2011 Practice Management News Compendium by California Academy of Family Physicians

Practice Management News Compendium CAFPâ&#x20AC;&#x2122;s Popular Practice Management eNewsletters, OďŹ&#x20AC;ering Valuable Tools for Family Physicians

Practice Management Compendium California Academy of Family Physicians is pleased to bring to family physicians and their office staffs a hands‐ on guide to the practical side of operating a medical office. It includes articles from consultants Barbara Hensleigh, Mary Jean Sage, and Suzanne Houck and covers legal and staffing issues, quality improvement, coding and payment, billing and more. Actual situations are analyzed and interpreted in the form of helpful case studies throughout the compendium. These articles were previously published in the e‐newsletter Practice Management News, and are available on CAFP’s website as well.

About CAFP CAFP’s mission is to advance the personal and professional development of California’s family physicians. With more than 7,000 members, including active practicing family physicians, residents enrolled in family medicine programs and medical students interested in the specialty, CAFP is the largest primary care medical society in California, and the largest chapter of the American Academy of Family Physicians. For more information about the CAFP go to www.familydocs.org.

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CAFP champions family medicine for California and helps family physicians improve their everyday practice lives.

CALIFORNIA ACADEMY OF FAMILY PHYSICIANS

Table of Contents Billing Issues 6 9 13 15 18

Ten Tips for Productive Billing and Prompt Payment Billing Opportunities You Can’t Afford To Miss Avoiding Claim Denials 2010 Coding and Billing Changes Five Services Every Family Physician Should Be Billing

November 2005 May 2006 August 2007 January 2010 April 2010

Coding and Payment 22 26 29 33 36

Strategies for Improving Accounts Receivable Management The Challenge of Coding and Billing Group Visits How to Ask For (and Get) Improved Payment from Plans Answers to Frequently Asked Coding Questions Collecting Outstanding Accounts Receivable: Is it Time to Update Your Collection Plan Policies? 39 Document Your Level IV Visits With Confidence

January 2010 March 2006 November 2006 August 2008 April 2009 July 2010

Legal Issues 44 Damaging Internet Comments: Don’t Just Read Them and Weep 47 Five Easy Steps to Implementing Informed Consent 49 Read Carefully Before Signing 51 Medical Malpractice Insurance – Traps and Tips 54 Ten Tips for Choosing a Lawyer 57 You and Your Hospital – The Ins and Outs of Hospital Contracting

December 2007 March 2008 June 2008 September 2009 November 2009 August 2009

Quality Improvement and Practice Redesign 62 65 69 72 75

Getting Started With Planned Care Where to Start with Improvement Do Patients Belong on YOUR Care Team? Mapping Your Way to Leaner Workflows Strategies to Improve Access and Make Office Visits More Patient‐Centered

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February 2006 February 2007 April 2007 February 2009 August 2009

Staffing Issues 80 Making Staff Meetings Work 83 The Value of Teams 86 Hiring and Training Medical Assistants

December 2006 July 2007 January 2008

Technology 90 Leverage Registries to Improve Chronic Illness Care 94 The Dos and Don’ts in Selecting and Contracting for an EHR System 97 Is There a Patient Portal in Your Future?

October 2006 May 2010 July 2010

Additional Topics 100 The Patient‐Centered Medical Home: Fad or Key to a Sustainable Future? 103 Panel Management News 106 New HIPAA Privacy and Security Requirements

April 2008 May 2009 October 2009

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Author Biographies

Barbara Hensleigh Barbara Hensleigh, a former NICU nurse, has practiced law for over 20 years. Her statewide practice is with the law firm of Andrews & Hensleigh, LLP, in Los Angeles, California. Ms. Hensleigh's practice is devoted to the representation of physicians, physician groups and healthcare entities in litigation, arbitration and administrative proceedings. Her partner, Joseph Andrews, who has special expertise in insurance coverage issues, contributed to these articles.

Suzanne Houck Suzanne Houck serves as President of Houck & Associates Inc, a leader in ambulatory care redesign consulting and training. Sue is the author of What Works: Effective Tools & Case Studies To Improve Clinical Office Practice, the first comprehensive book on ambulatory care redesign. She also has experience as an ambulatory care manager and nurse practitioner throughout the United States and Africa. Sue has a Masters in Business Administration and has presented at national conferences for the numerous healthcare organizations including the American Hospital Association, Medical Group Management Association, American Medical Group Association and the Outpatient Care Institute. She formerly served as Chief Operating Officer of Critical Care Incorporated as well as health care consultant for KPMG Peat Marwick. Mary Jean Sage Mary Jean Sage has extensive experience in the health care field that spans a period of over 20 years during which time she managed diverse groups of professionals in delivering patient care. A founding Principal and Senior Consultant with The Sage Associates, Mary Jean is a nationally known speaker, consultant and educator. As a health care management specialist, Mary Jean assists health care professionals address and resolve management and business development issues. Her unique blend of administrative and clinical experience has earned her an enviable reputation as an expert in managed care operations and reimbursement management. She was instrumental in developing the Certified Medical Billing Associate program for the California Medical Billing Association and served as the initial Certification Director for the program. She currently serves as an advisor to a number of billing and coding publications.

DISCLAIMER The articles in Practice Management News do not constitute legal, practice management or coding advice. These articles are for informational purposes only and do not create an attorney‐client relationship. You should contact your attorney to obtain advice with respect to any particular issue or problem.

PRACTICE MANAGEMENT NEWS: COMPENDIUM

Billing Issues Ten Tips for Productive Billing and Prompt Payment Billing Opportunities You Canâ&#x20AC;&#x2122;t Afford To Miss Avoiding Claim Denials 2010 Coding and Billing Changes Five Services Every Family Physician Should Be Billing

November 2005 May 2006 August 2007 January 2010 April 2010

Ten Tips for Productive Billing and Prompt Payment Mary Jean Sage

November 2005

It is estimated that only about 70 percent of claims submitted are processed and paid on the first submission. That leaves an astounding 30 percent of claims unprocessed or returned unpaid. While not all of the factors that influence claims payment are within your control, you can take steps to lessen the frustration and unnecessary expense (such as staff time, clearinghouse fees, paper costs, and mail charges) associated with claims delays and denials. To ensure that you receive full and timely reimbursement, try these tips: 1. Update and verify each patient’s insurance coverage At each visit, copy both sides of the patient’s insurance card so that you are sure to get the correct claims filing address as well as other important information. If you have any doubts, verify the patient’s coverage online, or by phone. This may take five minutes, but that’s less than the 90 days that will lapse while your office tries to collect payment from a patient who has provided invalid insurance information. Follow the same procedure for any secondary insurance the patient may have. 2. File claims daily It’s hard enough to get claims paid when you send them in. They definitely won’t get paid sitting in your office. 3. Use electronic billing whenever possible Submit your claims electronically if you can; they will be more likely to make it to the correct destination than in the U.S. mail. They’ll also be processed faster, and you’ll have a printout that shows when you sent them, as well as a confirmation report of when the insurance companied received them. This report is vital information if you have to fight for payment. If you can produce the report that shows you sent that claim within the time limit, they must pay your claim, even if a timely filing limit has passed. There are two things that are of utmost importance about this report: n Make sure the office staff reviews this report and corrects any problems that may have prevented a claim from being submitted to the insurance payer. n Keep the report for an appropriate period of time in case you need to prove timely filing 4. Reduce claims denied for missing or inaccurate information If missing or inaccurate information is causing claims denials for your practice, they can be reduced by implementing a procedure to double‐check every claim for completeness and accuracy prior to sending it to the payer. Common billing errors include providing incorrect or incomplete patient information (member number, policy number, full name of subscriber) and incorrect or incomplete service information (date of service, diagnosis codes, CPT codes and modifiers). 5. Avoid denials and delays caused by coordination of benefits issues Routinely ask all patients whether they have secondary or other insurance coverage. Gathering this information and using it when billing the insurance carriers can reduce the number of delayed claims pending coordination of benefits. Verify whether each payer listed in the patient’s file is the primary or secondary carrier. Remember the “birthday rule” for dependent children covered under more than one policy: The payer whose subscriber has the earlier birthday in the calendar year will be the primary payer.

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6. Reduce the number of denied or delayed Medicare claims in your office Ask new patients age 65 or older (or current patients who’ve turned 65 since their last visit) to present a copy of their Medicare and other insurance cards, and update records as needed. Remember, it is possible for a patient to have only Medicare Part A or Part B, or to be ineligible for Medicare despite being 65 or older. It is also important to find out whether Medicare‐eligible patients have group health insurance. Federal laws determine when Medicare is the primary or secondary payer. If Medicare is the primary payer, check to see if Medicare automatically “crosses over” and sends the claim to the secondary or other payer. The Medicare Remittance Advice Notice should indicate when a claim has been crossed over to the secondary payer. 7. Eliminate claims denied as duplicates Check your EOBs to see if your practice experiences a substantial number of claims denied as duplicates. Avoid having claims denied as duplicates by: n Establishing a minimum rebilling cycle of 30 to 45 days to allow time for the original claim to move through the payer’s cycle. Resubmitting a claim in less time uses unnecessary resources and is likely to result in the claim being denied as a duplicate. n Reconcile claims denials and claims payments at least every 7 to 10 days, and work through any electronic error and rejection reports in the process. This will help you avoid common mistakes such as refilling a denied claim, or billing the patient’s portion to the insurance carrier. n Don’t automatically rebill all outstanding claims. When a claim requires follow‐up, your first step should be to contact the payer (by phone or e‐mail) for additional information. To reduce the number of appeals or corrected claims denied as duplicates, remember these things: n Unless the plan directs you otherwise, do not simply stamp a claim as “Second Request” or “Appeal” or “Tracer.” These claims will generally be treated as new claims and will be denied as duplicates. n Be sure that any appeal or correction is submitted to the correct address. Many payers request that appeals be submitted to an address or post‐office box that is different from the one used for original claims. 8. Make sure secondary insurance is billed While Medicare crosses claims over to a secondary insurance, other insurances do not. At the time of posting a payment from a primary insurance to the patient’s account, make sure a claim is requested or generated for the secondary insurance. Don’t forget to attach a copy of the EOB from the primary insurance. 9. Go over explanation of benefits with a fine‐tooth comb Don’t just use the explanation of benefits to post payments; use it to make sure you are being paid what you are due. Look for unnecessary downcoding, bundling, and denials, and investigate. For example, if a company elects not to pay you for both an office visit and an ear lavage on the same day, you will want to appeal this claim; or if the payer pays for a 99213 office visit instead of the 99214 visit without having asked to review documentation, you will want to appeal this as well. 10. Know your managed care contracts Read your managed care contracts and familiarize yourself with coverage terms. Be aware of any stipulation such as filing deadlines, and make sure your office adheres to them. Know which plans have deductibles, which have co‐payments, and which cover office visits for preventive care as well as illness. Collect for deductibles, co‐payments and non‐covered services while the patient is in the office. With the average cost of generating a patient statement at $9 to $12, you don’t want to have to send monthly statements to patients. CALIFORNIA ACADEMY OF FAMILY PHYSICIANS

Go over the fee schedule for each plan and determine how much you’re being paid for each service. Remember, a patient’s co‐insurance is a percentage based upon the reimbursement the payer “allows,” not what your fee might be. Collect the patient’s co‐insurance while the patient is in the office. Developing a “reimbursement template” will be helpful for your staff to ensure they collect the correct co‐insurance. You can store this in the computer where it is easily accessible to the staff. You can also provide a manual template; simply use one of your superbills and mark it up with the expected reimbursement by service. Develop one for each of your major payer groups.

The Bottom Line: Follow‐through and Persistence Pay Off When it comes to billing, follow‐through and persistence are a must. If your cash flow remains stagnant, so will your practice. If you’re like most family medicine practices today, you can’t afford that.

