You need not be tethered to the office due to HIPAA

Spending time with family and living life should not be sacrificed to HIPAA. That is, you can use your cell phone to communicate with your patients. And hopefully, you will from some scenic places, or while spending some quality family time.

HIPAA does not restrict you communications to encrypted emails, and landlines.

But you do have the continued obligations to implement technical, physical and administrative safeguards in using your cellphone as you do any other communication device.

So, if you're going to use your cell phone, be smart and safe about it.

Make sure your cell phone is password protected if it has patient information on it. This is especially true if your phone is linked to your EHR and practice management electronic systems.  If you’re going to end emails, you have to have the same encryption safeguards that you do with your office systems.

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Then makes sure you take steps to secure the phone physically. That has the locator functionally on in case you lose it. Control who you let use your phone. That is, don’t pass it to your teenager as an amusement device, or to call them friends.

And when you do speak with patients, its like the elevator at the hospitals – be cognizant of where you are when you do speak. Don’t carry on the call in a public place, find a corner or walk away from the crowd. And when speaking is cognizant of what you say, trying to avoid saying anything that could identify the patient, or publicly share sensitive personal health information.

A good practice is to tell your caller upfront that you are on a cell phone and ask if it is ok to continue the conversation, or if they would prefer to be re-contacted when you can get to a landline or more secure location. This lets them know where you are and lets them take part in the responsibility for the call.

Another responsibility that does not change is the obligation to document. So, check out the recording features of your phone, again, password protection is a must. After the call, record a simple reminder note that the call occurred, when, any medical advice is given, and on what basis you make it. And if you are committing to calling in a prescription, make sure you record it and call it in. You need not dictate a full not, that can wait till later, but you want enough to know what to enter into the patient’s medical record when you do.

So, get out of the office without being out of patient contact. Far better, of course, is if you have coverage so you can get out of the office and be out of patient contact for at least a little while.

Types of Denials - How to Get Paid

Claim denied and some reason code is given. Now you have to research what it means and what to do about it.  In too many cases, office staff puts these aside to work on later, and then that put aside, become pushed aside for other priorities, and becomes denied for lack of timely appeal.  Revenue loss.

Denials are very different from rejections, and staff needs to be able to read an understand the Explanation of Benefits (EOB) messages.  Rejections are errors in the data that was submitted, correct it, re-submit it and move on.  Practices should never let rejections become denials because they are not fixed and resubmitted timely.

Denials are another matter completely.  Here the payer is saying no – we won’t pay.

There are two basic reasons for denial – failure of the patient to be eligible for the services you provided, and failure of you to be authorized to provide the service that you provided.  These can only be fixed by an appeal.

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Denials for lack of patient eligibility means that the health plan is saying, not my responsibility. The problem is that you do not know what the plan is relying on when they say that because you only relied on the information that the patient gave you at time of service.  And here is the rub.  You may have even verified eligibility at the time of service, but low and behold, now they are saying that the patient was not eligible.  This is a fight you can’t win, and appealing will only result in further denials.

This is a problem you have to make the patients.  Bill them, pass on a copy of the denial and let them fight with their insurance company.  Hold them responsible, and if you have planned for such an event, you have taken a contingent credit card authorization to bill the card just for this type of possibility.  Bill the card, and your done.  Now if the insurance company relents based on the patient arguing with them, and you do get paid, promptly issue a credit to their card.  And be sure to keep the patient in the loop; advise them of the denial and the credit card billing and if paid, advise them of the credit being issued.

Denials for lack of authorization run the gambit of the lack of a referral for the procedure, to a requirement that you are “accredited” or certified” to provide a certain procedure or service.

Your office should build a matrix of all the plans that you participate with, and which of those plans, or products of those plans require pre-authorizations, referrals, or accreditations/certifications. And if you are adding a new service, especially a piece of technology, don’t believe the salesman that tells you that you will get paid by everyone for using it.  Make sure you verify with the health plans directly. (Or better yet, make the salesman guarantee his words with consequences)

If you are a specialist then there is a likelihood that at least some of your pay sources will require prior authorizations or referrals.  Best to know beforehand.  And never let the patient dismiss your request for a referral with the promise that they will get it later.  Get it before services are rendered.  Two ways (1) invite them to all their primary care physicians and ask that it be immediately faxed, and (2) invite them to sign a waiver that if they do not get the referral, or it is invalid, or if they claim it is not needed, they will take personal financial responsibility and pay the bill, in full.  And get that contingent credit card.

If your practice includes ancillary technology, such as imaging services, be sure to verify that if you provide them to your patients they will be covered by the payers.  Imaging services, in particular, are increasingly coming under the egis of specifically contracted subnetworks, and if allowed by practitioners, only if they are “accredited or certified” to provide.  

And always monitor your denials.  Not only do you want to appeal anything where the payer has its facts wrong, you want to bill out to the patient when appropriate, you also want to learn from one denial to avoid it reoccurrence.  Too many offices only react after hundreds, or perhaps thousands of dollars are lost to the same denial reason, repeated and repeated.

