part question: How will the funds be divided and who decides how they are divided? This reminds me of the health maintenance organization (HMO) capitation days when the payer contracted with the hospital and a large medical group for a percentage of the premium. The payer frequently would have the most accurate data for the patient population and dictate the fair share of the premium for everyone involved.

If you experienced losses in your practice, you provided more services than necessary. If you made more than a reasonable profit regardless of the reason, the payer could reallocate funding to the participants for a more equitable distribution.

It will be critical for all the stakeholders in an ACO to believe they are being treated equitably and, if not, at least equally unfairly. If financial risk is involved, performance transparency will be mandatory. And remember the golden rule: He who has the gold makes the rules.

Tips for providing services to ACOs that your medical practice has no direct stake in:

• Negotiate a contract with reimbursement that has no risk and pays market rates.
• If you are required to take risk as part of the deal, limit the amount of risk with a minimum reimbursement floor.
• Assuming you are required to provide unlimited services for fixed reimbursement, carefully define the type of services you are willing to provide. This will help manage your exposure to loss.
• Negotiate for your share of ACO surpluses. When downside financial risk is involved there should also be financial awards when your practice does a good job managing patients and meeting quality benchmarks.
• The agreement with the ACO should be well documented under a contract. Short letters of agreement and handshake deals tend to fall apart when disputes arise.
• Determine all of your responsibilities under the ACO agreement. These organizations will probably require varying degrees of physician participation that will not be compensated.
• Check if ACO patients are required to use your services. Do you have a monopoly and adequate volume that is worth a discount on services?

These suggestions certainly aren't all inclusive. The main idea is to protect your organization when making an arrangement with an ACO (read more in MGMA Connexion magazine about ACOs, login required).

Remember, the ACO concept is in its infancy. Although the early development generally relates to Medicare patients, it is almost certain that this concept will expand to commercial patient populations. This certainly resembles the HMO capitation concept that also promoted quality and preventive care through coordination and fixed reimbursement that involved risk.

You can expect to see a variety of ACO models develop with many payment schemes ... I mean methodologies. ACOs have many positive goals and objectives. Just be sure to understand the financial ramifications.

Guest blog by Elizabeth W. Woodcock, MBA, FACMPE, CPC, healthcare speaker and co-author of Operating Policies & Procedures Manual for Medical Practices, 4th Edition

Does your medical practice have a written policy for employee professional appearance? If so, have you recently revisited that policy?

Having a professional image is important for your medical practice to stay competitive. If patients see professionalism, in addition to receiving courteous treatment and quick service, they will be impressed.

You may think that setting guidelines for professional appearance is more difficult today than in years past, but women's skirt lengths and men's long hair used to challenge human resources managers. Now it's body piercing, tattoos and skimpy clothing.

Whether it's the 1970s or the 2010s, these issues have a common source – people declaring themselves as individuals or maybe not knowing what's considered "professional." Either way, today's medical practice administrators and human resources managers must know where to draw the line so the group practice projects a competent, professional image.

It isn't easy to address a workforce that comes from multiple generations, backgrounds and beliefs. This is where a written policy (and the book Operating Policies & Procedures Manual for Medical Practices, 4th Edition) can help.

Instead of "dress code," think "professional appearance."

Stress in your written policy, and in its enforcement, that the policy is for the image your practice wants to project to its patients and the community.

While your policy may need to have a few very obvious examples of what you consider unprofessional (tank tops, hooded sweatshirts, etc.) don't get too detailed. Fashion trends change too quickly for you to include every possible contingency. Who could have predicted surgically implanted horns or other 3D body art? Or the "urban kilt" for men? (Although I’m OK with that one personally, some long-time patients of the practice might not be able to adjust.)

In addition to becoming dated almost overnight, an overly detailed dress policy leads employees to get lost in the details instead of focusing on the "professional presentation" concept.

Explicitly state dress code parameters.

Your professional appearance policy should also address other important details of how you want employees to present themselves, such as:

• Clothes must be clean, neat and in good condition without tears or obvious stains.
• Employees must maintain clean personal hygiene, address body odors and avoid strong perfumes.
• Hair must be clean, neatly trimmed and contained in such a manner that it does not come in contact with patients.
• Hairstyles, hair color and cosmetics should project the practice's professional image.
• Jewelry should be small and simple. For example, earrings may be visible on the ear only and cannot obstruct work.