Determining Co‐Insurance To determine what a patient’s co‐insurance might be, you first need to know how much you expect the payer (insurance company) to allow for any given service. You must start by having a fee schedule from the particular payer. If your contract doesn’t have a current fee schedule attached (insurance companies have been known to forget to include these with your copy of the contract), you must call Provider Relations or Contracting at the plan and ask for a current fee schedule. Many plans now have this information available online through their provider portals. Occasionally, you will need to fax a copy of all CPT codes used in your practice to the plan, so they can provide the information to you. Whatever it takes, get the fee schedule! Remember, co‐insurance is a percentage of what the insurance plan allows, not necessarily what the insurance company pays. Make sure you collect the full amount of any co‐insurance. You will have some managed care plans that have contract language that appears to prohibit the practice from collecting from the patient until the insurance company has been billed and paid. Often, insurance plans are flexible with this stipulation, and if you can show that it would cost more to bill for the co‐insurance than the amount of the co‐insurance itself, it may be acceptable with the plans to collect for the co‐insurance at the time of the service. (For example, a patient has an office visit and the insurance company allows $50 as the contracted fee allowance. The patient’s co‐insurance is 20% of the allowed amount, or $10. It is not cost effective to spend $9 to $12 to generate and mail a statement to the patient to collect $10. Therefore, collect it at the time of the visit). Make sure you have a good track record of collecting the correct amount, however.

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Billing Opportunities You Can’t Afford to Miss Mary Jean Sage

May 2006

How many times have you advised a patient to quit smoking and then devoted a good chunk of time explaining why and how they should do it? Or spent from 5 to 10 minutes of your time reviewing and then signing either a certification or re‐certification from a home health agency for one of your patients under their care? Or performed a “Welcome to Medicare” exam for a female patient and did a cancer screening with a breast/pelvic exam and obtained a Pap smear? Or performed the same Welcome to Medicare exam for a male patient and did a digital rectal exam as a cancer screening? Did you bill for these services as separate services or consider them part of another service? If you didn’t bill for any of the above mentioned services separately, you could be losing revenue in your practice. Medicare Physicals and Other Services For the past year, Medicare has been paying for an initial preventive physical exam (IPPE) when a patient first becomes eligible for Medicare benefits. This exam must be done within the first six months of the beneficiary’s Medicare eligibility. Too often we see other services being provided at the same time as this exam, but not being billed separately, such as cancer screenings or illness‐related E&M services. Consider the following example (and then see the appropriate way to bill for it in the box below): A patient, whom you have been following for some time for her hypertension, has just turned 65 and is now covered by Medicare. She makes an appointment for her “Welcome to Medicare” preventive exam and wants to have her Pap smear during the same visit. You use your well‐trained medical assistant, and a good set of well‐developed templates, to help perform all seven of the required elements of the IPPE, which are: 1. 2. 3. 4. 5. 6.

Review of comprehensive medical and social history Review of risk factors for depression Review of functional ability and level of safety A focused physical exam which requires height, weight, blood pressure, and visual acuity Performance and interpretation of an electrocardiogram Brief education, counseling, and referral to address any pertinent health issues identified in the first five elements of the exam 7. Brief education, counseling and referral, with maintenance of a written plan (checklist) regarding separate preventive care services covered by Medicare Part B Correct Coding and Billing Service CPT /HCPCS G0344 Initial Preventive Physical Examination G0366 Routine 12‐Lead EKG with interpretation and report

Diagnosis V70.0 V70.0

Expected Payment* $94.51 $26.42

*Expected payment amounts are California Area 99 As part of element #7, you perform a cancer screening by doing a breast and pelvic exam and obtaining a Pap smear.

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Correct Coding and Billing Service CPT /HCPCS G0101 Cervical or Vaginal Cancer Screening, Pelvic & Clinical Breast Exam Q0091 Obtaining, Preparing & Conveyance of cervical or vaginal smear to lab

Diagnosis V72.31

Expected Payment* $36.73

V72.31

$39.53

*Expected payment amounts are California Area 99 In the course of doing the IPPE you note that the patient’s blood pressure is elevated and upon further inquiry you find that her diary of home blood pressure readings shows it has been elevated frequently. She tells you she has had frequent headaches over the past month. You subsequently decide to adjust her medication for hypertension. You make a separate note documenting this. Correct Coding and Billing Service CPT /HCPCS 99212‐25 Established Patient Office Visit – Level II

Diagnosis 401.1

Expected Payment* $37.76

*Expected payment amount is California Area 99 Total reimbursement for this visit should be $234.95 (compared to $120.93 for the IPPE only). If you performed or provided any of Medicare’s other covered preventive services, those should have been coded and billed additionally. Counseling for Smokers Medicare, as well as other commercial insurance carriers, pays for tobacco or smoking‐ cessation counseling sessions; the patient doesn’t necessarily need to make a separate appointment. Medicare pays for up to eight tobacco‐cessation counseling sessions per patient per year (two attempts of four sessions each) if the patient has a tobacco‐related illness or is taking a medicine that interacts adversely with tobacco. If the patient meets the diagnosis criteria, you may bill for the smoking‐ cessation counseling that’s done during a regular E&M visit. CMS has developed two HCPCS Level II G codes to report these services — G0375 for counseling that is longer than 3 minutes and up to 10 minutes and G0376 for counseling that is greater than 10 minutes. Medicare considers any counseling that is less than three minutes to be part of an E&M service. The diagnosis code you use for this service should be the patient’s condition that is exacerbated by the tobacco use, or the condition that is being treated with a drug which may interact adversely with tobacco use. You should have your billing staff call private insurers to find out how they’re covering smoking‐cessation counseling and how they want it reported. Make sure they also ask how often it is covered as well. Consider this billing scenario: A 66‐year‐old patient comes to the office with his second bout of bronchitis in six months. After assessing the acute problem and prescribing the appropriate medication, you once again advise the patient to quit smoking. A 12‐ minute counseling session ensues while you ascertain his willingness to quit and you assist with the attempt to quit by suggesting ways and any appropriate medications to help. You ask the patient to set a “quit date” and then schedule a follow‐up visit to monitor progress and deal with any challenges associated with the attempt to quit.

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Correct Coding and Billing Service CPT /HCPCS 99213‐25 Established Patient Visit G0376 Smoking Cessation Counseling, greater than 10 minutes Visit # 2 (1‐2 weeks later) G0376 Smoking Cessation Counseling, greater than 10 minutes

Diagnosis Expected Payment* 491.9 $51.49 (chronic $24.61 bronchitis)

491.9

$24.61

*Expected payment amounts are California Area 99 While this may not be a very lucrative billing opportunity, it does give you a chance to collect for a service you’re probably offering anyway! It also helps maintain patient loyalty when you help the patient kick his tobacco addiction. Home Health Care Certification and Re‐certification How many times has an office staff member stopped you in the hall of the office and asked you to sign a Home Health Care re‐certification or how many times have you opened your mail to find two or three patient care plan certifications for your patients from the Home Health Agency? These are services family physicians often perform, but don’t bother to complete a charge ticket so the service of certification or re‐certification can be billed. Most often patients who are home‐bound and require Home Health Services are Medicare patients, and Medicare pays for this service. There are some billing tips every office should be aware of to get paid appropriately: n Medicare allows payment for certification of the home health plan for any patient who has not received Medicare‐approved home health care for at least 60 days. n HCPCS code G0180 is used to bill the service and the Home Health Agency’s Medicare certification/provider number must be entered on the claim. n The date of service is the date you (the physician) sign the plan of care. n The two‐digit “place of service code” should be 11 (office), because you provided the service (certifying the plan) in your office (not the patient’s home). n HCPCS code G0180 is used to bill the service and the Home Health Agency’s Medicare certification/provider number must be entered on the claim. n The date of service is the date you (the physician) sign the plan of care. n The two‐digit “place of service code” should be 11 (office), because you provided the service (certifying the plan) in your office (not the patient’s home). n Medicare’s allowable for this service is $73.20 (California Area 99). The patient’s deductible and co‐insurance apply to this service. n Medicare allows payment for re‐certification of the home health plan once for a patient’s home health certification period, which is every 60 days. n The HCPCS code G0179 is used to bill for this service and the claim completion requirements are the same as those for care plan certification. n Medicare allowable for this service is $56.16 (California Area 99). n The patient’s Medicare deductible and co‐insurance apply to this service as well. To meet documentation requirements for providing the review of the home health agency’s care plan, the physician should note in the patient’s medical record: the review of the plan and acceptance or modification of the plan. A copy of the plan itself should also be made part of the patient’s permanent medical record.

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While these two services may not be provided to large numbers of patients, they are services that require physician time and other office expense to provide, so they should be billed, and not just taken as an expense to your practice. To ensure you bill these services, require that a billing slip (e.g., superbill or charge ticket) be presented with the certification/re‐certification for physician review and signature — that way you won’t forget to bill! n Medicare’s allowable for this service is $73.20 (California Area 99). The patient’s deductible and co‐insurance apply to this service. n Medicare allows payment for re‐certification of the home health plan once for a patient’s home health certification period, which is every 60 days. n The HCPCS code G0179 is used to bill for this service and the claim completion requirements are the same as those for care plan certification. n Medicare allowable for this service is $56.16 (California Area 99). n The patient’s Medicare deductible and co‐insurance apply to this service as well. To meet documentation requirements for providing the review of the home health agency’s care plan, the physician should note in the patient’s medical record: the review of the plan and acceptance or modification of the plan. A copy of the plan itself should also be made part of the patient’s permanent medical record. While these two services may not be provided to large numbers of patients, they are services that require physician time and other office expense to provide, so they should be billed, and not just taken as an expense to your practice. To ensure you bill these services, require that a billing slip (e.g., superbill or charge ticket) be presented with the certification/re‐certification for physician review and signature — that way you won’t forget to bill!

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Avoiding Claim Denials Mary Jean Sage

August 2007

Insurance claim denials can be costly for any family medicine practice. Denials may lead to one of two different sce‐ narios: A. If the denial is not appealable, your practice will experience a loss of income for a service already performed; or, B. You will incur increased expense in appealing the denial — a situation no practice wants to be faced with, particularly as reduced payment from many payers affects practice income. Being proactive with office policies and procedures allows you to minimize the chances for claims denial with all carriers. Consider how your office handles the following policies:

Verify Insurance Plan Coverage Frequently: While this may seem obvious, in fact the number of claims denied or returned because the wrong insurance carrier is billed is staggering. It is the number one reason claims are not paid upon first submission. Consider how your office verifies insurance plan coverage, benefits and eligibility — especially on established patients who are seen routinely, or at least more frequently than once a year. At a minimum, insurance plan eligibility should be checked quarterly and more often if it is employer‐sponsored coverage. This is because employ‐ ment can change frequently, and also because group health plan coverage can be dependent upon how much the employee works in a given period of time (e.g. monthly). If an employee hasn’t worked a given number of hours in that period, he or she might not be eligible for health insurance coverage. Eligibility on these plans should be checked monthly. Periodic checking is also important because the number of Medicare Advantage Plans being made available to enrollees has increased significantly. Nearly every commercial health insurance company now has at least one of these plans; medical practices are seeing more and more Medicare‐eligible patients switch to one of these private fee‐for‐service plans. In this scenario, the Medicare patient is allowed to keep his or her traditional (red, white and blue) Medicare card, but will also have a card from Blue Cross, Blue Shield or another commercial health plan. Medicare patients typically tell the physician’s office they have “Medicare” without indicating which private plan they also have. While these plans are still Medicare, the NHIC (California’s Medicare administrative carrier) is not billed for patient services. Instead the commercial plan is billed. Often the practice doesn’t realize this until they bill Medicare and the claim is rejected, indicating that a different plan must be billed. The practice then needs to start all over with this claim and bill a different carrier. You and your billing staff can find more information about the Medicare Advantage plans offered to patients in your geographic area here. A zip code search will reveal the plans currently offered to enrollees. Another policy to implement which assures you are billing the correct Medicare plan is to ask any Medicare patient to present a copy of ALL health insurance cards he or she has. You must, however, educate your office staff on the other Medicare plans and how to recognize them versus other commercial health plan cards.

