Mary Pat recently sat down with Peter Polack, MD of Medical Practice Trends for another podcast to talk about one of the most important parts of any practice: The Bottom Line. In this two-part podcast series, Dr. Polack and MP discuss ideas for cutting costs and raising revenue to strengthen any group’s financial position.
Mary Pat’s Note: This post has always been popular because it answers one of the most burning questions in Healthcare: “How can I improve my bottom line?” If you have used any of these ideas in your practice- or have some of your own to share- let us know in the comments below!
BUILD ON WHAT YOU’RE CURRENTLY DOING:
1. Add physician hours – add evening or weekend hours; start your office hours earlier and end hours later.
2. Reduce physician time off – decrease vacation or change weekly days off to 1/2 days off.
3. Set a minimum number of providers to be in the office seeing patients at all times the office is open.
4. Have each provider add one new patient visit to his/her schedule weekly.
5. Add ePrescribing to recoup additional Medicare revenue and streamline prescribing (there are free ePrescribing software packages available, but evaluate them carefully so they don’t add more complexity to the system instead of less.)
6. Report PQRI measures to recoup additional Medicare revenue.
7. Charge patients an out-of-pocket fee for completing patient forms – disability forms, etc. and reserve office visits for treating patients.
8. Choose an EMR that qualifies your practice for the ARRA money (although it has been widely promoted that in a larger practice, an EMR and its associated work will cost more than you will get from the government.)
9. If you are in an underserved or rural area, check to see if there might be grants or funds available locally, in the state or federally, for adding a service to your practice.
10. If your practice does Independent Medical Exams (IMEs), reviews records or depositions, make sure that your fee schedule for such services is current and that the fees are collected before the physician provides the service.
What are the hallmarks of a well-managed practice? There are many, but here are 10 basics.
The practice has foundation documents appropriate to the corporate structure and written agreements describing how income and expenses are shared by physicians and/or other providers and how partners enter and exit the practice. The owners of the practice and management meet monthly.
The practice has documents that set the guidelines for operations such as a compliance plan, disaster plan, personnel handbook, job descriptions and requirements for annual evaluations, raises, bonuses and progressive discipline. Management and staff meet monthly.
The net collection percentage is 95% or more. This means that of the expected collectible dollars, 95% is collected.
The practice has a budget and variances are addressed.
The unfilled appointment percentage is 5% or less. This is in retrospect, so it includes no-shows. The practice has a marketing budget and a written marketing plan.
The practice has a line of credit or other means to draw upon in the case of unexpected cash flow drop.
A single commercial payer comprises no more than 50% of the practice business.
Employee turnover rate is 10% or less. New employees are onboarded with training, coaching and competency testing.
The practice has the ability to produce management reports to track and trend production, payments, adjustments, and denials. Process Improvement (PI) is used to address negative trends.
Patient satisfaction is prioritized and measured, and improvement is valued.
Many practices and providers take their patient schedule for granted. They overlook the opportunity to improve both productivity and effectiveness by managing their schedule. Here are ten tips for office managers to make sure that the patient schedule works for you and for your practice.
1. Evaluate the schedule template with the providers and nurse manager quarterly.
By using actual issues from the previous period, discuss what has worked and what has not. Have providers share their concerns and
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discuss their recommendations for change. Nursing often has many ideas to improve the flow of patients through the practice and is a valuable source of information. Keep track of changes made and evaluate their effectiveness at the following meeting.
2. Standardize visits types.
There are many reasons an individual provider likes their “own” schedule. As managers, we know that this makes it very difficult for the front desk staff to do their jobs. Standardization reduces the potential for errors and disruption that proprietary schedules may cause. Your role in the discussion with providers will be that of facilitator, staff advocate, and coach.
Bring forward options for standardized visit types. Many practices use a block template based on 10, 15 or 20-minute blocks of time. The number of blocks used per visit type are agreed to and used to fill the schedule. There may be additional restrictions placed on the schedule such as no more than one new patient per half-day session. Minimize the number of restrictions or ideally eliminate them to assure your days are as flexible as possible to meet your patient needs. You may also want to consider open access scheduling. Moving to this system often takes time and effort to eliminate the backlog of booked patients but once fully in place can be very successful.