And if you don't want staff tattoos or body piercings visible at work, say so in your policy.

Consider uniforms.

Many physician practices are moving toward uniforms because they solve a number of problems. Some employees may have difficulty figuring out what to wear to work. Subsidized uniforms also can alleviate some of the financial pressure employees (especially those on the lower end of the pay scale or those who are sole breadwinners for their families) might feel as they attempt to comply with your dress code.

If you go the uniform route, consider these ideas:

• Establish a standard look by purchasing a full set of uniforms for each employee (at least five days worth is recommended).
• Buy shirts, scarves or other complementary gear and guide employees on how to mix and match.
• Extend a subsidy or discount for a line of dress you recommend from a Web site and allow employees to choose from a small menu of styles.
• Choose classy but stylish patterns. A soothing and stylish color palette looks more professional than the garish patterns and colors I see in some medical uniform catalogs.
• When introducing uniforms, make it fun by asking staff to vote on the three or four styles you've selected as finalists.

Restrictions on appropriate dress, jewelry and other matters of appearance can feel like an infringement on religious and cultural freedom to some. Make sure an attorney familiar with labor issues reviews your policy before you publish it.

Simply asking everyone to apply their own "good taste" leaves your practice's image in the community to chance. You don't have the time to scrutinize each employee's choice of clothing. Take the direct route to clarity and consistency by writing a concise professional appearance policy.

Download a sample dress code policy, excerpted from the Operating Policies & Procedures Manual for Medical Practices, 4th Edition book.

By Kenneth T. Hertz, CMPE
Principal, MGMA Health Care Consulting Group

"What?" you say. "We do treat our practice like a small business!" Perhaps, but that's often not what I find as I travel the country working with a broad range of medical practices.

Instead, I find firefighters putting out fires every day. Fix this problem in the front office. Mary is out today, who can fill in? The fax doesn't work. Each of these are important to the practice, but what I don't see is planning – developing strategic plans, budgets, marketing plans and recruiting plans.

It's more important than ever to manage your practice like a small business. A day in healthcare is like a day in any business: increasing demands for information, new ways to leverage technology, improving customer service, increasing transparency, more aggressive compliance, reduction in revenue, increasing costs, and the list goes on.

Here are five simple recommendations to look at your practice through a new lens.

1. Know who your customers are.

Your customers are your patients, and they hold the keys to your business's success.  As a medical practice administrator, you must ensure that your practice is patient-centric. While healthcare is your product, service is your business. 

2. Continually educate yourself, your physicians and your staff on business news.

Whether from Seth Godin's or Fast Company's blogs, books by Malcolm Gladwell (don’t forget to see him at the MGMA 2010 Annual Conference in New Orleans) BNET or the Wall Street Journal, find out what is happening in the world beyond healthcare and share it with your physicians and staff. I don't often see managers growing beyond the medical field by reading Peter Drucker or John Kotter. Taking care of yourself helps you take care of the practice.

Sign up for RSS feeds from a broad range of sites. Learn about what's happening in other specialties, locations and industries. Keep abreast of changes in healthcare, including new payer and payment strategies, alignment strategies and organization structures. Evaluate news and information from both sides of the equation: provider and business owner. The impact may be different depending on which side of the equation you're on.

3. Failure to plan really does mean planning to fail.

Successful businesses plan for the future. Develop a vision and mission for the practice by:

• Creating and monitoring an annual operating budget
• Evaluating new service lines
• Considering alignment strategies

Look at capital needs several years out, particularly in light of new technology demands such as electronic health records.

4. Become a proactive, not reactive, manager.

Meet tasks head-on instead of waiting for them to become challenges or issues, especially when it comes to your employees. Some ways to be proactive include:

• Manage your costs
• Review and evaluate your insurance coverage every year
• Understand capacity, process and work flow and staffing needs to ensure rightsizing in your office
• Actively recruit, train and retain the best staff possible
• Understand the different generational needs of your employees

5. Instill a decision-making discipline in your practice.

Many practices I work with have no processes in place to make decisions. Decisions are made – eventually – but the process is almost as painful has having your wisdom teeth extracted without Novocain. Often, managers don't want to address this, but you've got to.  