2. Billing for services found to be “medically not necessary”: This is a second reason claims are commonly denied or not paid. All too often, practices write this money off and do not bill the patient for these services.

CALIFORNIA ACADEMY OF FAMILY PHYSICIANS

You can be proactive in reducing these denials by knowing which of the services you provide are tied to specific diagnoses, time periods (e.g., annually, biannually, every five years) or other payment conditions. Next, implement a policy to address how to bill for these services if one of the conditions is not met. For example, many health plans cover an annual well‐woman exam up to a certain age, and then biannually thereafter. If you have a female patient in the biannual coverage age, but she insists on having an annual exam and pap smear, the service will likely not be paid by the health plan because it deems the service not medically necessary for this patient’s age group and absence of other health factors. How do you ensure you will be able to collect from the patient for this service? Every practice should have a policy on dealing with advanced beneficiary notices (ABNs). While this is a Medicare concept, you can use it with other carriers as well. Basically, the patient should be notified prior to the service being provided or performed that the insurance company may deny payment based on medical necessity. The patient should be given the opportunity to elect to have the service done and accept financial responsibility for the service or refuse to have the service provided. The patient should be asked to sign a notice specifying their decision. Medicare has a specific ABN form which can be downloaded along with a sample poli‐ cy on administering the use of an ABN.

3. Updating Codes (ICD‐9, CPT, HCPCS): Every year the code sets used to report and develop insurance claims are updated. Using invalid codes is a frequent source of claim denial. You need to keep your coding resources up to date by purchasing the hard copy resources or subscribing to online resources for diagnosis codes (ICD‐9 CM), and services codes (CPT and Level II HCPCS). These resources are not enough, however. You must be prepared to implement the use of any new codes in a timely manner. Many insurance carriers have done away with the traditional “grace period” of allowing the use of old or deleted codes after the annual release of additions, deletions and other revisions for those codes. Now claims are denied immediately following implementation dates. This becomes a bigger challenge when payers have different implementation dates for accepting these changes and you have to deal with multiple sets of rules. Every family medicine practice should plan ahead for possible changes to their existing code sets. Beginning one to two months before mandatory code usage deadlines, each practice should: 1. Secure new coding resource materials and review any changes being present; 2. Review use of any changed codes; 3. Implement procedures to make the necessary changes to your practice management system(billing), appointment scheduling if appropriate, and electronic health record, if you have one; 4. Implement procedures so your practice can handle multiple code sets for different payers for a period of time; and, 5. Monitor post‐payment Explanation of Benefits or Remittance Advice activity to gauge acceptance of coding changes by various payers. CAFP has a coding and billing monograph, with a yearly supplement of up‐to‐date changes in CPT and documentation, available on our website at www.familydocs.org/practic‐resources. When you prepare for coding changes (typically September through December), it is also a good time to have a staff meeting to review all the procedures and services being provided to your patients. This meeting will help to ensure that all services are being billed and that you and your practice aren’t losing income by providing non‐ reimbursable services. Reviewing how your practice handles any of the above three policies will minimize the chance of frequent claim denials.

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2010 – Coding and Billing Changes Mary Jean Sage

January 2010

It's the time of year to implement CPT updates. Similarly, changes to the Centers for Medicare & Medicaid Services (CMS) Medicare Physicians Fee Schedule (MPFS) are effective January 1, 2010. The combination makes it especially important for you to remain current and avoid unexpected revenue changes. It's also the time of year when most patients incur new deductibles; remember to collect any deductible amounts at the time of the visit. n Medicare Changes The most talked‐about change for 2010 is not a new code, but the elimination of consultation codes, and resulting payment, from the MPFS. Consultation codes remain unchanged in the CPT manual, however. CMS has issued instructions to use new or established patient visit codes (99201‐99215) to report consultations provided in an outpatient setting. Codes for initial hospital or nursing facility care should be used instead of con‐ sultation codes for those sites of service. A new CMS modifier ‐ AI ‐ identifies an admitting physician's charge for initial hospital care. Other physicians asking to see the patient in the inpatient setting should use the appropriate initial hospital care code (CPT 99221‐99223). Because family physicians tend to use consultation codes infrequently and because CMS adjusted some payment value from the consultation codes to the E/M codes used in their place, most will not lose revenue; some even may experience a slight increase. One issue that will affect family physicians involves billing for preoperative clearance. In the past, family physicians have been encouraged to bill a preoperative clearance as a consultation, using the primary diagnosis of preoperative exam V72.8 (1,2,3,4). Now, that preoperative clearance service must be billed as either a new patient visit (if you have never before seen the patient, or if it has been at least three years since you've seen the patient) or an established patient visit. Continue to use the preoperative exam diagnosis (V72.8#) as the primary diagnosis; report any underlying diagnosis the patient has as secondary diagnosis. Private payers have not yet announced any policy changes; continue to bill non‐Medicare plans with consultation codes (99241‐99255). Be sure to use the appropriate site of service, based on where the preoperative clearance was performed. n Initial Preventive Physical Examination (IPPE) Section 611 of the Medicare Modernization Act of 2003 (MMA) established the IPPE benefit. IPPEs enable patients to receive a complete examination with additional screening tests within the first six months of Medicare enrollment. This exam had a base value of 1.34 RVUs (equivalent to a 99203 visit). Section 101(b) of the Medicare Improvements for Patients & Providers Act of 2008 (MIPPA) changed the benefit as follows: 1. Adding Body Mass Index 2. Adding End‐of‐Life Planning 3. Removing the screening electrocardiogram (EKG) as a mandatory service of IPPE After receiving comments that this was undervalued, CMS increased the physician work RVUs (code G0402) to 2.30 RVUs, equivalent to code 99204 beginning January 1, 2010. Also beginning January 1, the IPPE will be available to Medicare beneficiaries during the first 12 months of enrollment.

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n E‐prescribing Incentive Bonus The 2010 e‐prescribing measure will be revised. Proposed changes include: 1. Eliminates the three numerator G codes (G8443, G8445, G8446) 2. Creates a new G code ‐ Gxxxx: At least one prescription created during this encounter was generated and transmitted electronically using a qualified electronic prescribing system 3. Expands the list of denominator codes to include nursing facility services and home visits Final 2010 e‐prescribing measure specifications, as well as the new “G” code number, will be posted to the CMS Web site no later than December 31, 2009. n Other Medicare Issues Payment Rates: A 60‐day freeze on Medicare payment rates has been approved by Congress and the president. Thus, the scheduled 21.1 percent physician payment cut has been delayed. The legislation is specific to the conver‐ sion factor only; all other 2010 Medicare policy changes will become effective on January 1, 2010. Participation Enrollment: CMS has extended Medicare's 2010 provider participation enrollment end date to January 31, 2010. This gives participating physicians an additional month beyond the normal cutoff (December 21, 2009) to make participation decisions. Medicare contractors will accept participation elections or withdrawals post‐marked on or before January 1, 2010. Provider status changes made during the extension period are retroactive to January 1, 2010 and will remain in effect throughout 2010. n CPT Coding Changes CPT coding changes often reflect new services and procedures. This year's additions follow that trend. Here are several that could be important. Sleep Studies: 0203T: Sleep study, unattended, simultaneous recording; heart rate, oxygen saturation, respiratory analysis (e.g., by airflow or peripheral arterial tone) and sleep time. 0204T: Sleep study, unattended, simultaneous recording; minimum of heart rate, oxygen saturation and respiratory analysis (e.g., by airflow or peripheral arterial tone). 95806: Sleep study, unattended, simultaneous recording of heart rate, oxygen saturation, respiratory airflow and respiratory effort (e.g., thoracoabdominal movement). HCPCS codes G0398 ‐ G0400: Also used to report unattended home sleep testing of Medicare beneficiaries (the service now described by code 95806). Venous Wounds: CPT 29581 is a new code to report the application of a multi‐layer venous wound compression system. It allows for differentiation from the single‐layer Unna boot. Vaccines: There are new codes and descriptors changes for vaccines. 1. Existing code 90669 for the pneumococcal conjugate vaccine now indicates that it's used to report a seven‐valent pneumococcal conjugate vaccine. There is a new code (90670) to report the 13‐valent version. This new code is marked with the “lightning bolt” symbol in the CPT book to indicate that it is ending FDA approval.

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2. There is a new code not listed in the 2009 CPT manual, but will be effective on January 1, 2010. The code (90644) can be used to report the new Hib‐MenCY‐TT vaccine. Code descriptors for some vaccines and toxoids now include age and “preservative free” designations. These are intended to assist in differentiating between similar products and services. n Nursing Facility Care: The Nursing Facility Care code (99304 ‐ 99310 and 99318) descriptors have changed to include time spent on the patient's unit or floor. Before 2010, they only included physician/patient face‐to‐face time. They now recognize the time you spend on chart review, documentation and communication with the patient's family. Remember that time spent off the patient's floor is considered pre‐ or post‐service work and is not included in floor time. n Beginning the Next Decade: While the changes for 2010 may not seem complex or as numerous as those in previous years, they are still important to and should be reviewed and systems updated to reflect those changes to assure every practice is striving for maximal payment.

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Five Services Every Family Physician Should Be Billing Mary Jean Sage

April 2010

Whether you’re a new or well‐established family physician, you want to do the best job possible in coding, billing and collecting activities. This article covers five common coding scenarios that are overlooked or challenging to family physicians. Scenario 1: Reading a Tuberculosis Test Site A tuberculosis test typically involves two visits, one to place the test and a second to read the test. Do you bill one or two different services? The correct way is to bill for the placement of the test (CPT 86580, skin test, tuberculosis, intradermal) on the day it was initiated. When the patient returns to have the test site checked, you should bill for an evaluation and management (E/M) service (CPT 99211). CPT 86580 covers the work of delivering the test to the forearm, counseling the patient and/or family members on what to look for during the test reaction time and advising the patient to have the test read within an appropriate time period (generally 48 hours). When the patient returns, CPT 99211 covers test reading (generally performed by a nurse or medical assistant) and medical record documentation. When reports are requested (i.e., employment and/or school entrance purposes), the 99211 includes report preparation. Scenario 2: Fracture Care Treating a simple fracture can be billed as a global fracture care service or a series of E/M codes. Either choice is correct and should be based on your work and documentation. The choice depends on your preference or, more importantly, which has a higher payment rate. Example: A teen falls while skateboarding and lands on his right wrist. He goes to his family physician’s office where he is examined and an X‐ray of the forearm is ordered. The patient is diagnosed with a buckle fracture of the wrist and the family physician splints the arm. The coding choices are: n Bill fracture care code 25500 (closed treatment of radial shaft fracture; without manipulation) which carries a 90‐day global period. This means all follow‐up visits, including initial casting or splint, are part of the fee. OR n Bill an E/M office visit with the casting and report any follow‐up visits as E/M services. Replacing the splint/cast during treatment can be reported more than once. In either coding scenario, you should bill casting/splinting supplies separately. How will your payment compare? It depends on your contracted rates or the Medicare fee schedule for your area. Do the math before deciding which way to code. Reminder: Your patient may not understand that the fracture codes are considered “surgery” even though no incision was made. It may help to explain your office policy when billing with these codes. If you refer your patient to an orthopedic physician, he/she can bill the office visit (e.g., 99201‐99215), as well as initial splinting (29125), the diagnostic x‐ray (73090) and supplies. Scenario 3: Joint Injections You may find that health insurance companies are reluctant to pay an E/M service done at the same time as a joint injection or arthrocentesis. The key to getting paid for both is to provide documentation that supports the need for two separate services. Another important factor is the appropriate use of the modifier ‐25 to show it was a “separate service.” 18

