The Harvard Business Review blog recently published an article “The Trouble with Treating Patients as Consumers.”

As I read the article I had the same reaction as one of the commentors, “Honestly, this article is so very poor in argument and thesis. The examples are hopeless.  Common sense dictates that patients and doctors make informed joint decisions about healthcare…”

The authors seem to make the case that one must be either a patient or a consumer; if you are one you can’t be the other.  I would argue the patient CONSUMES healthcare resources when being provided care for their presenting problem, so then by definition the patient is a consumer.  There is an exchange of time, knowledge and expertise for currency, again a consumer.

To me the Mayo Clinic program cited, is a wonderful example of Mayo understanding that they must partner with the patient to assist them in becoming better health care consumer.

Why must we assume that information or decision making is a burden?  I thought we were moving away from the paternalistic mindset.

There is a movement toward the Health Care Home model of primary care.  This model is based on a team approach to care where the patient is an equal member of the care team.  This approach comes from the assumption that no one person has all of the answers, but by bring together a team, each will contribute their knowledge to the pool of possible approaches for the the best outcome.  The patient participates in this decision making process and becomes a better consumer. The assumption is that the patient receives assistance with lifestyle changes for chronic illness and receives the best information to choose the best treatment for them for acute symptoms.

As long as the patient/consumer dichotomy exists, the longer the patient will persist in the mindset that someone else should pay, because someone else made the decision (or made them make the decision).  And the consequences are already becoming a reality.

The Atlantic published an article recently informing us that 5% of us spend 50% of all health care dollars.  A friend commented my sentiments with “this is news?”

When I was working exclusively with the older population some 20 years ago, we were talking about similar numbers.  In the age of high tech health care, this rising cost reality will be the case.

In a modern age this is to be expected.  Given our technological capabilities, we can cure most of the acute illnesses that would have sealed our fate before such technology and knowledge was available.  I thought it was now common knowledge that chronic illness is the new frontier now that we have conquered most of the known acute illnesses.  And chronic means expensive.  So the finding “…found that high spenders often repeated from year to year” doesn’t seem like any big “ta da!”

To me, the article is much ado about what we have known for quite some time.  Healthcare demographers have been warning about this for over 20 years.  We have known the Baby Boomers would cause skyrocketing costs.  We just have never had the political will to address it proactively.

So here we are.

There have been several articles in the past couple of weeks about physicians filing for bankruptcy.

Physicians provide a service for which they should to be paid.  And the front desk and business office need the help of the physician to collect what is due.  What do I mean by that?

Several things:

• Patient responsibility as a percent of total revenue is projected to approach 30% in 2012.  Are you ready to collect nearly 1/3 of your revenue from the patient?
• Nearly 50% of all benefit plans are now high deductible health plans.  You will need to collect from half of all patients, not insurance, for the first 3-6 months of the year.  For many of your healthy patients, you may not receive any money from the payer.  If your processes have not changed to deal with this reality, schedule a staff meeting today.
• Price estimates must be developed and USED.  A minimum amount must be collected from every patient.  Probably a minimum of $150.  Remember it’s easier and cheaper to refund than to collect.
• When a patient has a $6000 balance, is unable to pay and is uninsured, you need to collect at the time of service for all future appointments.  And BTW, $20 monthly payments will not get the outstanding balance paid off.  Can you really afford to continue seeing this patient?
• When seeing newborns, they should be treated as self pay patients until active insurance is verified. Help them make the call to their insurance company while their waiting to be seen. What happens if the parents don’t get the child added to their insurance within 30 days?
• Every patient’s insurance must be verified prior to the date of service.  All walk-ins need to be verified before being seen.
• Copays must be collected before being seen.
• Use ABNs and Waivers for procedures not supported by the diagnosis.  If you don’t get these signed, you can’t bill the patient.  This could account for as much as 10% of revenue depending on your specialty and practice.  Use electronic tools to help you with this.

Your practice is a business.  A business that cares, but yet a business. Your mission has to be supported by sound business practices. It’s time to up your game.  Are you ready for the challenge?

The AMA’s House of Delegates recently adopted a resolution directing the organization to vigorously work to stop implemenation of the ICD10 code sets.

This has been in the works for many years, with many delays.  The U.S. is the last industrialized nation to adopt this code set.  So why all the hubbub?

First, the U.S. is the only one of these nations to base reimbursement on these codes (other nations are one payer systems and use the codes for disease reporting only). And over the course of the past years in modifying the core set of codes, the committees responsible for finalizing the code sets caused them to mushroom out of control.  In many cases, there is a 1:20 ratio of ICD9 To ICD10 in the number of codes possible for a disease.