3. Track scheduling errors and issues perceived to be scheduling errors monthly.
Errors in scheduling cause patient dissatisfaction, back up your waiting room, and lead to stress and possibly short tempers. Ask providers and staff to tell you when they think patients are scheduled incorrectly. Track this over time to determine if changes in the system are needed, how visit type use can be improved, and what training may be needed.
4. Know where scheduling bottlenecks are.
What is your average wait time in the office per provider? Do a time study on each provider and measure how long it actually takes for a patient to get through an office visit. Note the time they arrive for check in and registration functions, their time in the waiting room, when the nurse completes check in functions in the exam room, when the provider enters the exam room, when the provider leaves the exam room and when the patient exits the office. Overlay this on your schedule. The information you gather will help you identify bottlenecks and provide meaningful data to share with your providers when recommending a change in the schedule template.
5. Know how much a visit is worth in revenue.
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Adding one visit per day by addressing schedule gaps, clinical start times, no-show appointments or changing the length of visits will increase your revenue. If your provider works four days per week and 48 weeks per year at an average visit reimbursement of $75, one additional visit per day will add $14,400 in annual revenue to the bottom line!
6. Train your scheduling staff and update the training regularly.
Training a new staff member often brings up questions the entire staff can benefit from. Be sure to keep track of questions and include answers in future written training materials as well as in staff meeting discussions. Develop a training checklist for scheduling staff and have both the trainer and new employee initial when each area is mastered. This checklist can also be used for annual performance reviews. For current staff, take a look at their computer terminals and see what “sticky notes” are posted there, indicating areas that need special consideration or additional training.
7. Have the schedule be a frequent agenda item for staff meetings.
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Get the staff perspective on what is working and what is not on a regular basis. You may find that nursing can provide a great deal of information on how the schedule impacts patient flow from their perspective. Take time for staff to discuss “what if” scenarios and how they would handle a particularly difficult situation. The goal is to have a schedule that staff understands, is user friendly and is consistently used.
8. Have a policy on the number of providers out at one time for vacation or holidays and follow it.
Everyone deserves time off but having many providers out at once can lead to a very hectic week for those remaining. Plan as much in advance as possible for time away. If you do end up with a number of providers out at once, remember that the person remaining will also be responsible for reviewing lab and radiology results for their colleagues as well as answering questions regarding patients that they may not know. Allow extra time in the schedule for this.
9. Know what changes in demand to expect during the year and plan for it.
Do you have more requests for acute visits in January, camp physicals in April, or school sports physicals in August? Minimize last minute adjustments to your schedule by knowing any seasonal trends in scheduling. Take a look at the schedules from past years to predict when you need more or less acute slots and adjust your schedule template for this. Manage the time you’ve allotted by marketing efforts in the office and local papers reminding your patients to schedule in advance.
You may also want to consider adding additional clinical hours during this time to make sure you can meet demand. Consider asking part time providers for extra hours per week or using per diem staff.
10. Deal with your patient no-shows.
Consider writing a policy on no-shows if you do not have one. If you have one, follow it. Make sure that your policy follows any state regulations to avoid patient abandonment claims.
Educate your patients. Develop a set of professional communications about your visit cancellation and no-show policy that begin with your welcome to the practice letter. Post a notice of your policy in your waiting room. Send letters following each no-show and then the termination letter stating the reason for the termination and that the patient is still responsible for their account balance. Be the contact person on the letter so that if the patient calls with questions, they speak with you rather than take up provider time or that of your staff.
If you have a patient that consistently no-shows but the providers do not want to terminate them from the practice, determine what other help you can provide to get the patient to the visit on time. Consider additional reminder calls, assistance with other services such as transportation, or offering the ability to come in and wait without a scheduled time. Though this may take more staff time, the revenue from the appointment should make it worth your while.
Donna Izor, MS, FACMPE is founder of West Pinnacle Consulting, LLC. Her 20 years of experience as a medical practice executive lends her special expertise in the areas of primary care and specialty practices, employed inpatient physicians, regulatory oversight, facility design, physician compensation and relations, and new program development. She has worked with academic, community hospital, and private practices. You can contact Donna at donna.izor@gmail.com.