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While CPT guidelines indicate that a separate diagnosis is not required for an E/M service and a procedure done on the same day, it is helpful to document the medical necessity of the two services if a separate diagnosis is available for each of the services. Consider using a symptomatic diagnosis as the reason for the E/M service (i.e., pain in the shoulder, pain in the knee) and a more specific diagnosis for the therapeutic procedure or injection, such as bursitis or arthritis. Example: An example claim might show the following codes: CPT 99213‐25 Diagnosis: 719.41 (Arthralgia, shoulder) CPT 20610 Diagnosis: 726.10 (Bursitis, shoulder) HCPCS: J3301 (x 4) Diagnosis: 726.10 Reminder: Don’t forget to bill for the medication injected into the joint, but remember that lidocaine or xylocaine is considered a local anesthetic and, as such, is considered part of the “global service” and not separately billable. There is currently no code available for either of these medications when used as a local anesthetic. Scenario 4: Mental Health Coding for the Primary Care Physicians (PCPs) PCPs, including family physicians, often find it challenging to receive appropriate payment when providing mental health or psychiatric services. Many payers will not pay PCPs for 90801‐90899 (psychiatric or psychotherapy) CPT codes as they tend to be reserved for psychiatric or psychological practitioners only. Instead, use an E/M code to report mental health services. E/M service guidelines in the American Medical Association’s CPT book instruct the provider “when counseling and/or coordination of care dominates (more than 50 percent) the physician/patient and/or family encounter, then time may be considered the controlling factor to qualify for a particular level of E/M service.” Because time becomes a controlling factor, it’s important to document time spent counseling and provide general comments about the counseling. Then, use a diagnosis code in the Mental Disorders category of ICD‐9‐CM (290‐319) to support the visit. Reminder: The 2010 Medicare Final Rule eliminated the discriminatory co‐payment rate for outpatient psychiatric services based upon diagnosis code range 290‐319. Medicare now allows 100 percent of the “allowed amount” and pays 80 percent of that amount for services with a diagnosis in this code range. You may encounter an additional restriction with commercial payers (especially those with “carve‐out” plans for mental health services) not paying a traditional E/M code if the primary ICD‐9 diagnosis is within the domain of mental health. For example, an ICD‐9‐CM diagnosis of 309.0 (adjustment disorder with depressed mood) may not be paid, but a 99214 with a primary diagnosis of 780.7 (malaise and fatigue) and a secondary diagnosis of 309.0 would be. This is an appropriate and necessary method of assuring adequate payment for valuable services. Scenario 5: Family Conferences A patient’s relative makes an appointment to discuss the patient's condition and course of treatment. You spend as much time with the relative as you would with the patient. Can this service be billed? In brief, the answer depends on the payer. Medicare holds fast to its rule that E/M codes must be conducted face‐to‐face; 1 some commercial plans follow CPT rules, 2 which allow for conversations with a patient or family member subsequent to the patient encounter. Insurance companies, however, usually won't pay for a family conference if the patient is not present. Since the policy varies, the best advice is to check with your payer in advance. Medicaid’s stance varies by state or region. In California, for instance, Medi‐Cal requires face‐to‐face time.

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If the patient is present at the time of the family conference and the discussion includes his or her care, the service is billable to Medicare and most commercial payers. Many practices follow this simple set of guidelines for billing family conferences to Medicare and other payers: n If the patient is present; and n If it is necessary to have the conversation for the care of the patient. Family members often want face‐to‐face contact without the patient present. In some cases, there may be a number of family members, so trying to do a phone conference may be impractical. Family conferences without the patient should be considered a non‐covered service and family member(s) should be billed directly. The charge should be made to the person requesting the service, not the patient. When the appointment is made, inform the relatives that the consultation is not a covered service, it cannot be billed to Medicare or other insurance, and the relatives will be responsible for paying for it at the time of service. Consider billing the family conference as a "conference" under CPT 99499. The diagnosis code most likely should be V65.1, person consulting on behalf of a non‐attending person. Reminder: Here’s a tip for billing conferences for nursing home patients. Nursing home services are based on unit floor time, versus physician face‐to‐face time. This means if you meet with the patient's relative at the nursing home instead of your office, the discussion time rolls into the total time of the patient visit on that day. Counseling/coordination as well as the total time of the visit must be documented in the medical record. Use the appropriate billing code (99304‐ 99310) when counseling dominates the patient/family encounter. We all strive to do the best job possible to collect for the vast array of services, and I hope these five strategies will make a positive difference for your practice.

1 See Medicare’s Internet‐Only Manual (IOM) for Medicare’s rules on E/M codes: It specifically says, “In the office and other outpatient set‐ ting, counseling and/or coordination of care must be provided in the presence of the patient if the time spent providing those services is used to determine the level of service reported.” 2 CPT, on the other hand, notes in its introduction to E/M codes that “Counseling is a discussion with a patient and/or family ...” So those payers that follow CPT guidelines allow these visits, as long as it doesn't contradict anything in their policy or managed care contract.

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Coding and Payment Strategies for Improving Accounts Receivable Management The Challenge of Coding and Billing Group Visits How to Ask For (and Get) Improved Payment from Plans Answers to Frequently Asked Coding Questions Collecting Outstanding Accounts Receivable: Is it Time to Update Your Collection Plan Policies? Document Your Level IV Visits With Confidence

January 2006 March 2006 November 2006 August 2008 April 2008 July 2010

Strategies for Improving Accounts Receivable Management Mary Jean Sage

January 2006

Accounts receivable (or revenue) management is multifaceted, and, as with every area of practice performance, the greater the commitment, the better the results. Getting paid fairly and appropriately for the work you do is one of the biggest concerns for family physicians. There may not be one BIG secret to improving revenue performance, but there are many little secrets and actions that can improve your bottom line. First Step to Increasing Revenue: Evaluate Your Contracts Contracting is vital to the process of capturing charges and increasing revenue. Most physicians and practice administrators agree that insurance companies do not pay physicians adequately for the services they provide. While the cost of providing medical services continues to increase each year, the reimbursements received from insurers have remained relatively flat or have even decreased. Many practices do little assessment of contracts offered to them. They simply accept managed care contracts and their corresponding fee schedules. In fact, many practices don’t know exactly how much insurance compa‐ nies pay them. Maybe the practice hasn’t requested the fee schedule, or the health plan has not responded to such a request. Other practices simply compare an offer to their existing contracts, and if the offer falls within an acceptable range, they elect to participate with the insurer. Ideally, the method should be more objective. The manager and/or physician should know the practice’s cost and consider only contracts whose pay exceeded that level. Practices need a quantitative method of assessing whether a contract will boost their profitability or whether the offered rate could potentially diminish providers’ take‐home pay. If lower‐paying patients displace higher‐paying ones, physicians lose income. Unfortunately, in many cases, that is exactly what happens. Practices that review contracts and attempt to negotiate higher reimbursement usually encounter some opposition. In most cases, practice leaders believe that insurers’ fees are unchallengeable. While this may hold true in some situations, a practice approaching negotiations correctly can usually find bargaining room. Successful negotiation requires preparation and the presentation of your argument in a clear and organized manner. You should: n Know your situation — determine exactly what the insurance company is paying you for your services now. n Present accurate and detailed information — generate reports that demonstrate the health plans’ reimbursement level and compare it with other carriers in the market. n Know exactly what you want and aim for higher than what you are willing to accept (for example, aim for 115 percent of Medicare’s fee schedule if you are willing to accept 110 percent). n Understand that no payer is likely to agree to substantial rate increases. n Be willing to walk away from the contract if the insurer does not respond favorably. Insurance companies are in the business of making money. The discounted reimbursement that they offer practices usually reflects the lowest level they believe necessary to acquire their desired provider panels. This does not mean that they won’t pay more — and you won’t know unless you ask! Good Front‐End Practices Make a Difference Patient registration performed in a practice’s front office is often inadequate to meet the needs of back‐office billing staff. In this “do more with less” world, often there are too few front‐desk employees for too many tasks.

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Front‐office staff are usually charged with: n n n n n n

Greeting patients Collecting demographic and insurance information Booking appointments Coordinating the referral process Answering the phones Managing patient flow

Registration generates a practice’s bread and butter with respect to timely reimbursement. Streamlining the process and keeping it cost‐effective should be a priority. Two options to consider are: separating the registration process from the front‐desk setting and establishing a central registration unit. 1. To separate the registration process, designate key staff as registration experts and shift the process to these employees. This frees front‐desk staff to manage patient flow and appointments. Although you may need to invest time and training for the registration unit, the return from increased cash flow should offset upfront expenditures. If your operational design permits, you might consider reorganizing existing staff into the registration unit rather than hire additional employees. 2. To establish a central registration unit, place a registration clerk in a back office working away from hectic front‐desk activities. This achieves a cleaner, more thorough patient registration. You may also want to consider pre‐registering patients by contacting them prior to appointments to ensure that you have all required demographic and insurance information. This works well in high‐volume offices (like many family practices) where it’s difficult to complete full registration at the time of visit. Patients then only have to verify their information when they arrive, expediting the registration process. Practices with lower patient volume may accomplish pre‐registration at the time of appointment scheduling. Some practices even pre‐register patients online. By pre‐registering patients, the practice has more time to verify insurance coverage and ensure that informa‐ tion provided is still in effect and entered accurately. If coverage issues arise, the patient can then resolve the problem with the insurance company before the visit. Regardless of the option chosen, the quality of registration information captured by staff trained to focus on that task is a great improvement over that of employees who must also handle extensive front‐desk tasks. Monitoring and Managing Accounts Receivable Examine accounts receivable (A/R) indicators to identify red flags, and know when it’s time to dig deeper to correct underlying problems and get the money collected. There are a few benchmarks that should be looked at each month. When the practice doesn’t meet the standards, start digging. These benchmarks provide a good starting point for evaluating A/R performance: n Total accounts receivable less than two times monthly charges; n Less than 20 percent of total receivables aged at 90 days or older; and n Collection ratio of 95 percent (or higher) of adjusted charges (adjusted charges are calculated by subtracting contractual adjustments from the monthly charges). If the A/R more than 90 days old rises above the norm, run a report on aging by payer class. This will identify any potentially troublesome payer. The out‐of‐norm aging could be the result of claims kicked back to the

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practice with errors, or claims might be stockpiled on the desk of someone at the insurance plan. It might even be an indication that the payer (insurance plan or IPA) has financial trouble causing it to stall payments. The faster you take action, the better your chance of collecting the revenue. There might also be large patient balances driving up the aged receivables. It may be time to tighten the financial policies on patient responsibility and improve collection procedures. Consider the following options: n Telephone patients for payment when a second statement does not result in payment. Phone calls are far more effective than patient statements. n Review your patient statements. Are they easy to understand? Do they clearly show the patient what is owed? n Evaluate your current dunning messages. The messages may need to be progressively stronger to get the patient’s attention. n To boost patient collections, consider a pre‐collection letter‐writing service. Patient collections are one of the most challenging responsibilities in the office, and sometimes the staff needs a little motivation. Setting collection target goals and offering incentives to collectors may improve the practice’s performance in this area. With employers passing more of the financial responsibility for medical care to patients, physicians and administrators need to pay close attention to how well this aspect of collections is managed. Effective and successful accounts receivable management begins with contracting and ends with collections, but every decision and step along the way influences the ability to get paid fairly for what you do. Physicians need to assume responsibility for these decisions and take control of practice finances. Sometimes that means learning how to say no. When you aren’t satisfied, do something about it! If it’s the payer, go back to the drawing board to renegotiate your contract. If the situation warrants it, fire the payer. If it’s a staff training or performance issue, address it. Give staff members the tools to do their jobs and hold them accountable. When to Assign an Overdue Account Turning an account over to an agency can improve your collections, but don’t do it too soon or wait too long. Based on the average probability of collecting, a current account is worth about 100 cents on the dollar in your hands. After three months, the value drops to 50 cents, and by nine months its worth is about 19 cents. This implies an overdue account should be assigned to the agency after six months unless there’s a compelling reason to do it sooner, such as: n You’ve gone through your usual billing series and have received no money and no communication from the patient; n The patient has told you he or she is not going to pay; n The patient has promised to pay many times, but has never paid; n The patient made partial payment once, but more than 60 days have gone by with no further payment or word from the patient; or n Mail has been returned as undeliverable with no forwarding address on file; you have made an attempt to find the patient, but have been unsuccessful. The longer you wait, the less chance the agency has of making the collection. This is because other bills have likely entered your patient’s life and he or she tends to regard the most recent as the most important. All accounts being considered for referral to a collection agency should be reviewed by the family physician before assignment to an agency.