Benchmarking Your Practice

So how is your practice doing?  A simple question, but to answer you have to ask a question; compared to what?  Well, let’s compare it with some recent information that MAGMA published about physician-owned vs hospital-owned medical practices.  Some striking differences.  For almost every benchmark the physician-owned practice performed better than the hospital owned practice. 

From MGMAs Data Drive 2017 Cost and Revenue

• Median total gross charges $1,876,174 $1,208,258
• Median adjusted FFS charges $1,033,830 $588,007
• Median Total A/R per FTE physician $169,281 $111,514
• Median days adjusted FFS in A/R 62.19 66.45
• Median gross FFS collection percent 53.90% 46.90%
• Median adjusted FFS collection percent 99.02% 96.75%
• Median bad debt due to FFS activity $19,612 $21,875

Data such as this can be used to benchmark your own practice, and answer the question, how’s your practice doing? 

Start with adjusted gross charges, which is what your charges are after adjusting for contractual allowances, you might even call this your actual billings.  How is the performance of the physicians in your practice in comparison?  This is a measure of your physician performance, the volume, and complexity of the patients seen.

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If your charges are less than the benchmark, you might want to take a look at the services you provide and determine if you are capturing all charges from your medical records.  An integrated EHR-PMS system should sweep the services form the medical record to the billings to capture everything.  Some studies say that upwards of 7% of all services performed and documented in the medical record are not transferred to billing.  

This is also a measure of how busy your physicians are.  How is their schedule?  Gaps in the appointment book mean lost revenue.  Are the gaps no-shows, or lost volume?  

From here the benchmarks are measures of your office staff performance.
Accounts receivable is money that has been billed but remains outstanding.  What is happening in your practice?  Ideally, you should be billing daily so that cash flow is maximized.  And your office should be aggressively pursuing claims with insurance companies older than 30 days since most states have regulations that call for physician claims to be acted on within 30 days of receipt by the insurance company.

The next big issue in accounts receivable is patient collections.  Balances due from patients.  What is your policy on collecting at the time of service?  Do you take credit cards as a contingent payment to be charged when the insurance company settles and advises the balance due?  If not, consider.  Otherwise, you will need to work on your collection practices at the front desk.

Private physician-owned practices are doing a better job in collecting funds due with 99% of FFS payments being collected.  How are you doing in comparison?
And when it comes to the ultimate bad debt, those charges that you are unable to collect, less than $20,000 a year is the benchmark.  Better still, if you are requiring a contingent credit card, you can often bring that balance even lower.

No benchmark is perfect for your practice, but if you don’t have anything to compare with you really don’t have a handle on your own performance, and where there are opportunities for improvement.

How to Increase Your Practice Income through Referrals

Patients follow your advice for continued medical care needs.  Its not just anecdotal information any longer. The National Bureau of Economic Research studies the impact of physician recommendations, price and geography on a patient’s choice of provider, and their conclusion – what you say matters.

Overwhelmingly, patients sought services from the providers, physician, hospital, ancillary, based on the recommendation of their physician irrespective of price, or geographic differential.  Transparency, the doctor next door, the big bill board, the advertising, the bottom line is that patient’s trust their physician.  While the reality is that not everyone will follow your recommendations, but the majority will.

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This means you have power of the purse, power to influence the economics of others.

The only way that you can use this information is to understand what your referral pattern means to others.  You probably already know what it means to clinical labs that grovel (and at times to too far) in seeking your specimens, but have you thought about your impact on others? The specialist, the hospital?

The best way to understand your role in others income is to measure it, that is estimate it.  Turn to your EHR/PMS to see what reports it is capable of running.  If your system can, take a periodic run of your referrals, and where they go.  Not its not going to be in your system, but you can estimate the economic value of your referrals in a crude way, by assigning a dollar value to an office visit and if to a proceduralist, an estimated value of their work, surgery, colonoscopy, etc.  Need a data source, you google Fair Health and see what the rates are on the average for these services. For hospitalizations, just use the average of $10,000, which is the average for a hospital stay in the US.

The value of this information is to understand the economic power that you and your referral pattern command.  Not that its your money, but your decisions mean income to others.

Now with this information consider if the revenue you are producing for others is being respected by them. 

For example, if you continually make referrals to Dr X and he never sends you a consultation report, then perhaps for the betterment of your patients, you should consider another physician to receive your largesse. Similarly, if there is a receiver of the bulk of your referrals, that makes your life more difficult by not taking patients with insurance A, again consider a conversation about it with them, and after they balk at accommodating your patients, slip into the conversation the estimated value of your referrals, if not the dollars the number of cases referred. A reminder may be even necessary to the physician when their office staff won’t accommodate a patient of yours that is in more immediate need of their services.

Specialists, with few exceptions (Allergy, dermatology ophthalmology) are largely in the wholesale business, that is their business is based on referrals, from you and from other referral sources.  While the specialist may command a certain higher stature by virtue of their specialty, they are dependent on your referral for survival.  This means that you have the clout to impact their responsiveness to you and your patients. 

Don’t be afraid to use it.