1. Add physician hours – add evening or weekend hours; start your office hours earlier and end hours later.
2. Reduce physician time off – decrease vacation or change weekly days off to 1/2 days off.
3. Set a minimum number of providers to be in the office seeing patients at all times the office is open.
4. Have each provider add one new patient visit to his/her schedule weekly.
5. Add ePrescribing to recoup additional Medicare revenue and streamline prescribing (there are free ePrescribing software packages available, but evaluate them carefully so they don’t add more complexity to the system instead of less.)
6. Report PQRI measures to recoup additional Medicare revenue.
7. Charge patients an out-of-pocket fee for completing patient forms – disability forms, etc. and reserve office visits for treating patients.
8. Choose an EMR that qualifies your practice for the ARRA money (although it has been widely promoted that in a larger practice, an EMR and its associated work will cost more than you will get from the government.)
9. If you are in an underserved or rural area, check to see if there might be grants or funds available locally, in the state or federally, for adding a service to your practice.
10. If your practice does Independent Medical Exams (IMEs), reviews records or depositions, make sure that your fee schedule for such services is current and that the fees are collected before the physician provides the service.
ADD TO YOUR CURRENT SERVICES:
11. Allergy testing & treatment
12. Dispensing pharmaceuticals
13. Dispensing nutriceuticals
14. Dispensing Durable Medical Equipment
15. Group patient visits
16. Coumadin Clinic
17. Heart Failure Clinic
18. Diabetes Education Classes
19. Add primary care to specialty care practices
20. Add specialty care to primary care practices
21. Research
22. Joint Ventures with other practices or hospital
23. Lease space to other entities
24. eVisits (virtual visits or email visits)
25. Elective procedures or services
26. Mid-level providers
27. Walk-in clinic
28. Occupational medicine: drug screens, employment physicals, etc.
29. Hospitalists
30. Medical Director of local nursing homes
31. Complementary & alternative medicine (CAM)
32. Aging in Place services
33. Social worker
34. Concierge practice
35. School team physician
EVALUATE YOUR REVENUE CYCLE MANAGEMENT:
36. Are you renegotiating payer contracts regularly?
37. Do your scheduling staff know how to educate patients about what payers you have contracts with and are in network with and what the patient’s financial responsibility will be?
38. Do staff know what typical new patient charges are to tell the patient?
39. Do you check every patient’s eligibility for insurance benefits immediately prior to every service?
40. Do you have patients sign a financial policy to acknowledge what they are responsible for based on their payer type?
41. Do you copy the patient’s insurance cards at every visit, or at least compare their current card to the card you have on file? Are you able to scan patient insurance cards and driver’s licenses into your practice management (PM) system?
42. Is your PM system able to download the information from the scan into the patient registration screen? If not, do you have a way to confirm that demographic and insurance information has been entered correctly from the cards?
43. Are your charges being posted daily?
44. Does the person who provides the service, or a documentation coding specialist, choose the CPT and ICD9 code?
45. Is the documentation for the charges being completed within 24 hours of the service?
46. Is your encounter form up-to-date with current CPT and ICD9 codes; do you order smaller batches of them so you can change the codes as new services are added in the practice?
47. Do you check the CPT and ICDD9 matching to make sure the codes are valid for the year, the codes adhere to NCCI and LCD edits before you finalize the charges?
48. Do you regularly audit medical records for coding and documentation and give providers feedback on where coding could be improved?
49. Are you using ABNs for Medicare patients who want services that Medicare might not pay for?
50. Do you file claims daily?
51. Do you correct claims daily when they are rejected at the practice management, claims clearinghouse or payer level?
52. Do you correct claims daily when they are rejected at the claim level and are not paid for for reasons that can be corrected?
53. Do you have your contract allowables in your PM system so you know when you are not being paid correctly by contract?
54. Do you appeal unpaid or underpaid claims?
55. Do you check recoupments or requests for refunds from payers and make sure they truly should be refunded?
56. Do you send insurance and patient payments to a lockbox to be scanned and stored digitally for your staff to post from?
57. Do you make payment arrangements in the office for balances after insurance has paid, or payment plans by drafting credit or debit cards?