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Working with a Collection Agency Since a collection agency is an extension of a practice, utmost care should be taken to choose one that reflects the attitudes and philosophies of your practice to the people who have ongoing financial relationships with you. Look for one that has a high standard of ethics, a good record with other doctors, and an attitude toward debtors thatâ&#x20AC;&#x2122;s compatible with yours. The collection agency should have the same high level of professionalism as the health care provider. When a collection agency is selected, both the practice and the agency must recognize that there has to be twoâ&#x20AC;?way communication and support for the relationship to be mutually satisfactory. When delinquent accounts are turned over to a collection agency, a practice has released them and given the agency full respon

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The Challenge of Coding and Billing Group Visits Mary Jean Sage

March 2006

More and more physicians are becoming interested in providing group visits for their patients. Patients have overwhelmingly expressed appreciation of the group visit environment, often reporting greater satisfaction with their medical care. Group visits are being provided for a variety of conditions such as asthma, congestive heart failure, GERD, and diabetes. As part of CAFP’s New Directions in Diabetes Care (NDDC) initiative, several of the practices participating in Collaboratory have started offering group visits. Managing coding and billing for group visits can be a challenge. Currently, there are very few CPT codes that describe services provided in group settings, and those that are available specifically describe services provided by someone other than a physician such as a medical assistant or a trained health care educator. Until a specific CPT code is developed for group visits run by a physician, it is recommended that physicians use code 99499 (“unlisted evaluation and management service”) to report the service. Because it is an “unlisted” service, documentation describing the service provided must be submitted with each claim. Since no set value is assigned to this code, however, it is important to find out in advance if your payer reimburses for this code. Typically, it is up to the carrier as to not only whether it will cover (pay for) the service but how much it will pay for that service. Medicare has weighed in on the subject of group visits and stated that only those services provided face‐to‐face between a physician and one patient are covered. Each practice should check with its primary insurance payers to determine if there is payment for group visits. If at the time of a group visit, each patient is provided a one‐on‐one encounter with the physician in addition to the time spent in the group, there should be no problem in billing for the visit based solely on that one‐on‐one encounter, which is an evaluation and management (E&M) service. CPT codes 99201‐99215 should be used to bill this service. 1 You should document appropriately to support the level of service billed. For an established patient this might be a level 1 or 2 visit. If vital signs were taken (by the nurse), a second system examined (foot check), and a change of medication made, then this visit could possibly be a level 3. Let’s look at how a group visit for diabetes management might be billed in the following example: A group of 15 patients with diabetes and its co‐morbidities meets for two hours once a month, for six months. The goal of the series is to address medical and other issues of concern to them and to effectively promote chronic disease management. The group visit is led by a physician, and nurses or medical assistants take everyone’s vitals at some point during the visit. The large group is broken up into groups of three patients each; each patient meets individually with the physician for a short time, either during the 30 minutes prior to the group visit, during the 30 minute break in the group visit or during the 30 minutes immediately following the group visit. During the individual encounter, the patient confers with the physician for a brief history of present illness; a foot check is performed (which can also be done during the group setting, however, Medicare does not pay for anything done in a group environment); and an inspection of the skin is done for any sites of irritation or ulceration. An inquiry is made about medication compliance and changes are made, if appropriate. If new symptoms or problems are encountered during this brief meeting that require more physician time, the patient is asked to make an appointment to see the physician again within a few days.

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Correct Coding and Billing Service CPT/HCPCS 99212 Established Patient Visit

Diagnosis 250.00 V58.67

Expected Payment * $ 37.76*

* = Expected Payment Amount is Medicare, California Area 99 If the practice chooses to bill the group visit as an unlisted E&M service as discussed above, in addition to the one‐on‐ one physician to patient encounter, the correct billing would be: Correct Coding and Billing CPT/HCPCS

Service

99212‐25*

Established Patient Visit

99499‐GA***

Unlisted E&M Service – Group Visit

Diagnosis

Expected Payment *

250.00 V58.67 250.00

$37.76** $15.00

* The “‐25” modifier is used to indicate that this service (99212) is a significantly, separately identifiable service from the other service provided that day (99499) and it should not be bundled with the other service. ** = Expected Payment Amount is Medicare, California Area 99 *** GA indicates an Advanced Beneficiary Notice was signed by patient before the service was provided Note: Total due from the patient is $22.55 ($7.55 co‐insurance from office visit and a group visit participation fee of $15).

Other Group Visit Considerations When providing services in a group environment, several other things warrant consideration: 1. If a non‐physician is providing the education and training for patient self‐management, there are CPT codes to describe this service in a small group setting. The codes specify that the health care professional must be qualified (trained) and use a standardized curriculum. These codes are: 98961 for 2–4 patients per group 98962 for 5–8 patients per group For health and behavior intervention that is provided by a non‐physician, but is not part of a standardized curriculum, use CPT code 96153 – Health & Behavior/Intervention, each 15 minutes, face‐to‐face; group (two or more patients). Remember, this code is for each fifteen minutes of face‐to‐face time with the non‐physician and patient. 2. Medicare, as well as other commercial insurance plans such as Blue Shield, Blue Cross, and Aetna, pays for a service known as “Diabetes Self‐Management Training.” There are HCPCS codes, also known as G codes, to report these services, and the services are provided either in an individual setting or in a group setting. The services are time‐based and reported in 30 minute increments. These services are not considered Medical Nutrition Therapy and should not be reported as such. The services can usually be provided by physicians, non‐physicians, or a combination of physicians and non‐physicians.

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The HCPCS codes used to report these services and related reimbursement are: Description of Service Expected Reimbursement* HCPCS Code Medicare Blue Shield Aetna G0108 DSMT, individual session, each 30 minutes $41.40 $43.71 $41.29 G0109 DSMT, group session, $24.04** $25.39** $23.97** each 30 minutes * Reimbursement is approximate and will vary based on geographic location in which service is provided. ** Reimbursement per patient.

Some payers, such as Medicare, have staff certification requirements to provide this service, while other payers require no particular certification. For Medicare, you must submit a certificate from the American Diabetes Association along with the modified CMS 855i or 855b form to be eligible. Each practice should check with major insurance payers for their patients to see how each handles the service. You should also inquire about any quantity of service or frequency limitations with each plan. Medicare allows 10 hours per patient of initial training and two hours per patient of follow‐up training each year. A description of Medicare’s coverage for DSMT (Diabetes Self‐Management Training) can be found here. 3. CPT code 99078 is used to report physician educational services rendered to patients in a group setting. This is a service code that is often not paid by payers, including Medicare. On the Medicare Physician Fee Schedule database, this is a bundled service, which means it is never paid separately even if it is the only service provided to the patient on a particular day. This eliminates any possibility of asking the patient to pay for the service. Therefore, it is not advisable to use this CPT code to bill any services provided at a group visit. It is worth a check with other insurers to see if this service is allowed. Remember, services reported with this CPT code should be educational in nature. 4. Private payers will likely not provide a carve‐out for your capitated patients. Many practices, including some involved in NDDC, still choose to make group visits available to all of their patients. But it’s important to know your patient mix in advance. In summary, any family physician should be aware that while group visits are becoming a reality in the way family medicine is delivered or provided, the billing and collection of payment for this type of service can be challenging. Some important things to remember are: n Know what types of service are being provided in the group setting. n Investigate billing opportunities, other than a physician‐to‐patient evaluation and management service. n Check with major insurance payers in advance to collect and review coverage guidelines and billing parameters for group visits. n Phone calls n Online access n Patient participation in contacting insurance n Be prepared to submit documentation to support the group visit concept/service.

1 “Group Visits for Chronic Illness Care,” in the January 2006 edition of Family Practice Management, recommends using CPT codes 99212 to 99214.

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How to Ask for (and Get) Improved Payment from Plans Mary Jean Sage

November 2006

In the summer edition of California Family Physician, CAFP provided a payer grid of the prevailing payment rates for many services related to the care of patients with diabetes. In response, some members contacted the Academy because their rates differed from the grid and they wanted to know what they could do to improve payment. While regional differences can account for some of the variation, most of us would agree that insurance companies do not pay family physicians fairly and adequately for the services they provide. While the cost of providing medical services continues to increase each year, payment has remained relatively flat or has even decreased in some instances. Meanwhile, many insurance companies are posting huge profits. Many medical practices simply accept managed care contracts, and their corresponding fee schedules, as they are received. In fact, some practices do not know exactly how much insurance companies are paying them. Practices that do review contracts and attempt to negotiate higher reimbursement are often met with great opposition from the insurance company. In most cases, the practice is quickly convinced that the fees are not negotiable, and that they must take it or leave it. While that may be the case in some situations, there is usually room for negotiating a higher rate of reimbursement if the practice approaches the negotiations correctly. Prepare to Negotiate First, muster the courage to go head‐to‐head with the insurance plan. Every day expenses creep up. If reimbursements or business levels are not increasing similarly, the bottom line is heading south. Determine your practice's dominant managed care plans and networks. List each by percentage of total business or by number of patients the practice sees. You can get most of this information from your practice management system. Start with your health insurance plan or preferred provider network (PPO) contract. Dig it out. Read it. Do your homework before contacting the organization. Most managed care contracts contain language concerning periodic fee adjustments. Without it, the managed care organization will want to avoid any such discussion; you must take the initiative. Also, review the termination clause in the contract. You can use this as leverage during the negotiations by suggesting you may invoke the 90 or 120 day termination clause in your contract if no agreement is reached by the anniversary date of the contract. Decide how you want to approach them for reimbursement increases. Be clear in what you want by determining the answers to these questions: 1. Do you want a percentage of your fee schedule? 2. Do you want a multiple of a standard fee schedule such as Medicare? 3. Do you want the multiples by department, by services or practice‐wide? You can separate the evaluation and management (E/M) codes from surgical or procedural codes and set aside the ancillary codes, such as medications and other supplies, for special pricing. You may want to consider negotiating only for your practice's most‐used codes to yield the greatest revenue. Notifying the Plan or Organization That You Want to Negotiate How do you let the insurance company know you want to negotiate a better reimbursement? You always want the opportunity to do the negotiating in person and not simply by exchanging mail back and forth. Doing everything via mail gives the insurance plans an easy out in denying your request. It is much more difficult for them to deny CALIFORNIA ACADEMY OF FAMILY PHYSICIANS

