Handling fixed assets under an office sharing arrangement

Suppose a physician will begin sharing his office space with another physician. They will maintain separate medical practices and will be sharing expenses only. They have agreed on a shared expense arrangement covering monthly office expenses and payroll.  The physician who has the office lease also has very sophisticated office and medical equipment in his office and feels the new physician should pay some rent for the use of his tangible assets. How should this be handled under an expense sharing relationship.

 

In similar arrangements, I have included an "Equipment Usage Charge" in the calculations which is basically writing off the cost of the equipment over its useful life (5 to 7 years) on a straight line basis. You can also call it "rent" if that is more understandable for the physicians. You might want to also add a profit amount to the equipment usage charge the same as you would in an arm’s length lease negotiation.

Promote cultural competency

Cultural differences between patients, staff, and physicians pose barriers to true patient involvement. Such differences can occur in thoughts, communications, customs, beliefs, and values. Cultural competence, therefore, is integrating the knowledge of cultural differences into your standards, policies, and practices to increase the quality of services and thereby improve patient outcomes. It promotes inclusiveness, respect, and value with regard to cultural differences.

Examining and improving cultural competence can have a positive impact on prevention, identification, and treatment of your patients. Failing to do so can affect what information you are able to gather for a patient history and about patient symptoms, which you use to diagnose illness and provide quality treatment. Handle these issues from an organizational standpoint, including incorporating them into your policies and procedures.

Deceased patients with unpaid balances

How are you managing the accounts of deceased patients when they have a balance?  If you were told there is no estate, are you confirming this with the courts?  Do you get involved in probate?

In case of unfortunate death of a patient who has a balance, it is best to first bill the patient’s estate. Most of time someone from the family will call and offer to settle the bill and ask for some discount (You should probably be offering some kind of a discount anyway in most of these circumstances). Since the cost of collecting by collection agency is at leaset 25%, offer a discount from 10% to 25% if they pay right away with a credit card or mail a check within a week.

If there is no response or no offer to settle by the family because they say the person did not have any estate, turn the account to collection agency.

Employee policy handling lax work effort that may lead to internal theft

A medical practice recently had two instances of what appears to be cash theft by an employee.  The staff in the reception area that handles the cash boxes had been quite lax for some time now when it comes to the security of their cash.  The practice wants to have zero tolerance but was unable to determine who is taking the missing cash. The practice recently adopted the following changes:

1.    The safe combination has been changed.

2.    New cash boxes and keys have been purchased. 

3.    New locks have been put on reception area draws where the cash boxes are kept during the day.

So what is a good policy regarding theft/missing cash?  Obviously if a theft can be proven, immediate termination must occur. But what about sloppiness or carelessness that could lead to a theft? How do you handle that?

I like how one physician office handles it – a policy called automatic Corrective Action - Decision Making Leave – used when employees don't lock draws; leave cash unsecured, can't identify where cash has gone due to sloppy work, etc. Under this policy, employee is sent home for a day without pay. It sounds much better than “Suspended Without Pay.”

Registration evaluation

Does the staff make it a priority to accurately gather and enter the necessary registration information for each patient? ___Yes ___No

 

Do they know what information is necessary to prevent claim delays or rejections? ___Yes ___No

 

Do they clearly understand the importance of recording information accurately? ___Yes ___No

 

Is there a clear understanding of what information is essential? ___Yes ___No

 

Is staff aware of what information is needed to do appropriate follow-up? ____Yes ___No

 

Does the staff discuss and obtain preauthorizations and referral information from patients? ___Yes ___No

 

Is there a clear understanding of when and how to obtain preauthorizations and referrals? ___Yes ___No

 

Does the staff understand and effectively communicate the financial expectations to patients? ___Yes ___No

 

Are copays collected at registration? ___Yes ___No

 

Does the staff discuss the payment options that are available to patients (credit cards, debit cards, cash, checks)? ___Yes ___No

 

Does the staff try to identify credit risks? ___Yes ___No

 

Does the staff recognize their potential to reduce patient statements? ___Yes ___No

 

Reducing payment denials

So what advice do I have for ways to reduce payment denials? Start simply – but right away – by implementing a system such as the following:

 

1.    Flag all denied charges, making a copy of the related EOBs and placing them in a folder.

2.    Hold staff meetings of the billing and collection personnel twice a month if possible or, at a minimum, once a month. In the meetings review and discuss the denials; why they occurred, and what corrective action needs to be taken to prevent them in the future.

3.    Implement the corrective action by communicating with the individuals who are involved with the process. In most cases this will be the people in attendance at these meetings – but not always. It could also include anyone from front desk personnel to even the physicians. For example, a denial pattern might be identified as stemming from the fact that a particular physician is filling out the patient charge ticket incorrectly.

Some things just don't change

I ran across the following email post from April, 2006; for some reason I kept it in one of my Outlook folders and after reading it, I can see why I did. The poster will remain anonymous but it sums up the level of frustration I am seeing out there today, especially in mid-size medical practices. It again shows physicians are too concentrated on overhead when the real problem is growing the top line. It also shows the level of frustration management has out there with their physicians. It’s not too amazing that the issues of 2006 are the same as those in late 2009. What do you think?