58. Do you have a policy of not sending statements?
59. Do you collect the patient’s portion of the service at the time of service?
60. Do you collect fees for elective services prior to providing these services?
61. Can your patients make payments online through your website?
62. Do you file a claim with a patient’s estate if they have died?
63. Do you accept cash only from patients who have passed bad checks?
64. Do you accept cash only from patients who have filed bankruptcy with your practice?
65. Do you inadvertently see patients who have been dismissed from your practice?
66. When adding a physician to the practice, do you timeline the credentialing appropriately so the physician can see patients with insurance as well as those without?
67. If your new physician is only partially credentialed with payers, do you have him/her see the patients with payers they are credentialed with and add payers to their schedule load as the credentialing comes through?
68. Do you meet with representatives from your largest payers monthly to establish relationships and bring problems to their attention? (the squeeky wheel theory of payer relations)
69. Are you pre-certing everything that needs pre-certification or pre-authorization or pre-notification to be sure the service will be paid?
70. Are you receiving payments via electronic funds transfer (EFT)?
71. Are you receiving explanation of benefits (EOBs) or remittance advice (RA) electronically?
74. Is someone in the practice responsible for staying current on changing coding requirements for Medicare, Medicaid, Tricare and commercial payers?
DECREASE EXPENSES:
75. Eliminate overtime. Evaluate the need for additional staff (part-time?) vs. overtime.
76. Send some staff home (sometimes called “low census”) when there are no patients to be seen.
77. Use volunteers. Tap into the local hospital volunteers, or recruit and train your own.
78. Hire an after-school student employee to do routine jobs.
79. Discontinue paying staff for inclement weather closings when the practice is not open.
80. Shop everything. Negotiate existing service contracts. Do not assume anything is non-negotiable. Negotiate the rent.
81. Get rid of yellow pages advertising. It rarely brings you new patients and is primarily a place to look up phone numbers. You will still get your white pages listing free with your phone service.
82. Utilize pre-employment testing to make sure job applicants have the skills you need.
83. Shop postage machines or look into stamps.com.
84. Join a group purchasing entity (hospital, professional association, etc.)
85. Improve your accounting cycle. Invoices and statements are matched up with packing slips and negotiated prices. Use purchase order numbers.
86. Get the payment discount by paying on time or early – ask vendors for an on-time or early payment discount.
87. Make sure office supplies are not going home with the employees. Make sure office supplies that are ordered are “really need” and not “sure would be nice.”
88. Remind patients of their appointments to decrease no-shows. Call patients who no-show and attempt to reschedule (unless they feel better!) Track no-shows and evaluate the reasons for them.
89. Consider charging for no-shows or dismissing patients for no-shows.
90. Have a good recall system in place. If patients leave without scheduling a needed follow-up, make sure that they are called if they have not scheduled within a certain amount of time. Keep track of annual wellness visits and remind patients to schedule them.
91. Take advantage of any discounts offered by your malpractice carrier by completing risk management surveys and having speakers give annual updates on decreasing malpractice claims. Some carriers give discounts for managers who are members of MGMA or Fellows in the ACMPE.
92. Evaluate any discounts on services or products offered by your physicians’ professional associations and societies.
93. Evaluate your leases – are those big old copiers and faxes worth paying for a service contract?
94. Consider speech recognition/voice recognition and eliminate transcription.
95. Review your computer maintenance contracts. Are you paying for maintenance on equipment or software that is no longer being used?
96. Take advantage of online CME for physicians, midlevel providers, clinical staff and managers.
97. Make plans to attend face-to-face seminars well in advance to take advantage of early enrollment discounts and good flight deals.
98. Evaluate outsourcing. Think about outsourcing transcription, coding, billing, pre-authorizations, credentialing, switchboard, payroll, accounting and medical records copying.
99. Replace your answering service with an answering machine educating patients on the limited reasons for calling after hours and giving the number of the physician on call.
100. Destroy archived financial and medical records that you are paying to store, once you have ascertained that they exceed the required time limit.
101. Hold a brainstorming session with the staff and ask for their ideas for increasing revenue and reducing expenses. The people on the front lines will have excellent ideas. In return, do not nickle and dime the staff to death by charging for coffee, reducing parking stipends or eliminating uniform allowances. Keep in mind that for your rank and file staff, having to pay for their own uniforms or paying more for parking might be a deal-breaker that causes them to search for work elsewhere. Try to focus on the bigger items for savings and make sure the staff know you are trying to keep their small benefits in place in appreciation for their work.