In this rapidly changing healthcare environment, your practice’s ability to survive will depend on your ability to make timely, thoughtful decisions. Learn how to assemble information, review and engage stakeholders in an evaluative process; make a decision and stick to it.

All your day-to-day tasks, such as revenue cycle management, managing denials, and having physicians complete their EHR entries and sign them, are very important. Fail to get them right and the practice will experience severe problems. But fail to set a strategy and your practice may not be well-positioned for the future.

Want to ensure that you and your business owners have done your best to protect and position your medical practice for longevity? Back up from the day-to-day fires and look at your practice through a business prism.

What advice do you have for treating your practice like a small business? Share in the comments.

By Cindy Dunn, RN, FACMPE
Senior consultant, MGMA Health Care Consulting Group

Editor's note: This blog is part of our "back to basics" series, a broad overview of key topics medical practice administrators use in their daily jobs.

Nonphysician providers (NPPs) are trained and licensed clinicians who can provide medical care and billable services. Some NPPs – such as certified registered nurse anesthetists, physician's assistants or surgeon's assistants – function under the direct supervision of a physician. Others may work more independently, such as nurse practitioners, optometrists and physical therapists.

Adding an NPP can increase the efficiency and effectiveness of your medical practice; more patients can be seen, physicians will have greater flexibility to see other cases, and it can enhance the level of revenue your providers generate. Plus, the direct and overhead costs associated with NPPs are relatively low when compared with physicians.

Who are NPPs?

Generally they are:

• Nurse practitioners (NPs)
• Certified nurse midwives (CNMs)
• Certified registered nurse anesthetists (CRNAs)
• Clinical nurse specialists (CNSs)
• Physician assistant (PAs)
• Clinical social workers
• Clinical psychologists (PhDs)
• Nonclinical psychologists
• PT, OT, Speech pathologists

In medical practices, NPs and PAs are most commonly employed.  There are many similarities between the two:

• An NP is a registered nurse (RN) who also has a master's degree and clinical experience. A nurse applying to become an NP usually has a bachelor of science in nursing degree.
• A PA is a healthcare provider who practices medicine under the direct or indirect supervision of a licensed physician. A typical PA program takes two years to complete. All states and the District of Columbia require a PA to pass the Physician Assistant National Certifying Examination (open to graduates of accredited PA programs).

Protocol requirements

The scope of practice, licensure and credentialing requirements for each NPP are established by state laws where the NPPs practice. Investigate what, if any, protocols are necessary to keep at the practice. Protocols outline the medical aspects of patient care agreed upon and signed by an NPP and a physician. They usually need to be reviewed and signed at least annually. Your state's medical and nursing boards have specific protocol requirements for NPs and PAs.

Typical job duties and training

Before you hire an NPP, analyze the benefits one would bring to your practice  as well as the issues that can cause headaches (MGMA Connexion magazine articles, login required). Review the job description and clarify expectations with the NPP before employment begins. In the practice, NPPs typically:

Clinical

• Obtains patient histories and performs physical examinations
• Orders and/or performs diagnostic and therapeutic procedures/tests
• Formulates working diagnoses for patients
• Develops, implements  and monitors therapeutic effectiveness of treatment plans
• Documents in the patient medical record all pertinent clinical findings in standard subjective, objective, assessment and plan format
• Assists physicians with in-office and hospital surgical procedures; performs other clinical duties as directed by supervising physician(s)
• Provides patient counseling, education and coordination of care as necessary
• Makes appropriate patient referrals to practice physicians and other healthcare providers
• Lends assistance and provides solutions to scheduling personnel for patient triage
• Participates in clinical meetings
• Performs call and hospital responsibilities as scheduled and/or requested by doctor

Administrative

• Reports to practice administrator for personnel matters
• Coordinates with clinical manager regarding operational issues, such as patient scheduling, medical assistance provided by certified medical assistants and RNs, and other patient flow matters
• Completes the provider section of managed care referral forms for specialty care and/or diagnostic testing
• Completes the clinical portion of third-party payer inquiries and disability forms as required/requested
• Helps order medical supplies and equipment as requested

Teamwork

• Works at and/or with any facility/doctor doing whatever is necessary to get the job done
• Proactively supports company policies, philosophies and decisions; seizes opportunities to positively influence support staff
• Facilitates a shared expectation of success within the support staff team; sets a personal example by "pitching in" when circumstances demand
• Listens to and accepts constructive suggestions from management team; seeks out others' point of view and actively participates in problem solving process

One sometimes overlooked item is training: NPPs, regardless of experience, will need the physician to explain how he or she envisions using NPPs' services. This is essential to a better return for patients and the practice.

