Hire help to keep your nurses efficient
Although I urge using nurses and other assistants to handle tasks that help the doctor see more patients, be careful about bogging down the nurses which, in turn, slows the doctor down. Seeing as many patients as possible during office hours—without compromising the quality of each visit—may require a part-time or full-time diagnostic technician or other special assistant to keep your regular nurses efficient.
If you worry about the cost of yet another staffer, try this:
- List all the diagnostic testing done in your office.
- List the expected number of tests per hour.
- Evaluate the data you collect against patient flow.
By taking these steps you may uncover some surprising data that will help you determine what sort of extra help can free up your nurses.
May 9, 2008 in Practice Management | Permalink | Comments (0) | TrackBack (0)
Actual lease vs equipment lease
Many times a physician practice will lease a piece of equipment and immediately think it can deduct the lease payments as they are made to the lessor. Many physician practices (and their advisors) forget about knowing when a lease should be treated as a "capital" lease (i.e. the asset leased is capitalized and depreciated and a related note payable is set up payable to the lessor). The following is a excellent summary of the rules by my good friend Bob Cimasi at the Health Capital Group (www. healthcapital.com):
Interpretations of various IRS rulings and accounting standards suggest that a lease transaction should meet the following criteria to qualify as a “true lease”:
(1) At the beginning of the lease term, the leased asset must have a projected fair market value at the expiration of the lease term of an amount greater than or equal to 20% of the value of the leased asset at the inception of the lease, excluding from consideration the effect of inflation and/or deflation and any cost to the lessor for removal. (1)
(2) The leased asset is projected to have the longer of (a) at least 20% of its expected normal useful life (the life projected at the inception of the lease) remaining at the end of the base term; or, (b) a remaining normal useful life of at least one year at the end of the base lease term. (1)
(3) The lessee cannot have a right to purchase or renew the leased asset for a price that is less than its fair market value. (1)
(4) The lessor cannot have a right to force the lessee to purchase the leased asset at a fixed price. (1)
(5) The lessor must have a minimum unconditional equity “at risk” investment equal to at least 20% of the value of the leased asset at all times during the lease term. This can be done in a number of ways: with cash, with other consideration, or by personally assuming the obligation to buy the equipment. (1)
(6) The lessee must not furnish any part of the purchase price of the leased asset, nor have loaned or guaranteed any indebtedness created in connection with the acquisition of the leased asset by the lessor. (1)
(7) The lessor must show the lease transaction was entered into for profit, apart from any tax benefits resulting from the transaction. Total lease payments that the lessee is obligated to pay over the lease term, when added to the equipment’s estimated residual value, has to be greater than the amount of money that the lessor is obligated to pay out for the equipment, such as debt service and equity investment, including any related direct equity financing costs. (1)
(8) The present value of the lease payments cannot exceed 90% of the Fair Market Value (purchase price) of the equipment. (2)
Notes
(1) Source: Revenue Ruling 55-540 and 2001-28
(2) Source: Federal Accounting Standards Board (FASB) Statement 13 - Accounting for Leases
May 9, 2008 in Taxes | Permalink | Comments (0) | TrackBack (0)
HIPAA and employee access to their own record
Another HIPAA Q & A from HcPro's newsletter Briefings on HIPAA:
Q: Do HIPAA regulations forbid employees from accessing their own records? For example, could a hospital employee review the results of his or her recent laboratory test?
A: The HIPAA privacy rule does not prohibit healthcare organization employees from accessing their own records. In fact, the privacy rule gives individuals the right to access their PHI. However, your organization’s policies may regulate this practice.
Many healthcare organizations have written policies that prohibit employees from using electronic health records (EHR) to access their own PHI. Instead, they require employees to request access to their PHI through the HIM department, just as they do all other patients.
May 8, 2008 in Regulatory | Permalink | Comments (0) | TrackBack (0)
Tips for your managed care exit strategy
As reimbursement continues to decline (has a managed care plan ever called you to say you were getting a raise?), physician practices are going to have to take a long hard look at continued participation in some plans. This is especially true with regard to your worst paying contracts. The following are a few exit strategy steps you might want to consider:
§ Review your various contracts for termination (“without cause”) notice requirements. For example, some could require 30 days notice, some 90 days, and others until the end of the contract year. Make a timing assessment or an ideal schedule for terminating your contracts to minimize any adverse effects on patients and employers. This also serves to buffer any dips in cash flow for your practice.
