Yearly Archives: 2013

by Joe Capko Frequent readers of this blog will appreciate that we consistently recommend that management foster a culture of support and mutual respect toward all staff.  Consistently, the best-run practices  invest in their employees and, correspondingly, reap the benefit of a highly-motivated, creative and responsible staff.  While we still advocate such an approach, one recent study that looked into the effects of electronic monitoring on restaurant workers got us thinking that there may be relevance to the medical practice. As in medical offices, employee theft is a considerable problem in the restaurant industry. It is estimated that 1% of revenues are lost to theft – a huge problem when profits average, as in the casual dining segment studied, about 3.5% of revenue.  The study, Cleaning House: the Impact of Information Technology Monitoring on Employee Theft and Productivity (), found striking changes in staff behavior upon the start of employee monitoring. The employee monitoring was via the algorithm-based Restaurant Guard product sold by NCR and can be integrated with their POS systems.  This electronic system is designed to flag employees that have a relatively large number of suspicious activities within the IT system, e.g., transferring a food order from one table to another, voiding partial orders, etc. To cut to the chase, bottom line revenues increased dramatically – almost a three thousand dollar a week!  What is perhaps most surprising is that the vast majority of the increase to the bottom line was a result of improvements on the sales side – meaning that while employees stole less, they also actively sold more, especially more high-margin drinks. Restaurants are particularly vulnerable to this type of theft because they tend to be high-volume enterprises with a relatively large number of cash transactions.  Nonetheless, with patient financial responsibility being an ever increasing part of your practice, we have to accept that the consequences of theft can be direr than ever for medical practices, too. It’s our hope and expectation that EHRs and practice management systems will eventually offer tools to alert busy managers to irregular patterns in staff behavior that may indicate theft. 

It almost always starts out the same way. A practice (usually a small one) loses its manager, or has its first financial troubles and realizes it really needs a professional manager, and one partner says innocently enough, "What about my wife?  She's got an amazing corporate background, and is getting bored at home with the kids.  She could work for a few months part-time, get us turned around, and then we could hire someone permanently." It sounds like a perfect solution.  After all, aren't the partners' spouses goals the same as the partners?  Who can we trust more than one of our wives (or husbands)?  Besides, it's only temporary .... After those few months, the miracle replacement manager who could be as loyal/smart/affordable as the partner's wife has, predictably, failed to materialize. And everyone is so grateful for the "magic" the temporary manager has pulled off -- it seems like she has literally saved the practice from bankruptcy! -- why would we want to replace her? Years go by.  The manager amasses more and more control over the business side of the practice. Maybe she seems a little insulted when you ask about the status of a particular account, or why a particular vendor has been getting paid so much. Then, little by little, some of the partner discussions that used to guide financial decisions stop happening.  The manager, after all, is "almost like a partner" anyway.  No one feels comfortable confronting or curtailing the manager -- their dear partner's husband (or wife) -- so problems fester.  The manager wants more pay -- argues it's "market rate" -- who will be willing to contest this?  The festering worsens.  The manager's productivity analysis seems to always favor her husband at bonus time.  Resentment is growing, bottled up.  Is the practice earning all the revenue it should?  Are payer contracts negotiated to best advantage? Nobody knows, and nobody feels comfortable asking. And what if the practice has new financial problems a few years down the road?  Where is our heroine now?  She's doing her best to appear neutral and professional, while simultaneously

We're looking for feedback on drug/device/technology rep behavior -- specifically, what kinds of behaviors are likely to trigger the opposite of the reaction reps are hoping for, making you disinclined to want to spend time listening to a pitch?  What's really annoying -- even disruptive to your practice? And, on the flip side, if there are any things reps have done for your practice that have been surprisingly welcome, helpful, etc., we'd love to hear that, too! All responses to the survey will be strictly anonymous (you don't even have to identify yourself if you don't want to), and will help us with an article we're writing that will help reps who want to learn how to connect more effectively (and less annoyingly) with the practices they serve. To complete the survey, click on this link - and thank you!