Billing and payer reimbursement for services

Understanding billing regulations will ensure medical practice compliance with complex Medicare regulations and increase NPP reimbursement revenue.

Individual payers (state, federal and private) typically set criteria for reimbursement of NPP services, and these differ from state to state. Historically, some payers have attempted to exclude the services of some NPPs from reimbursement. Today, most payers, including Medicare and Medicaid, recognize NPPs' services, which requires the medical practice to complete the same credentialing process followed for physicians. Practices that use NPPs in hospital settings face the same hospital credentialing process as they do for their physicians. 

Medicare rules only apply to Medicare billing. Many commercial insurers follow some or all of the Medicare guidelines. Contact your commercial insurers and request their billing policies in writing. In some instances, your practice may be reimbursed for services covered by commercial insurers that Medicare will not cover.

• Medicare billing guidelines
  
  Your medical practice can bill Medicare directly for NPP services or under the "incident-to" guidelines. If the practice bills directly, services are reimbursed at 85 percent of the Medicare fee schedule amount. "Incident-to" billing services are reimbursed at 100 percent (same as billing for the physician). All NPPs must have a Medicare National Provider Identifier to bill Medicare directly. Learn more about avoiding the pitfalls of Medicare's 'incident-to' rules in the MGMA Connexion (login required).

The recent release of the final meaningful use requirements moves electronic EHR incentive money one step closer for medical practices. But before you worry about meeting the "core" and "menu set" requirements, first identify which EHR stage of adoption you're in – purchasing, implementing or optimizing – so you can make smart business decisions along the way.

MGMA recently interviewed Margret Amatayakul (known as Margret A), author of Electronic Health Records: Transforming Your Medical Practice, 2nd edition, to get her perspective on how EHRs have changed and what she hopes for the future.

Margret A has a long string of certifications: MBA, RHIA, CHPS, CPEHR, CPHIT and FHIMSS, but don't be intimidated.  If you don't have an EHR, the book provides a step-by-step process for preparing your practice. If you do, the book helps you optimize its use.

MGMA: What drives your passion for EHRs so much that you wrote a book dedicated to them?

Margret A: My passion derives from my early interest in combining healthcare and business as career interests, and especially using information technology to improve effectiveness and efficiency. Between grammar school and high school my parents sent me to the Illinois Institute of Technology to learn computer programming – using keypunch cards and a gigantic mainframe!

MGMA: You've always been on the forefront of this technology. In the past 10 years, what are the greatest changes to EHRs that you've witnessed?

Margret A: In the past 10 years, products have matured, but true users have become ever more sophisticated in their desires – with the result that vendors have a difficult time addressing new and unsophisticated users and those who want much more.

Of course, within the last couple of years, federal promotion of EHRs and offer of stimulus money have created the impetus for those who have been reluctant to use and/or spend. I've been through four decades of applying information technology to healthcare, and I suspect it will take at least another decade for EHRs to become ubiquitous. Today, some practices are recognizing that EHRs are becoming a cost of doing business; I hope it will become the benefit of practicing quality healthcare. 

MGMA: In the book you cover everything from a vendor demo sample schedule to sample layouts of EHR workstations. Which portion did you enjoy coaching readers on the most and why?

Margret A: I am a very firm believer that success with an EHR follows an 80/20 rule. Eighty percent of success from EHRs comes from planning and addressing what I call the "people, policy and process" issues. While I like to work with technology, I find that you can take any solid EHR product and, with a great job of preparing users, redesigning workflows and solid training, achieve great adoption; just as it is has been widely observed that a "superior" product can be poorly implemented with few using it successfully.

MGMA: Which phase do you think presents the most challenges when adopting an EHR: the prepwork, the implementation or the optimization? Why?

Margret A: Each phase has its own challenges, and they are also dependent upon each other. Many of my clients think that once the vendor selection process is over, the rest is easy. I remind them that not only is the implementation the real work, but if they have not done sufficient prep work, the implementation and optimization phases will be even more work.