§ Serve termination notices and then watch and observe the effect on your patient counts and receivables. Also, look into termination agreements from all perspectives. If a patient decides to leave the practice, take the necessary steps to transfer his or her care.
§ Conduct a review of your retail fees. This is a critical step for specialists. If you want to retain patients, I recommend an adjustment of your fee schedule—generally an adjustment down.
§ Train your staff, including phone staff, billing staff, and anyone else who may come into direct contact with your patients. This is important for scheduling staff, for example, because they have the opportunity to intercept patients and prepare them for any out-of-network differences that they may experience along the way.
§ Review your practice’s financial policy for write-offs. Also review your financial guidelines for patient income (e.g., hardship cases). These are especially critical for maintaining cash flow.
§ You must have physician buy-in every step along the way. You can’t have one physician who is not on the same page as all the others. The communication between the physician and the patient in the exam room has to be consistent with this plan. It has to really be part of the culture of the practice for this to work.
§ Look carefully at accounts receivable. In many cases, I think you’ll see fewer patients but make the same level of money.
May 8, 2008 in Managed Care | Permalink | Comments (0) | TrackBack (0)
Practice start ups - finding the right counsel
This actually is a critical component to getting off on the right foot. That is, making sure that you have the correct legal and business structure that will work with the entity that you are trying to organize. If you are new to the area, my recommendation would be to go to the local medical society to find out what Healthcare Attorneys or CPAs have a large focus on healthcare and are available in your area. You might also ask hospital administration or a colleague for a recommendation. Making certain that your Attorney and CPA have a healthcare background can be very critical to you. Not necessarily in the initial corporate documents because many people can provide those to you as well as tax advice but in the long term making certain that those individuals are focused on the healthcare industry. Things change so frequently that it is important to have someone who has that kind of background. If you are from the area, look to your peers for advice. They are going to be able to tell you some of the best stories, the good and bad. So, it is important that you look for those who have a strong background in healthcare. It will make a difference in the long run.
May 7, 2008 in Practice Management | Permalink | Comments (0) | TrackBack (0)
Difference between direct and incident-to billing
This is where many practices have become confused. Medicare has offered two different options for the non-physician providers that we are focusing on today, NPs, PAs and CNS. Medicare has said that those providers can bill one of two ways. Those methods are known as direct billing and incident-to billing. The direct methodology is fairly straightforward. Under this scenario the providers would go through the credentialing process with Medicare in the same way the physicians in the practice would. They would receive a provider number and as a result they would be able to submit bills to Medicare directly for their services. If you actually looked at a printed copy of that claim form it would have the non-physician providers name and provider number at the bottom of the claim. When practices choose to bill under this methodology there are a number of requirements.
The first requirement, and it is an obvious one, is that the provider be credentialed. Beyond that they should know that there is a payment differential when billing using the direct methodology. Medicare has indicated that when billing direct they will reimburse practices 85% of the physician allowable. So there is a reduction in payment. On the flip side, what practices gain by using this methodology is a little more flexibility and freedom relative to the regulations. When billing direct there is no requirement from Medicare that the physician be in the office physically supervising that non-physician provider and the work that they are doing. So, if the physician were at the hospital, making rounds or operating, it would be acceptable for the NP to be in the office seeing patients and billing for that work if they were billing direct. The other issue that becomes important for practices to think about is how to schedule the various physician and non-physician providers. When you bill direct Medicare has indicated that you have flexibility in the types of patients you see. You can see new patients, you can see new patients with a collection of problems, you can see established patients, you can even see established patients who are coming to you with a new problem. So Medicare gives you some flexibility in the kinds of patients that these non-physician providers are allowed to see and bill for when they bill direct.
The other option that Medicare has granted to this class of providers is what we call incident-to billing. Under this scenario the non-physician provider wouldn’t have to go through the credentialing process. They would simply bill for their work under the name and number of their supervising physician. So if I printed a claim form that was going to be sent to Medicare in this instance at the bottom of the claim form it would list the physicians name and number and not the non-physician provider even if that was the person who performed the service. Obviously to use this methodology a physician must be present in the office at the time the service was rendered by the non-physician provider and in fact it has to be that physicians name and number that is included on the claim form.