 

I'm ten days behind in posts, and just took some time today to try and catch up.  The thread on age, job performance and turnover, and all the rest was just outstanding.  Well done to each and every one of you.  I am so proud to be a member of this listserv.  I am taking a huge risk in posting this, because some of you know me, and some of you know my group.  I am relying on the kindness of strangers (as well as known colleagues) to listen to my rant without using it in any way against me or my organization.  I am just so frustrated I have to get this out:

 

The reason I am ten days behind in my email (not to mention job, and life) is that three of my doctors walked in ten days ago and demanded that I make deep cuts in our staffing.  The actual document that I was presented stated that I was expected to have two employees per physician as a staffing goal, and no more than three staff per physicians at the outside.  I do not need to explain to any of you that the rest of the document was equally deranged and out of touch with reality.  I tried to explain median staffing.  I tried to explain benchmarking.  When that didn't work, I turned to the most delusional of the three and stated, "Alrighty, then.  We'll leave your medical assistant and surgery scheduler.  You're out of luck for anyone to answer your phones, schedule your appointments, verify insurance eligibility, register your patients, code your office visits and surgeries, key them, collect them, perform your transcription, take your x-rays, handle your credentialing, negotiate your contracts, and pay your bills." 

 

I feel as though I was watching my entire life flash before the list's eyes as I read everyone's posts.  Been here three years this month, so the honeymoon is over.  The group is compensated based solely on production (you eat what you kill, so we don't play well with others and we REALLY don't cooperate with projects over the long-term that might affect an individual's bottom line adversely, despite improving the overall health of the organization).  God forbid anyone make or keep a plan for more than a month at a time.

 

When the dust settled, I had 36 hours to make the cuts, although they were not as severe as originally demanded. I set a world's record for firing people last Friday morning, and terminated 9 individuals, one of whom had been with the group for fifteen years.  And oh yeah, in writing, the doctors stated (and this is a quote):  "Our ultimate goal is to make this a fun place to work, while providing excellent orthopedic care in a cost efficient manner.   Perhaps an employee purpose statement is required by which to screen and evaluate workers and to assist in our decision making processes."  Note to list:  I have no idea what that sentence means.  None of the doctors participated in making decisions on the cuts, nor did they want to.  None of them participate in the hiring process.  One did charge that I maintain office morale.  Always a happy statement to hear when combined with demands for significant cuts.

 

That I can take.  Business is business.  I made the best choices I could under the circumstances, and I think we will survive the this short-sighted and hysterical response to a temporary problem (a doc just decided to retire with one month's notice).  I handled it all as professionally as possible under the circumstnaces, but what I did NOT appreciate were the threats made by one doctor.  He suggested that he suspend my pay, since the group is in transition and his paycheck has been affected.  He also stated that I do nothing, know nothing, and am incompetent.  I have had situations before where I clashed, disagreed with, or had other conflicts with physicians, but nobody has EVER stated that I wasn't working hard, or that I was incompetent.

 

So, I guess this is where age comes in:  I am old enough and mean enough at fifty-two to survive this, and I'm old enough and mean enough at fifty-two to smile at a young doctor who has the affrontery to claim that I am both incompetent and lazy and say, "Oh, no, I don't think so." 

 

Sometimes being a survivor just means working hard and staying lucky, and smiling in that special way that reminds your physicians that they really are better off with you, or waiting until you electively move on.

Schedule for patient convenience

Physicians used to be advised to keep their office hours during the "civilized" part of the day-between 9 a.m. and 5 p.m. Things have changed, however. Now you must increasingly apply marketing principles in order to offer your patients the features that they (the buyers of your services) want. And this leads to maintaining hours that better suit the buyers. In marketing, these buyers have become known as the "nocturnal market," working by day and buying goods and services during traditionally closed hours.

This shifting market has caused many physicians to open their offices on one or more evenings per week. Larger groups have either created apparently separate "convenience centers" or simply stayed open all weekday evenings until 9 p.m. or 10 p.m. While harder on physicians' personal lives, the changes have been more than necessary.

Use caution when discussing your malpractice case

You may be tempted to ask a physician friend to review your malpractice case to determine whether you are missing anything. Resist this temptation. The rules of malpractice cases do not give you the privilege to talk to anyone but your lawyer without having to share the contents of the discussion with the opposing side. If you discuss your case with a colleague who does not feel you acted appropriately, the plaintiff's attorney may subpoena your colleague to testify against you.

Sorry for no post yesterday – I was traveling to Washington DC to attend the Mid-Winter meeting of the National Society of Certified Healthcare Consultants (www.nschbc.org). For updates from the conference, go to www.twitter.com/rtacpa.

Practice has cure for insurance paperwork – avoidance

Patients' frustrations with health insurance paperwork are well-known. But it's also a frustrating tangle for doctors and their staffs.  CNN reports about one innovative practice that has decided to take on the insurance paperwork monster -- by completely avoiding it.

Dr. Val Jones joined a small practice, DocTalker Family Medicine in Vienna, Virginia, where the doctors do not even take insurance.  They charge a simple, relatively low fee for each service. That's it. The doctors at DocTalker grew tired of seeing patients struggle with baffling insurance paperwork while both their health and wealth were on the line.  Jones does not believe the insurance industry set out to cultivate the paperwork jungle. She thinks it just grew over time. But now that it is there, she suspects they are making so much money off of it, that there is no real incentive to clear it up.

Former insurance industry executive Wendell Potter agrees. He said one way insurers make money is by allowing confusion to reign.  "And people often just give up," Potter said, "and don't pursue payment when a claim has been denied or been paid inappropriately or not adequately. And the same is true with doctors and hospitals." He believes billions of dollars are at stake.