We're looking forward to participating -- it's open to all, so join in at 10am Pacific/1pm Eastern on Tuesday, 9/10. Follow us -- @CapkoandCompany Follow Kareo -- @GoKareo    

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Chances are good that your EHR includes some easy-to-implement patient portal features that can save your staff time and increase the profitability of your practice.  As an example, consider your current intake process for new patients. Most practices still use a paper form that is filled out by patient at the time of the first appointment and that is subsequently re-entered by staff into the EHR – a needlessly cumbersome and tedious process for the patient and staff.  Fortunately, almost all EHRs that include patient portals can help automate this process, sometimes completely. In the best implementations, patients can log-in to the portal and complete their forms whenever they prefer – and the data entry task for your staff essentially disappears, saving time and eliminating possible errors.  How might this feature alone affect your bottom line? Paul Louiselle reported in the Journal of Medical Practice Management (Nov/Dec 2012) that his pediatric surgery practice will save roughly $23,000 in staff time in the first year alone by automating new patient intake forms. Many duties of your front desk staff are highly repetitive and, as such, are potential opportunities for automation.  We take for granted phone trees that can help by providing directions or hours of operation in addition to simply routing calls, but it’s important to remember that at one point even these phone systems were cutting-edge technologies.  Patient portal functionality, will become ubiquitous in coming years - the sooner you implement, the more your practice can profit.  If you cannot take on another task, don't get discouraged. Many practices we help have existing staff that will embrace a new career challenge – understanding the potential for a patient portal to help your practice can be a wonderful opportunity for one of your staff to really shine. Among their many functions, patient portals often offer secure electronic communication between patients and physicians, lab results, prescription refills and other clinical features. The adoption of these and other clinical functions warrants caution.  Physicians are often and rightly concerned about how communicating with patients via the patient portal will affect reimbursement.  Physician owners or practice

Judy's webinar and follow-up Q&A on patient-centered medical homes (PCMH) are now available on Kareo.com at the following links: Q&A Webinar    

Several media outlets have reported that UnitedHealthcare has just unveiled new capabilities on its MyUHC.com patient portal that allow patients to make credit card payments for their portion of their care (e.g., deductibles, co-insurance) and better understand how the sharing of financial responsibility works.  UHC promises that the site will help make members more educated consumers about their healthcare -- presumably encouraging them to be more judicious about spending by raising their awareness of the costs of care.  The on-site demo shows that the site will offer at-a-glance summaries of all their accounts -- out-of-pocket spending, progress against deductible, even utilization of FSA and HSA accounts. The information side of this -- implemented with help from InstaMed -- looks like a huge leap forward.  Will patients embrace the payment portion as well?  It will also be interesting to see how the patient payment portion plays out for practice collections.  For example, will practices be able to easily log in to confirm that a patient has made, say, a pre-payment needed before surgery?  What reconciliation tools will be available?  And will patients be more likely to request "bill me" because they'll say they plan to pay at the portal?  The portal also is expected to allow patients to "easily" dispute claims -- what does this feature mean for practices? Another open question: the demo states that the ability to make payments may not be available for all plans.  Will this lead to more collection confusion for practices with UHC patients?  On the plus side, anything that clarifies the portion of the bill that is owed by patients -- and places the responsibility for that breakdown on the health plan, not the practice -- is bound to ease the burden practices face to explain large amounts owed to bewildered (and sometimes unhappy) patients.  Practices might even encourage patients to look up and verify their amounts due while at their front desks. Have any readers received communication from United about the new portal at their practice? To read more or check out the demo: UHC Adds Provider Payment Service to Member Portal [Health

Penny Noyes's recent webinar for Navicure provided a boatload of helpful info about working with payer contracts -- for free and with CEU credit from AAPC to boot! Check it out here: Working With Payer Contracts - Increase Your Reimbursement

Recently, we worked with a practice that was spending several minutes on the phone -- sometimes ten minutes or even more -- giving verbal driving directions to all of its new patients. Yikes! The practice did it for two reasons.  First, they believed that patients were frequently getting lost when relying on directions from the web -- and that this was causing patients to miss appointments or arrive very late; consequently, they thought the time investment was worthwhile to prevent these problems. Second, they believed that patients valued this "personal touch." Of course, there are numerous costs associated with spending so much time with each patient on a matter that really should be more automated.  Most immediately noticeable to us was the receptionists' reluctance to interrupt the lengthy process of giving directions to pick up other incoming calls, so other patients -- perhaps patients with urgent needs -- were frustrated in their attempts to reach the practice.  Voicemail piled up -- and, quite possibly, prospective patients may just have dialed the next practice on their list of referrals. The practice's assumption about the 'personal touch' was also problematic -- they genuinely believed people valued this extra time with a 'real human,' but, really, who wants to stay on the phone ten minutes or more, jotting directions that will have to be read while driving?  This is 'service' circa 1985 at best!  Worst of all, some of the patients who were familiar with the area might even have been a little insulted at the implication that they could not find the address without spoon-fed directions. Unfortunately, problems with mapping sites and GPS systems giving inaccurate directions to your practice are not terribly uncommon -- especially if you're located in a new office park or other location on new street.  Some street names are also prone to more user error -- for example, here in San Francisco, problems when people confuse "street" for "avenue" are legendary; a location on 4th Street could be a 30-minute drive from the same address on 4th Avenue at some times of the day.  But, even though your location might be more prone than others to these