that request when you are face‐to‐face with them, or at the very least have the plan representative on the phone with you. Start by phoning the health plan or network and asking who you would speak with to discuss your current reimbursement rate. If you don't know where to start at the organization, begin with Provider Relations or Customer Service for Providers. This representative will usually not be authorized to negotiate reimbursement lev‐ els, but they should be able to direct you to the appropriate person or department that can hear your request. If you get the party line response of “You must submit your request in writing and the appropriate department will consider it,” think about how you are going to submit that request. I recommend that you submit a request to be heard: 1. Inform the insurance company that the practice is not satisfied with the current reimbursement due to whatever the issue is ... rates are inconsistent, rates are below local average, rates are not based on a standard relative value system that takes into account practice expense, etc. 2. Request a meeting with a representative authorized to negotiate reimbursement levels ‐ the meeting can be held via telephone if the payer so requests, but you want to have verbal communication with the plan to present your case. Know Your Practice’s Strengths and Weaknesses As you converse with an insurer, clearly articulate your practice's strengths and weaknesses. You probably have more muscle than you realize. Make reasonable fee demands; don't give away your rights to be paid adequately for your doctors’ services. Consider developing your own fee schedule and submit it to the health plan as the first negotiating tactic. Propose higher reimbursement rates than you expect to receive; you must give yourself room and be willing to accept slightly lower rates than you propose. That is part of the art of negotiating! It’s harder to ask for higher rates if the managed care organization first offers ridiculously low fees. Expect a protracted negotiation timetable ... perhaps three to six months. Remember, it’s to the managed care organization’s economic advantage to delay the fee increase process as long as possible. The payer will take its time getting back to you with counter offers. To let the managed care organization know your practice is serious, consider alerting the organization up‐front that you will consider invoking the termination cause in your contract if no agreement is reached by a given date. If you are going to use that tactic, however, then you need to be prepared to walk away from the contract if the managed care organization accepts your termination notification. Use a Sensible Fee Schedule A fair and defensible fee schedule will help you negotiate successful contracts. You need sound data and references. Use published fee schedules from other plans and from government plans, such as Medicare, to compare rates. Your practice should decide where it wants to be on the fee schedule. Be sensitive to competitive or highly visible fees, such as those for routine office visits and well‐care, allergy injections, and immunizations. Your practice’s decision on these will depend on its market and competitive arena. Remember: When negotiating, if you can identify a particular extraordinary increase in your practice expenses, you make a better case for higher reimbursement.

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Use Your Leverage Medical practices have leverage through patients, the news media and sometimes contracts. Your practice may have competitive advantages because of the scope of services it provides, or it may have a competitive advantage because of the number of family medicine practices in a geographic area. Use every negotiating tool at your disposal. n If the plan is not competitive, and you know the payer is paying you less than other payers, show them evidence. n If you use an electronic health record, allowing your care to be both efficient and of high quality, remind them of that. n If you have large numbers of the plan's enrollees as part of your practice, use that as leverage. n If you provide ancillary services, such as lab, x‐ray and other diagnostic services, remind them of the complete patient care you provide. n Remind the insurer that patients in your area prefer your physicians and why: easy appointment access, short wait times, etc. Recommendations for Physicians and Administrators Insurance companies are in the business of making money. To accomplish this, they have to collect more premi‐ ums than they pay to physicians, hospitals, home health agencies, hospices and pharmacies. The discounted payment that they offer practices usually reflects the lowest level they believe necessary to acquire their desired provider panel. This does not mean that they won't pay more. And besides, it can't hurt to ask. You can’t just ask for more money, however. You must understand exactly how much an insurer pays your practice and what its competitors pay. You must determine your costs for providing are and your minimum acceptable payment levels. Present your argument in a clear and organized manner. Initiative and Persistence Pays Off: A Case Study Dr. John Doe (we have changed his name to provide anonymity), a family physician in California, started approximately one year ago to contact the major health plans with which he contracts, to seek higher reimbursement for his services. To date, he has been successful with six of the approximately eight plans he has approached. He now gets a minimum of 112% of the Medicare fee schedule for several plans, with at least one plan paying up to 135% of the area Medicare fee. While regional variations may mean that your rates are different, the payment increases are illustrated below (for E/M codes): 112% 99212 $51.30 99213 $62.06 99214 $108.39

135% $61.84 $83.78 $130.53

Dr. Doe hasn’t been successful with each plan he contacted. Of two plans that haven’t decided yet, one is still considering his request. The medical director from the plan has met with Dr. Doe, and has received documented evidence that they are not competitive and are paying lower than others in his geographic area. At this point, the medical director has agreed to take the information back to the plan for consideration of an increase. The final plan has agreed to have Dr. Doe’s request heard at the "corporate" level, but have been using what appears to be a stall tactic in having “corporate” set up the phone meeting to begin talking about a rate increase, a scenario Dr. Doe encountered with a number of the plans.

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Here’s Dr. Doe's advice to other family physicians who would like to garner increases in health plan payment: 1. Requests for increased payment carry more weight with the insurance plan if the request comes directly from the physician. The plans like to talk and meet with the physician. You know your practice, and your patients. You make the call. 2. Initiate your request with a phone call. Some plans may subsequently ask the request be made in writing, but ultimately a face‐to‐face meeting with the plan is the most successful. 3. Strive for contact with the health plan's medical director ‐ they are the physician's advocate with the health plan. All medical directors have e‐mail addresses and phone numbers; be tenacious in developing your contact list for renegotiation. 4. Do your homework and know exactly what each plan is paying you for your major services, and how that compares to other plans in the area. 5. Be persistent with your follow up. If they don't call back or schedule a meeting in an acceptable time frame, call again and keep after them. Dr. Doe’s final message to other family physicians: “If you don't ask, you will never receive, and you may be pleasantly surprised with your results when you do ask.”

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Answers to Frequently Asked Coding Questions Mary Jean Sage

August 2008

n Getting Paid for DMV Exams: Q: We recently saw a patient for a physical exam requested by the Department of Motor Vehicles (DMV). The patient had Medicare and when we billed the exam, we used a diagnosis code of V70.0 (General Medical Exam). The patient, while elderly, is very healthy and had no other diagnosis. I used 99215 because I did a full physical exam and used a modifier ‐32 to indicate that the service was mandated. Medicare denied the claim, saying it was considered a “screening service.” How do I get paid for these exams when patients need to have them before their driver's licenses can be renewed? A: Remember, Medicare rules require that services can only be paid for by Medicare if they are related to the treatment of illness or injury, except for those preventive services that have been specifically legislated for coverage. When you used the diagnosis code of V70.0, you were indicating to Medicare that this was a routine or screening service. In fact, most health plans would not pay for this service. You should code the service with a preventive medicine services code (CPT 99397 if 65 years old or older). You should also ensure that the patient is aware that Medicare will likely not cover this service and, therefore, will have to pay for the visit. If the visit doesn't meet the coding requirements of a preventive medicine service (i.e., complete history, complete physical exam) and your only option is to bill it with a CPT code such as 99215, then you should make sure your patient signs an Advanced Beneficiary Notice (ABN). Bill the service with the GA modifier to indicate the ABN is on file. (GA is the code that is appended to a coded service to signal to CMS that the provider has an ABN on file for the service performed.) Then, when Medicare denies the service because it is considered a screening service, you may bill the patient directly for the exam. An ABN form is available in both English and Spanish from: www.cms.hhs.gov/cmsforms. A third option for billing these types of services is to simply establish a financial protocol for health plan non‐billable services such as a DMV exam. You don't need to assign a CPT code to the service and it should be known by all your patients that these services are billed directly to them (because insurance policies generally don't cover them). When you establish your fee for such a service, remember to keep in mind you will likely be asked to complete some type of a form to document the service, and you will want to include the form completion in the fee for the service. n Getting Paid for Discharge Day Services: Q: I saw a patient in the morning as part of my regular rounds and then later that afternoon I discharged the patient. How can I code and get paid for both visits? A: You should use a hospital discharge day management code to report all services provided to a patient on the date of discharge. Use hospital discharge code 99238 if you spent a total of 30 minutes or less on the services; 99239 if you spent more than 30 minutes. Remember, the time is not required to be continuous. Include the time of the morning visit in the time spent performing the discharge activities later that day. Discharge day management includes, as appropriate, the final examination, discussion of the hospital stay, instructions for continuing care for all caregivers, preparation of discharge records, prescriptions and completion of any referral forms. Because this is a time‐based service, be sure to document the approximate time you spent rendering the services. n Getting Paid for Emergency Office Visits: Q: Can you tell me when it would be appropriate to use the CPT 99058 (services provided on an emergency basis in the office)? Can we use that for our patients who call in the morning and request a same‐day appointment? CALIFORNIA ACADEMY OF FAMILY PHYSICIANS

A: It would not be appropriate to use this code simply for “same day” appointments. CPT 99058 (defined by CPT as “service(s) provided on an emergency basis in the office, which disrupts other scheduled office services, in addition to basic service”), is an add‐oncode. This means it is intended to compensate you for the interruption in your office schedule when you are taken from one patient to attend to or render emergent services to another patient. Here’s an example of how it might be used: A 10‐year‐old asthmatic patient comes in for a scheduled appointment for follow‐up on the asthma exacerbation. While waiting in the reception area, he begins to wheeze profoundly. His mother approaches the receptionist to alert her about the wheezing and the patient is immediately ushered to an exam room. After a quick check by the nurse, the physician is interrupted from another patient and asked to immediately see the asthmatic patient. Considerable time is spent with the patient before the physician can return to the patient visit from which she was pulled. This disrupted the flow of other patients for the next couple of hours. You would code and bill for the asthmatic patient (established patient visit 99212‐99215) based upon the level of care given plus CPT 99058 (emergency service). Be sure to document the nature of the services you performed and the time required to handle the emergency. n Billing for Care of the Hospice Patient: Q: I am sometimes asked to see a patient who has enrolled in a hospice program. When I try to bill for my services (usually either a hospital visit or a nursing home visit), I am never paid because this is a “hospice” patient. Aren’t I entitled to be paid for my services, too? A: Just as the transition from curative to palliative care is important for therapeutic options, it also signals an important change in billing practices. While those changes may be major, it can be easy to make a mistake and, given the nature of patients' illness, hard to recover payment if not properly submitted the first time. Here's how the hospice benefit works: Enrolling the Patient: You must first determine that your patient would be best served by enrolling in this program (administered through Medicare Part A). Two physicians ‐ the patient's primary care physician and the hospice medical director ‐ must verify in writing that the patient is not expected to live more than six months. The patient must also sign a statement agreeing to receive only palliative care in the future and discontinue all attempts to cure. The original certification is good for 90 days and can be re‐certified for 90 more days. The benefit never expires. If the patient lives longer than the initial six months, re‐certification needs to occur every 60 days and only one physician has to sign the re‐certification form. How the Benefit Works: Patients select a physician and hospice agency when they enroll for the program. The benefit is capitated; the agency is paid for each day the patient lives and thus cannot collect or bill for other services during that time. Paying the Physicians: If you are employed by the hospice, your payment is considered part of the hospice’s capitated payment, and you cannot bill separately. If you are not employed by the hospice agency, you can bill for palliative care using the same CPT codes normally used for non‐hospice patients and appending the GV (attending physician, not hospice‐employed) modifier to the CPT code(s). Only the provider the patient selected during enrollment as the hospice physician, and one who is not an employee of the hospice agency, can bill for these services. The patient may switch his/her hospice care to another physician, but only once per certification period and the patient must sign a form to do so. Treating Hospice Patients for Issues not Related to the Terminal Illness: You should be paid if the proper modifier 34