Probably the most challenging aspect of adopting an EHR is gaining physician engagement throughout the entire process – from spending time studying and defining requirements to reviewing templates and decision support rules thoroughly and monitoring results. One of my physician clients observed that his colleagues often understand EHRs at the intellectual level, but do not appreciate them at the intestinal level until they use them. The problem is, such lack of preparedness results in loss of productivity, shortcuts and, hence, less than desirable use of the system in the end.

MGMA: Selecting the "right" EHR for the practice can be overwhelming. What advice do you have for administrators in this situation?

Margret A: I've suggested why I believe a practice should plan thoroughly, but do not get into "analysis paralysis." EHR is a big investment, and I understand that practices want to get it right the first time. However, getting it right has a lot less to do with the product than the process of educating oneself about EHRs in general, implementing change management and constantly pushing oneself to use ever more of the system.

MGMA: This book is great for practice administrators, but also includes information for physicians. How will physicians benefit from the information?

Margret A: Many have written or spoken about the importance of managing change, addressing workflow and process redesign and educating users. There are still many physicians who believe they can turn over the process of selection to an administrator, have the vendor implement the product in a week, and expect the EHR to be sufficiently intuitive that they do not need to spend time being trained how to use it.

But a tool that is becoming close to being a medical device (something being discussed today by the FDA and others) should be treated with the respect of medical devices. Hopefully, the book also emphasizes that an EHR impacts all stakeholders in the practice – administrators, front and back office staff, nurses and physicians.

Another favorite mantra of mine is that an "EHR is not about automating the chart; it's about automating and using information to improve health and healthcare." To get the most out of the EHR, physicians must learn to push information-related processes to staff and patients, with the result that staff will free up time for physicians to use the EHR most effectively, and patients will be more engaged and compliant with treatment, wellness and prevention regimens. EHR has been said to be technology that creates a clinical transformation – and I truly believe that.

Is the only time your patients talk to their doctor during a 15-minute visit? If so, patients may feel more like a number and less like a person. Or, they might be confused about their follow-up care.

A recent MGMA e-Source newsletter article reported that more doctor communication equals better patient care. Fortunately, there are plenty of ways to support the relationship patients have with providers, leading to greater patient satisfaction and the No. 1 priority of your practice – quality care.

1. Help patients ask the right questions

Empower your patients – and help your physicians at the same time – by educating them before their visit on what they should ask their doctors. The Agency for Healthcare Research and Quality's "Questions Are the Answer" site provides helpful tips for patients to give and get information from doctors to prevent medical errors. The site even allows users to build and print their own question list.

2. Adopt an EHR

Physicians will spend less time with charts, more time focused on patients. Plus, the information from patients' personal health records can be shared with them during the visit, helping them to feel more confident that their doctor is ahead of the technology curve.

3. Encourage feedback about your patients' experience

Place feedback forms in your waiting room, have a Web form on your Web site and even have physicians hand out feedback cards to patients after their visit. Being open and welcoming to feedback will encourage patients to be honest and may reveal some opportunities to enhance communication with their doctors.

4. Use e-mail

Convenient for patients, e-mail is less disruptive on your front office staff (think triaging phone calls) and can be answered during scheduled hours instead of right away. Offer a structured form on your medical practice's Web site that allows patients to chat with doctors, as well as choose from a variety of options such as: refilling prescriptions, requesting an appointment and getting test results. (MGMA members who use MGMA AdminiServe partner Medfusion get a discount on these services.)

Note: All sensitive health information must be delivered through a secure Web link and Web site, rather than by attaching it to the e-mail itself. Read a doctor's perspective in "Making Web visits work for your practice" from the MGMA Connexion magazine.

5. Make it all about the patient

What your patients experience before they talk to a doctor can affect how they feel about him or her. Employ compassionate staff who love to work with people and convey that each patient is a valued individual.

6. Accommodate foreign language speakers

If your patient base includes those who speak other languages, ensure that doctors and clinical staff can communicate with the patient before agreeing to see them. Also, ensure that signs in the practice, prescriptions and patient statements include translations for non-English speakers. Through MGMA and the AHRQ/HRET you can order patient safety resources in Spanish and English.