An article on Entrepreneur magazine's website spotlights four ways any small business -- including a medical practice -- can be the victim of crimes committed by employees.  Worth a quick read: http://www.entrepreneur.com/article/227689?goback=%2Egde_4802172_member_266727166#%21

Join our founder, Judy Capko, for a free webinar sponsored by Kareo: "How to Implement a Successful Patient-Centered Program."  The focus of the webinar is the Patient-Centered Medical Home (PCMH) -- how to implement it and what it means, revenue-wise, for your practice.  Among the topics Judy will cover are: The seven guiding principles of the PCMH Key program standards and metrics used to determine and measure success How technology contributes to efficiency and reporting needs Appropriating payment based on value-added components To register -- for free! -- visit this page: http://go.kareo.com/webinar-info-web-20130821.html

Today's Physicans Practice blog has a great tip for primary care and urgent care practices: negotiate with payers for higher after-hours reimbursement.  A key negotiating point: compare costs for seeing the patient versus referring them to the ER (that ought to get some payer attention!). It's important to understand the differences between several different codes that apply (99050, 99051, 99053) to properly bill for services, and to establish a pattern -- read the full post to learn how: How to Code, Negotiate After-Hours Reimbursement at Your Practice  

The Washington Post has a great article today about criminals capitalizing on uncertainty and confusion about Obamacare to defraud patients, especially elderly Medicare patients. Scams involve contacting patients and claiming to be navigators from Obamacare calling to "set up your Obamacare card" or collect information "required to maintain Medicare."  Fraudsters make these claims to persuade victims to reveal financial and medical identity information. Read the complete article here.

A new Harvard Business Review blog post spotlights the benefits of friendships between team members in increasing employees' commitment to their work and their organization's mission.  A wide range of organizations -- from Southwest Airlines, to Google, to Zappos -- were noted as examples of companies that had achieved a high degree of comradeship, even a family-like culture, by instilling a sense of shared mission and purpose.  In turn, this creates higher performance and lower turnover -- not to mention a workforce that gets excited about showing up every day and contributing. The idea that a shared mission can enhance teamwork and performance is great news for medical practices! Employees are often drawn to the healthcare field because they share a sense of service to patients.  This common sensibility gives practices a big head-start on building bonded teams. Choosing employees who connect with your practice's culture and mission -- whether it be integrative medicine, leading-edge research, superstar surgery, sports medicine, community service, a high-touch, concierge model, or any other defining practice identity -- is the first step to creating a team that gels naturally.  From there, the key is allowing teamwork and bonds to form, and encouraging them as they develop.  Creating projects that allow staff to participate actively in extending your practice's objectives -- special clinics, marketing programs, patient satisfaction goals, etc -- is a great way to extend and build on natural connections between team members.  Be sure your team feels they have both the means to contribute to the mission and a voice, and you're on your way to creating the esprit de corps that is a hallmark of a high-functioning team.  

Turns out that even Google finds it difficult to hire the right people.  Google has a history of being notoriously single-minded in its quest to hire "the best and brightest."  In Google's case this meant that only applicants that had advanced degrees from elite institutions and graduated at the top of their classes need apply.  In a recent interview published in the New York Times, Google's Laszlo Bock, Senior Vice President of People Operations, discussed some surprises that emerged from studying Google's hiring techniques. If Google is right, virtually nobody is better than anybody else at interviewing prospective employees. High GPAs, test scores and skill in brain teasers are all practically useless.  According to Laszlo, the best interviewing questions are those that uncover both how a prospective employee behaved in a situation and their attitude toward a particular work challenge.  Using a consistent set of questions that probe an applicant's behavior - such as how they solved a problem - and attitudes seems to be most useful. Google now asks all employees to assess their management twice a year. In our experience far too few practices take the time review the performance of managers from the perspective of those that they manage. Employees should have an opportunity to rate their managers on their transparency, clarity and fairness. Providing honest feedback to managers is essential if they are to improve their performance. Performance in this case means increased staff morale, lower turnover, higher patient satisfaction and, of course, higher profitability. Leadership is often a week area within medical practices. Key leadership attributes are fairness, consistency and predictability. With a challenging day-to-day workload, many practice administrators and physician leaders fall short on these measures. These shortcomings affect not only staff morale, but also the bottom line since staff often disengage from refining office procedures that can improve patient care and profitability. Read the short interview here: http://nyti.ms/1cOFANS        