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is used when billing for those services. For services not related to the terminal illness, bill Medicare with the stan‐ dard CPT code(s) for that service, but include the modifier GW (services unrelated to terminal condition). Any physician treating the hospice patient for a condition unrelated to the terminal illness may bill with this modifier. Patients Improving or Choosing Curative Measures: If the patient decides to pursue anything beyond palliative care, he/she should be removed from the Medicare hospice benefit program and returned to traditional Medicare. Once that occurs, you should no longer use modifiers when billing for continued care. In those cases, it is important to work with the hospice agency to transition care and ensure that future Medicare claims are paid. n A New Medicare Carrier is Coming to California. Are You Ready? As you probably know, the Centers for Medicare and Medicaid Services (CMS) will be transitioning Medicare Administrative Carriers. By September 2, 2008, Palmetto GBA will replace NHIC as the Medicare Part B carrier. In advance of this date, there are several important deadlines for signed agreements and applications that must be submitted to Palmetto GBA. In order to prevent a delay of your Medicare payments and interruption of your claims processing, you must do several things as soon as possible: 1. All providers who currently receive electronic funds are required to complete an EFT (Electronic Funds Transfer) agreement (CMS 588 form) with Palmetto GBA. The deadline for completion of the EFT Agreement is currently August 15, 2008. You should receive a letter of confirmation from Palmetto GBA indicating your agreement has been processed. If you have not or do not receive a confirmation, contact Palmetto GBA to ensure they have received and processed your agreement. 2. All providers who are direct submitters and currently transmit electronically are required to complete both the EDI (Electronic Data Interchange) application and EDI Enrollment/Agreement as soon as possible. If you utilize a billing service or clearinghouse, follow‐up with them to ensure they have completed the EDI Application. Since they are considered the submitter, they are required to submit the EDI Application while you (the physician) are still responsible for submitting the EDI Enrollment/Agreement. Once you receive confirmation and a password from Palmetto, you may participate in "]”early board” and begin submitting claims to them. This process is highly recommended as a means to test your connections and file transmissions prior to the cut over on 9/2/2008. The EDI and EFT applications and agreements are available for download here: www.palmettogba.com/j1. Their Website also has a wealth of other useful information about the transition, including all the local coverage determination policies. Palmetto GBA is sponsoring a number of transition webinars to address all changes to Medicare claims submission and processing. Access the J1 Web site and select the “Learning and Education” link to see a list of topics, times and dates. Finally, every practice that bills Medicare should encourage their staffs to download the Transition Manual from the Website; it contains all the specific details about changes to claims submission and processing.

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Collecting Outstanding Accounts Receivable: Is it Time to Update Your Collection Plan Policies? Mary Jean Sage

November 2009

Accounts receivable (A/R) and collections are central components of your practice’s revenue cycle. Managing this cycle is more important than ever, given the current economic climate. Recent research by the Medical Group Management Association 1 indicates that nearly 35 percent of practices surveyed had experienced an increase in uninsured patients. Approximately the same percentage had watched accounts receivable increase as well. If you don’t have specific collection plan policies, now is the time to get started because you’ll likely see more patients asking for your policies on paying deductibles, co‐payments and coinsurance. Practices with established written policies and procedures typically see increased collection rates. Most financially‐stable patients attempt to fully pay medical bills, in part because they know that unpaid bills have an adverse effect on credit. Establishing a payment plan, rather than not honoring outstanding financial obligations, is the preferred outcome for most patients. Patients who can’t pay their balance at the time of service will often go straight to the source of care, their doctor, to arrange payment. It’s sometimes difficult for physicians to say no. On the other hand, practices often book any patient requesting an appointment if and/or when they can be fit into the appointment schedule. The step frequently missed is checking to determine if a patient has an unpaid balance. When developing collection policies, put them in writing so each member of the practice, staff and physicians, know and can enforce them. Payment plans should have, at a minimum, these elements: 1. The minimum balance to qualify; 2. How much the patient owes each month (as an amount or percentage); and 3. The amount of time the patient has to pay the balance in full. In most cases a payment plan should last a maximum of six months. Make sure the specifics are in writing and signed by the patient and a practice representative. Provide a copy to the patient and keep one in your files. The details of the payment plan should also include reference to what will happen if the patient’s financial obligations are not met (i.e., if no payment is made in 60 days, the patient may be discharged from the practice). You should also consider whether or not to ask the patient to sign a promissory note for the amount due. Finally, monitor the compliance of any payment plans initiated. Someone in your practice should be responsible for enforcing the terms of the plan, as well as tracking payments. Many practice management systems have the capability of monitoring plan progress; they can generate payment notices and reminders. It may take some time to configure your system, but appropriate automation of these functions saves time and makes good use of your practice management system's capabilities. Facilitate collecting outstanding A/R by ensuring you have the capability to accept debit cards; check scanning technology can also be useful. You may also want to consider hiring a collection agency to recover delinquent accounts; if you do, make sure you monitor the agency to ensure you’re getting your money’s worth. Also, you should be knowledgeable about the agency’s tactics in collections; overly aggressive tactics are inappropriate. If all else fails, small‐claims court is an option. Each physician should make that decision based on the practice’s philosophy. The Red Flags Rule

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The Federal Trade Commission’s (FTC’s) “Red Flags” rule, which takes effect on May 1, 2009, will affect most medical practices. Review the rule's implications before developing new policies or plans. You should also review any existing policies to see if they are still appropriate given the new Red Flags requirements. What is a Red Flag? As part of the FTC’s implementation of the Fair and Accurate Credit Transactions (FACT) Act of 2003, medical providers may need to require “creditors” to establish a program to prevent identity theft in their practices. The program must incorporate Red Flags ... that is, indicators of a possible risk of identity theft. The rule defines a creditor as “any person who regularly extends, renews, or continues credit; any person who regularly arranges for the extension, renewal, or continuation of credit; or any assignee of an original creditor who participates in the decision to extend, renew, or continue credit.” The FTC interprets this to include a medical provider if the provider does not regularly demand payment in full for services or supplies at the time of service. This includes, for example, a provider who bills a patient’s insurance company before requesting payment in full. In the FTC’s February 4, 2009 correspondence to the AMA and other physician organizations, it reinforced this point by stating: When a physician submits a claim to an insurance carrier first and then bills any remaining unpaid amounts to the patient, whether she does so as a courtesy to the patient or because she is required to do so as a matter of contractual or state law, the physician is deferring the consumer's payment of his or her share of the claim (i.e., the physician is billing the patient after having provided the patient with medical services). The FTC considers a physician who engages in this type of arrangement to be a creditor for purposes of the Red Flags rule. If you determine that you are a creditor, you then need to figure out if you maintain “covered accounts.” As defined in the regulations, covered accounts are accounts that permit multiple payments or transactions and that pose a reasonably foreseeable risk to customers or to the safety and soundness of medical practices from identity theft. Identity theft can include financial, operations, compliance, reputation or litigation risks. The FTC considers patient billing records to be “covered accounts.” If you determine that you qualify as a creditor who maintains covered accounts, the Red Flags rule applies. Your practice must develop an identity‐theft prevention program that contains “reasonable policies and procedures” (which may incorporate existing policies and procedures) to achieve the goals of the Red Flags rule: 1. Identify relevant indicators of a possible risk of identity theft (“Red Flags”) 2. Detect Red Flags 3. Prevent and mitigate identity theft 4. Update the identity theft prevention program In the February 2009 correspondence to the medical community, the FTC noted that due to the risk‐based nature of the requirements, it did not believe the rule would impose significant burdens on most providers. It gave examples of a low‐risk practice (a small practice with a limited, well‐known patient base) and a high‐risk practice (a clinic in a large metropolitan area that treats a high volume of patients). It stated that in low‐risk practices, an appropriate program might involve checking photo identification and having policies to deal with the theft of a patient's identity (including not trying to collect the debt from the patient and separating the medical records of the real patient from those of the identity thief). For more information on developing a program for your practice that incorporates the goals of the Red Flags rule, please go to the CAFP website and download: http://www.familydocs.org/files/PMNAttachment_April09.pdf

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CMS Implements New ABN Form On March 3, 2008, CMS implemented use of the revised Advance Beneficiary Notice of Noncoverage (ABN), CMS‐R‐131 http://www.familydocs.org/files/CMS‐R‐131_Form.pdf. This form replaces the General Use ABN and the Lab ABN for physician‐ordered laboratory tests. The form (English and Spanish versions) and notice instructions are posted on the Beneficiary Notice Initiative web page www.cms.hhs.gov/bni. Some key features of the new form are: 1. Has a new official title, the “Advance Beneficiary Notice of Noncoverage (ABN),” in order to more clearly convey the purpose of the notice 2. Replaces the ABN‐G and ABN‐L 3. May also be used for voluntary notifications, in place of the Notice of Exclusion from Medicare Benefits (NEMB) (CMS FORM 20007) 4. Has a mandatory field for cost estimates of the items/services at issue 5. Includes a new beneficiary option, under which an individual may choose to receive an item/service, and pay for it out‐of‐pocket, rather than have a claim submitted to Medicare Be aware: The ABN‐G and ABN‐L will no longer be valid as of March 1, 2009.

1 Medical Practice Today: What members have to say, http://www.mgma.com/article.aspx?id=19810.

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Document Your Level IV Visits With Confidence Mary Jean Sage

July 2010

Family physicians may have concerns about the documentation of Level IV visits. Some physicians recently reported receiving a letter from a health plan (e.g., Blue Cross, Humana, Guardian) or Medicare warning that their use of high‐level codes (Levels IV or V) was greater than other physicians in their specialty. Some health plans request medical records while others alert physicians about possible problems with their data and ask to review the physicians’ billing practices to ensure they are in accordance with the Current Procedural Terminology (CPT) Evaluation and Management (E/M) coding requirements and the Center for Medicare and Medicaid Services (CMS) 1995 or 1997 documentation guidelines. Physicians believe they could be coding more patient visits at Level IV, but are unsure what documentation is required and fearful of being audited. The result is physicians undercode to be safe. This is unfortunate because proper coding could add more revenue to the practice. If a physician has 20 patient visits and at least two of those visits are coded at Level IV instead of Level III, the result is an additional $100 per day or $500 per week. This means additional revenue of up to $20,000 annually for a practice. It is important for family physicians to code with confidence and understanding of what is sufficient documentation to support the level of care they are providing. Any E/M service has three key components: history, exam and medical decision making. For an established patient visit, two of the three components must meet specific criteria when performing the service. For a new patient visit, all three of the key components must meet specific criteria. A Level IV established patient visit requires a detailed history, a detailed physical exam and medical decision making at a moderate complexity level. A summary of the criteria for a 99214 visit is below. Detailed History The history component of the visit is fairly straightforward. Begin the note with a chief complaint (i.e., the reason the patient came to see you). Then add an extended history of present illness (HPI) that includes four or more descriptive elements about the chief complaint from the following choices: location, quality, severity, duration, timing, context, modifying factor or associated signs and symptoms. While only four elements are required, you can certainly add more elements if needed to fully describe the chief complaint. According to the 1997 Documentation Guidelines (see 1995 vs. 1997 side bar), you can also meet the HPI requirements by documenting the status of at least three chronic conditions. The key phrase to remember here is “status of.” It is insufficient, for example, to document that a patient has hypertension, diabetes and asthma. Instead, you might document as follows: “Patient has hypertension controlled with diet and exercise, diabetes controlled with insulinand asthma requiring an inhaler twice daily.” An extended review of systems (ROS) is required for this visit and can be fulfilled by noting two to nine systems associated in some way with the chief complaint. CPT recognizes 14 possible systems as part of the ROS. Finally, a pertinent past, family and social history must be noted. This involves documenting at least one specific item from any of the three history areas. A commonly used notation is “non‐smoker.” That phrase helps fulfill your history requirement.