This is also an unfunded mandate.  There are great costs to converting.  Prime among them, IT system changes and staff retraining, in addition to many other change related costs.

But the AMA has known this for some time.  Why wait until now when most large organizations are well into implementing their conversion plans?  Why, when CMS has emphatically stated that there is no delaying or turning back, and that they have given providers ample time to prepare for the transition?

I’m not happy with this either, but my opposition was voiced long ago, yet unsuccessfully.  The train is well down the track at this point and the AMA’s protestations seem too little, too late.

(above is partial list of codes for an insect bite.)

Healthcare billing practices are grossly out of date; ironically just as out of date as our current payment system.  Current systems were established post WW2 when employer sponsored plans paid for almost 100% of the price of care.

Today, 50% of plans are HDHPs carrying $2000-$4000 annual deductibles with $4000-$10,000 annual out of pocket maximums.  This new reality needs a new system for collecting for services provided.

This new system will require an all out culture change, in and out of our organizations.  We need to educate staff, physicians, patients, payers, plan sponsors, etc.  This new system requires that providers collect AT THE TIME OF SERVICE.

Yes, I can already hear your objections, because I’ve heard them all over the past 5 years as I have attempted to implement this new system in organizations with staff who have been in their jobs for many years.  They remember the “good ol’ days” when all they needed to do is greet the patient and ask them to take a seat.

Today, the new system requires that our receptionists/front desk staff/ or what ever you choose to call the staff responsible for first contact, to do many more tasks.  I have advocated for some time that we should be moving billers from the business office to the front desk.

Using the 80/20 rule, most practices should easily be able to produce a visit price estimate prior or during a visit, for their most common visit types.  Then we need to add a check out process.  If you need to be trained, contact your local dentist, they figured this out long ago since dental coverage most often covers only 50% at best.  This is now our new reality, we can learn good collection practices from our dental colleagues.

Action items:

• Retrain front desk staff
• Move billers to the front desk
• Develop price estimate tools
• Educate patients/staff/providers
• Redesign patient flow, incorporate check out process

The time to act is now.  You can’t afford to have your A/R increase another 10% in 2012.

When it comes to social media and your online reputation as a health care provider, the best defense is a great offence.

How? you ask?

1. Start a blog
2. Post to to twitter
3. Create and interact on a professional (not personal) Facebook page
4. Post to Google +
5. Link your blog posts to Twitter, Facebook and Google+

The plan is to have enough of your own current and relevant material online so that when others Google you, it is your content that shows up on the first page of Google search.

Make sure your Twitter, Facebook and Google+ profile contain complete information about you.  These profiles are your online marketing pieces.

Find out what others are saying about you.  Google you.  Answer legitimate issues honestly and request that any mistakes be corrected.

Don’t wait for someone else to write about you, create your own content about you now.  Your reputation deserves the time and effort.

1. Complete and Accurate Registration Information

A successful revenue cycle starts with the registration process. From the spelling of the name to the patient’s date of birth, to the insurance identification number. Assuring that registration data is complete is a must for quick claims turn around and positive cash flow.

Depending on your EMR/practice management system, the registration process may also trigger important clinical processes in your system, including medical necessity prompts.

Insurance companies use name, date of birth and identification number as the primary way to identify the member in their systems. If any one of these is missing, transposed or misspelled, it will stop the claim from processing.

One of the key data points many forget to collect is the insured’s date of birth. This is crucial when the relationship between patient and insured is not self. For example when the patient is a child and the insured is the parent, the claim will reject if the covered parent’s date of birth is missing from the claim.

Another key elements in registration is making sure that the insurance coverages are listed in the correct order. When they are in the incorrect order the claim will deny for incorrect COB information.

2. Patient Collections at the Time of Service

Consumer directed health care plans have become more popular in recent years. This has put more responsibility on patients to pay a larger portion of their healthcare expenses. This also has put more pressure on providers to collect more money from patients rather than from insurance companies. Unfortunately providers have not reeducated their staff and providers to be comfortable asking for money. These factors have caused providers’ self pay A/R balances to increase dramatically. This, along with the recent economic environment, has caused bad debt expense to spike as well.

Staff can be trained to use some very simple scripts to feel more comfortable asking for money at the time of service. For example, “Ms. Smith I see you have a balance of $200 dollars would you like to pay for that by cash, check, or credit card.” The most important part of this is to understand is that even if you are successful only 50 percent of the time, this is 100 percent more than what you were collecting before you started asking.