We give a lot of webinars, and we watch a lot, too!  It can be so tempting to do other things while the webinar 'plays in the background' -- but, then you pop your head up and realize you missed one of the more valuable tidbits.  You also realize that you're neither attending the presentation nor really doing a great job on your other work.  A bit of a lose-lose, as opposed to the multi-tasking you were aiming for. One of the best things about the internet is that so many great people are sharing their knowledge with the world -- often for free or at a fraction of the cost of a conference.  But, the information loses its value if you don't fully engage with the material. Today's Harvard Business Review tip discusses this very problem -- with a few great tips to get more out of any webinar.  Really, it all comes down to taking it seriously -- just as you would any presentation you weren't able to watch while writing emails or wearing your pajamas. By the way, the HBR tips focus on turning a webinar into an event -- inviting colleagues, distributing notes, etc.  But, if you're not able to do that, we have another tip for you:  Watch the recorded version of webinars that contain really important data -- either on a weekend or after the workday (i.e., at a time when you can put other things aside). Here's the link to the HBR tip.

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Recently, we worked with a practice that had been victimized severely by internal theft.  This theft was facilitated by the practice's failure to take advantage of EFT of payer reimbursements -- instead receiving checks from many of their contracted plans. The physicians had trusted the practice manager when she said that EFT had been elected whenever available (naturally, embezzlers always rely on goodwill from their employers!).  But, had the physicians been on top of HIPAA rules regarding EFT -- intended to standardize and encourage EFT by January, 2014 -- they might have been more skeptical of the manager's claims that EFT either "wasn't available" or "was in process." Checks received at your office can be a temptation for would-be embezzlers.  It's unfortunately not all that difficult to deposit checks made out to your practice to a different account (ATMs, for example, can be a way to deposit checks to an account with an entirely different name -- and, of course, some embezzlers are crafty enough to set up a new account for themselves with a similar name to your practice's). It's rare that a payer won't pay your practice electronically, direct to your account, if you ask them to -- and, in a few short months, there will be a standard for all payers to pay this way.  Be skeptical if an employee claims that it is difficult or impossible to avoid receiving checks in the office.  Even if you prefer to receive checks -- say, because you're concerned about matching up advice notices with payments, or because you're worried about direct deduction of payment retractions or other unexpected adjustments -- remember that a lockbox service at your bank can help keep temptation (and access) at bay.

Last week at the Florida MGMA conference, I had the pleasure of presenting to their lively group on a decidedly unpleasant subject: embezzlement and medical identity theft at physician practices.  While internal theft is such a disillusioning topic -- embezzlement has frankly become part of far too many of our engagements recently! -- presenting ideas for preventing and spotting it to motivated practice administrators does at least have the upside possibility of helping administrators thwart would-be criminals before they get too far with their nefarious intentions. In fact, I was reminded by a participant that the very best way to stop an embezzler is not to hire him or her in the first place!  When I put up a slide showing article clips and pictures of medical practice employees who'd recently been arrested and charged in FL for stealing from their organizations, one of the attendees raised her hand to say she'd actually interviewed one of them recently for a job.  Thankfully, this administrator had noticed that reference checks were fishy -- references were unwilling to discuss the candidate for the most part -- until one person simply revealed, 'check arrest records.'  This was all the clue the savvy administrator needed to dig deeper and find out what she needed to know to avoid hiring someone who'd recently been fired for stealing. It's stunning to realize that that the candidate was apparently interviewing for the job while out on bail (and charged with stealing over $1MM over several years from her prior practice), without, of course, admitting this fact.  Kudos to the administrator for persisting when references were reluctant to talk.  There is a common misconception that it is better to say nothing than to tell the truth of why an employee was dismissed -- even when not revealing the reason exposes others to potential harm.  (What if the employee had been dismissed for stealing patient identities?  Not alerting other practices to the risk could jeopardize patient information at the next practice that hires her -- and even expose the first practice to liability for not fully responding to the