In billing this way, practices do lose a little flexibility in terms of how they schedule their various physicians and non-physician providers. The other issue that is sometimes problematic is that Medicare restricts when you use the incident-to billing methodology. They indicate that that would only be acceptable for established patients who are returning to be seen with an established problem because by definition they would describe incident-to as a non-physician provider who is an extension of the physician completing ongoing care. So, by default this methodology isn’t used for new patients or established patients who present with a new problem. That can create some scheduling challenges for practices and practice executives may be thinking that with the increased supervision, what is the benefit of billing incident-to? If you don’t have a credentialing provider number for the non-physician provider, incident to billing is your only option. But more importantly, what some practices are looking towards is the fact that when you bill incident-to, the practices are paid 100% of the physician allowable. This makes sense because the physician’s name on the claim. So some practices trade increased reimbursement for more restrictions in flexibility and scheduling needs.
May 7, 2008 in Practice Management | Permalink | Comments (0) | TrackBack (0)
Dear Physicians: Start paying ^&%*($ attention to your practice
Does this scenario sound familiar: Medical practices delegates all oversight, supervision, and daily office management to the practice administrator yet only to find out later that things are REALLY screwed up? I recently saw this again at a large specialy practice and the situation was familiar to those in the past - the doctors just wanted to practice medicine and leave everything else to the administrator.
This just can't happen; physicians need to realize that a medical practice IS THEIR medical practice and as such need to take ownership of it. To avoid such instances from happening, a physician or physician group should do these things:
1. Have a monthly financial meeting. Review the finances of the practice and engage a formal agenda to review and discuss all other practice issues;
2. Implement checks and balances. Make sure your CPA is looking at your finances on an ongoing basis and is asked to attend your monthly financial meetings;
3. If large enough, implement physician committees. This will keep physicians involved;
4. Survey the employee group. Employees see what is going on each and every day - get their feedback on how the office is running, how they are being treated, and ideas to improve the office.
May 6, 2008 in Practice Management | Permalink | Comments (0) | TrackBack (0)
Identify and use staff members' strengths
Imagine this: Your staffers know each other's abilities so well that they smoothly step in to perform their tasks while efficiently handing over other tasks to more suitable and willing staffers. Your practice operates more efficiently, your employees are more satisfied, and overall patient care improves.
No, this is not Shangri-La. It's a product of diligent effort to identify your staff member's individual strengths and structure their jobs so they do more of what they do best. Here are some tips to recognize and use staffers' strengths:
- Overcome the "If I can do it, anybody can" attitude. It's human nature to take our own talents for granted and assume that whatever is easy for us should be simple for others. Recognize your staffers' differing strengths, and ask them which job they feel they most enjoy and are most suitable for.
- Use personality tests to further understand yourself and your employees. Tests serve as excellent tools to help team members understand each other.
- Encourage staff to trade duties to take full advantage of strengths. Each gets to do more of the work that suits him or her, making everyone less stressed and more productive.
May 5, 2008 in Practice Management | Permalink | Comments (0) | TrackBack (0)
GAO Finds Health Savings Accounts Used by Wealthy, Not Average Working Americans
Here is something interesting from last week's HFMA newsletter; as you might recall, there was a hope that health savings accounts participation would continue to rise.....................
May 5, 2008 in Miscellaneous | Permalink | Comments (0) | TrackBack (0)
Whiteboards and HIPAA
From HcPro’s newsletter Briefings on HIPAA:
Q: Is writing patient's full names on whiteboards permissible? Using only initials and/or first names to identify patients is very confusing for nursing staff members and physicians. Using full names can prevent costly errors.
A: As a covered entity, you must use the minimum amount of information necessary. Using the patient’s full name on a whiteboard is acceptable if you can justify this as the minimum amount of information necessary to support the provision of care.
Ideally, whiteboards with patients’ full names on them should not be visible to the public. Ensuring that whiteboards are in a location visible only to staff members is a good practice. If you deem it necessary to use patients’ last names on the whiteboard, using only their first initials is preferable to using their full first names. This practice would limit the PHI on display.
May 2, 2008 in Regulatory | Permalink | Comments (0) | TrackBack (0)