3. Complete & Detailed Documentation

Medicare along with most other payers are looking more closely at documentation to support medical necessity. Documentation of medical necessity has become the proof needed for payment. The absence of one piece of critical detail in documentation can mean the reduction of payment by several hundred dollars.

Another reason providers should be getting used to more detailed documentation is to prepare for the conversion to ICD10. Do not get use to using a unspecified codes. Payers are indicating they will pend claims for more documentation rather than paying at a reduced rate.

4. Correct Coding

Medical coding translates the clinical documentation into numerical and alphanumerical values. The process of performing this translation is called abstracting. The provider or coder selects the most appropriate codes based on the clinical documentation.

Some providers do their own coding while others will hire professional coders. Regardless of the way you go, one should make sure that those that are doing the coding are well versed in all of the coding rules, and there are plenty of them. Medicare has their set of rules and each payer has their own set of rules as well. In addition to the primary codes there are modifiers that can be used to better describe the services provided. Some of these requirements go by terms such as OCE editor, correct coding initiative (CCI), medical necessity edits and others.

I’ve known physicians who have taken coding certification courses in order to feel comfortable in their knowledge of what is needed to document and code correctly for maximum reimbursement and compliance.

5. Timely Submission and Follow up of Claims

One of the common problems I see in physician offices is a delay in documentation of the visit. This delay causes delay in coding which in turn causes a delay in billing. When this occurs been coding and billing it is also delayed. Each day the account is delayed in going out the door is a delay in cash in the bank and is adding days to your account receivable balance.

With the adoption of electronic medical records this should become less of a problem. Gone is the day when staff should find records in the trunk of the physician car. The goal is to get the claims to the insurance company as soon as possible with the fewest errors possible.

Getting claims to the payer is only half of the story. Now we have to have work flow that follows up on them once they have been submitted. Billing staff have to know the payer requirements for successful claims processing. In today’s world of electronic claims most payers should have remitted a payment or a denial back to you with in 14 to 21 days. Your practice management system should be able to create work queues to identify the claims that are outside of the normal processing guidelines.

 Marla Durben Hirsch reports in the article,  EHR adoption costs continue to hold physicians back, that current users and potential purchasers of electronic health record (EHR) software recognize the value of using EHRs, but the high cost is causing nearly one-third of physicians to hesitate from taking the plunge, according to a recently released survey by Sage Healthcare Division.  77 percent of all respondents saw the ease of use and speediness of an EHR, 32 percent of medical practices who are in the market for the technology remain stymied by the capital investment.

“[M]eaningful use incentives are still one of the strongest drivers for most physicians (64 percent) to implement technology,” Sage said in its statement.

Current EHR users are also more aware of the technology’s additional benefits, such as:

• Meeting their business goals of lower costs and improved patient service (80 percent)
• Improved staff efficiency (74 percent)
• Increased availability of floor space that was previously occupied by paper records (72 percent)
• Ability to share patient information (38 percent)
• Reduced paper and office expenses (52 percent).

Some of the capital investment costs can be avoided by choosing a hosted solution such as Practice Fusion or etransmedia.  Practice Fusion is free, supported by unintrusive ad revenue or a small monthly subscription to remove the ads.  Practice Fusion is an EMR only.  etransmedia is a monthly subscription for access to Allscripts MyWay, both EMR and PM, offered through Costco.com at a reduced rate for executive members.

“It’s too expensive.”

“It will slow me down.”

“I don’t have time to learn the darn thing.”

All of these excuses and more are used to delay implementing an EMR/EHR in private practices.   Consider however a recent article new study published in the Journal of Political Economy. According to the researchers, EMRs help give better access to important patient information so providers can give improved care that is more cost-effective when compared with other healthcare interventions.  True, this study looks at hospital EMR use, but EMR use, when deployed correctly in a private practice can also be a powerful tool in the goal of improving care.

EMRs are a tool, simply a tool.  They can be used well or they can muck up the process.  When implemented and used well, they can be an integral and indispensable part of quality care just as labs and radiology tests have become.

Get more information about a no risk way of trying out an EMR by clicking here:

Try Practice Fusion

The Journal of the American Medical Association reports that a higher level of primary care physician workforce, particularly with an FTE measure that may more accurately reflect ambulatory primary care, was generally associated with favorable patient outcomes.

Despite widespread interest in increasing the number of primary care physicians, the relationship of the primary care physician workforce to patient-level outcomes is not well understood.

Along the same lines, Reuters reports that some researcher estimate that if the US could achieve the optimal level of primary care providers it would translate into nearly 50,000 fewer deaths and about 436,000 fewer hospitalizations over a year.

The key is to recruit enough medical students to choose primary care practice over the more lucrative specialties.