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Here is how you would determine what your level of history would be:

In many cases, the criteria for a detailed history may be the easiest to fulfill. Once the level of history is documented, you only need one of the next two components to meet the necessary criteria for a Level IV established patient visit. Detailed Exam Documenting the exam may be a little more challenging if you do not have the time or need to perform a detailed exam in a short visit or straightforward complaint. To meet the visit criteria according to the 1995 guidelines, five to seven body areas or other symptomatic‐related organ systems must be examined and documented. The body areas include the head, neck, chest, abdomen, genitalia, back and each extremity. The organ systems include constitutional (e.g., vital signs), eyes, ear, nose, throat, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, skin, neurologic, psychiatric and hematologic (lymphatic and immunologic systems are included with this one). Here is how you determine your level of physical exam:

A notation indicating “negative” or “normal” is sufficient to document normal findings of a physical exam. Moderate Complexity Medical Decision Making This component can be the deciding factor as to whether your visits achieve Level IV status. It is divided into three sections ‐ Diagnosis, Data and Risk ‐ that are used to determine the complexity of the patient encounter. To qualify for any one of the specific levels of medical decision making (straightforward, low, moderate or high) only two of the three areas are required. The diagnosis and data sections can be simplified with a point‐scoring system. 40

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Number of Diagnoses or Treatment Options Problem to Examining Physician Self‐limited or minor (stable, improved or worsening) Established problem (to examiner); stable, i mproved Established problem(to examiner) worsening New problem(to examiner);no additional work‐up planned New prob.(to examiner); add, work‐up planned TOTAL

No. x Points = Result No. Points Max. = 2 1 1 2 Max. = 2 3 4

Result

The Diagnosis Section deals with the number of possible diagnoses or the management options that must be considered. Three points are needed to meet the 99214 criteria. If your patient has a new, previously undiagnosed problem, you have met the criteria for this component of medical decision making. If you are dealing with an established, previously‐diagnosed problem, decision making will be less complex, and the patient will have to have more than one problem to meet the Level IV criteria. An established problem that has worsened earns two points. An established problem that is stable earns only one point. In this case, you could add points for each of three stable problems or have one stable and one worsening problem and score three points for the diagnosis section. The Data Section deals with the amount and complexity of data to be ordered or reviewed. Like the diagnosis section, the data section requires three points to qualify for a Level IV code. The easiest way to achieve three points is to order an X‐Ray, ECG and blood work. You can earn two points for both review and summarization of old records and discussion of the case with another health care provider. If you combine that with ordering any testing, you can earn three points. Data to be Reviewed Review and/or order of clinical lab tests Review and/or order of tests in the radiology sections of CPT Review and/or order of tests in the medicine sections of CPT Discussion of test results with performing physician Review and summarization of old records and/or obtaining history from someone other than patient and/or discussion of case with another health care provider Independent visualization of image, tracing or specimen itself (not simply review of report) TOTAL

Points 1 1 1 1 2 2

The Risk Section is based on the overall risk associated with the presenting problems, diagnostic procedures and management options. The highest level of risk in any one of these three categories determines the overall risk. To view the complete Table of Risk, please go to http://www.familydocs.org/files/JulyPMN_Table_of_Risk.pdf. A moderate risk is required for a Level IV code.

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For the presenting problem to be of moderate risk, your patient needs to have one chronic illness with mild exacerbation, two or more stable chronic illnesses, an undiagnosed new problem with uncertain prognosis, an acute illness with system symptoms or an acute complicated injury. The other two categories of risk usually follow the presenting problem. Using the point system for the Diagnosis and Data Sections and the Table of Risk, your Medical Decision Making Summary should look like this: Medical Decision Making Minimal Complexity Low Complexity Moderate Complexity High Complexity

Problem Points 1 2 3 4

Data Points 1 2 3 4

Risk Minimal Low Moderate High

Time‐Based Billing Often a quick acute illness visit turns into a much longer visit due to patient needs. If you spend at least 25 minutes with the patient and more than half of that time is spent counseling the patient, you are qualified to code a visit as Level IV irrespective of the history, exam and complexity criteria described above. Document your visit as appropriate, but remember to document the content of your counseling or care coordination and report the total visit time and counseling time. For example, you might report that the “total visit time was 25 minutes, more than half of which was spent counseling the patient and coordinating care.” Code Correctly Undercoding to stay on the safe side is not financially viable. You may have incorrectly coded in the past due to lack of knowledge or out of fear. In the future, be compensated for the complex work that you perform every day by following these simple rules for Level IV visits. Documentation Guidelines 1995 vs. 1997 The Choice is Yours! It is up to the individual physician whether he or she chooses to use the 1995 documentation guidelines or the 1997 documentation guidelines The biggest area of difference in the two sets of guidelines is documenting the physical exam. In the 1995 guidelines, the level of exam depends on the number of body areas or organ systems examined and documented. They do not specify what constitutes an exam of any area or organ system. They do not indicate how much documentation is necessary to substantiate that the area or system in question has, in fact, been examined. The 1997 guidelines define complete exams for 11 organ systems and significantly expand the definition for multisystem exams. Either version may be used, but it is not permissible to combine them on any one patient. For example, you cannot use the 1997 guidelines for history and the 1995 guidelines for exam and medical decision making. It is permissible, however, to use the 1995 guidelines on one patient and the 1997 on another.

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Legal Issues Damaging Internet Comments – Don’t Just Read Them and Weep Five Easy Steps to Implementing Informed Consent Read Carefully Before Signing Medical Malpractice Insurance – Traps and Tips Ten Tips for Choosing a Lawyer You and Your Hospital — the Ins and Outs of Hospital Contracting

December 2007 March 2008 June 2008 September 2008 November 2009 August 2010

The articles provided in Practice Management News are general. They do not constitute legal, practice management or coding advice in any particular factual situation or create an attorney‐client relationship. Consult your attorney for advice in your particular situation.

Damaging Internet Comments — Don’t Just Read Them and Weep Barbara Hensleigh

December 2007

The media recently reported the story of a 13‐year‐old girl in Missouri who committed suicide after reading Internet messages disparaging her and suggesting the world would be better off without her. No criminal charges were filed, even after it was discovered that an ex‐friend’s mother wrote the messages, assuming an online alias in retaliation over her daughter’s broken friendship. The parents of the girl have yet to file a lawsuit. Damage from use of the Internet is not limited to disastrously misguided pranks. The Internet can be used to post false statements, disparaging comments or unflattering opinions about physicians and their practices. There are numerous blogs, opinion sites and evaluation sites encouraging patients, employees or nurses to “go public” about you, your office and staff. Anecdotal comments by patients can be more damaging than survey information. This is complicated by the fact that anonymity can encourage false statements and make allegations hard to dispute. Once the comments are published, the damage has been done, and you have little ability to respond. Where managed care forces physicians to be gate keepers, patients are more willing to see physicians as adversaries rather than allies. The purpose of this article is to discuss the legal and practical problems posed by Internet postings of false statements, disparaging comments or opinions. We will look at a variety of potential problems and their possible solutions. They will range from false statements by a readily identifiable individual to opinions about the practice by anonymous individuals. False Statements by a Known Individual The legal principles of defamation and slander apply to individuals who post messages or information on the Internet. Accordingly, an identified blogger who makes a false statement about a physician (for example, that the physician has sex with anesthetized patients) can be held liable for all damages flowing from the publication. Damages may be difficult to prove, particularly with a relatively new practice. With an older practice, it still may be speculative just to show that patient appointments dropped immediately after the posting. The physician may be required to locate patients who will testify they stopped going to the physician after seeing the information on the Internet. Regardless, because the defamation is related to one’s profession, under the laws in some states, including California, the physician need not prove actual damages. They are presumed. Punitive damages can be assessed against the guilty party even in the absence of provable damages. Besides defamation, there are other grounds to sue someone who damages your practice through posting false statements on the Internet. These claims include interference with profession, interference with prospective business advantage and interference with contract. In case of actual or potential damages, you are advised to obtain legal counsel. With the advice of counsel, you should take steps to mitigate damages. Your lawyer can send a forceful letter demanding retraction of the comments posted. The potential defendant also should be asked to post a statement apologizing for the false statements. Where the retraction does not stop the damage, a lawsuit may be in order. In some cases, courts may issue an injunction prohibiting the continued posting of false statements. False Statements by an Unknown Individual Anonymity will not protect a slanderous scribe. While the law is still struggling to catch up with the technology age, some states already have addressed the situation in which an individual anonymously publishes false information, hiding behind a user name which does not identify him or her. If your practice is subject to such an attack, you may be able to sue the individual by his user name or as a “Doe” 44

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defendant. The filing of the lawsuit provides an opportunity to have the court issue a subpoena to the Internet service provider, requiring that provider to produce documents identifying the individual by name and other pertinent information. Once the provider identifies the subscriber who posted the defamatory material, the individual’s true name can be substituted into the lawsuit as the defendant, and the subscriber can be served with the lawsuit. You are not required to wait — and should not wait — until the individual is identified to take steps to protect your practice. If the subscriber’s e‐mail address is known, there is nothing to keep you from contacting the potential defendant, preferably through counsel, and demanding that the defamatory comments cease, be retracted and an apology issued, all using the same Internet outlet through which the defamatory comments were originally published. Actual Opinions of Known and Unknown Bloggers The law does not provide any more protection to individuals or businesses injured from Internet postings than it does for those injured by other publications. Opinion statements are generally not actionable, no matter how obnoxious and regardless of where made. Expressions of opinion generally are protected free speech. Thus, actual opinions (i.e., your office staff was rude, you are abrupt) are not legally actionable. Even though not actionable, you should not suffer in silence from an adverse anecdotal opinion about you, your practice or your staff. You may choose to proactively maintain a website with favorable comments about your office and medical care. You can utilize patient surveys, including online questionnaires, to obtain feedback about your practice. The results of satisfaction surveys may undercut the negative opinion of a single blogger and provide the ability to immediately address patient complaints. “Secret” patients, like “secret” shoppers, retained by you, can assess your staff and provide input that may lead to office changes and decrease the chance of adverse Internet comments. You may also wish to review some of the most popular Internet forums in your region. You can search for your name and any comments that may have been made about your practice. You don’t want to hear months down the road that negative comments were posted. Do not underestimate the power of your loyal patients! They may see the isolated statement by a single patient as portraying you unfairly. These patients, once made aware of the negative comments, may post rehabilitating statements in response. Opinions by Competitors One danger of anonymity and the Internet is that competitors may use it as a means to attack your practice under the guise of a patient or patients in your practice. Imagine a slew of anonymous opinions that your office is dirty and your staff is rude. The opinions, while not actionable if coming from patients who have been to your office, may be legally actionable if contrived by a competitor to take business. Such conduct would be grounds for liability under unfair trade practices law, among other things. The law may provide a broad spectrum of relief, including injunctive relief. Naturally, the principles of mitigation apply equally to this type of assault on a practice. If the competitor is discovered (and may not be until after litigation is filed), then a demand should be made that the competitor remedy damages through additional postings and apologies. Only in this manner can one be assured that the same population reading the original postings may read the retractions. Liability of Internet Service Providers Federal law immunizes Internet providers from lawsuits for postings, even where the provider knows the posted information is defamatory. Accordingly, there is little point in suing a provider, even for defamatory postings.

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Conclusion The best defense against false and disparaging Internet postings about you or your practice is a good offense. You should liberally use patient surveys to determine patients’ views of the quality of your practice. A website including favorable comments about your practice with an online questionnaire also may be helpful. Having positive information preceding negative information can sometimes negate the power of negative information and avoid the need to play “catch up” once negative information is posted. Permitting complaints to be quickly addressed, before the patient chooses to broadcast complaints in another forum, may also be useful. Where your practice has been attacked through false information or by a competitor under the guise of anonymous patient opinions, it is important to demand online retractions of the information, using the same mode of publication as was used with the original publications. Finally, do not be hesitant to elicit support from supportive patients to balance rogue publications by a patient who had a bad day. The articles provided in Practice Management News are general. They do not constitute legal, practice management or coding advice in any particular factual situation or create an attorney‐client relationship. Consult your attorney for advice in your particular situation.

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Five Easy Steps to Implementing Informed Consent Mary Jean Sage

March 2008

Family physicians encounter informed consent issues in clinical and hospital settings. Many physicians resolve the issues by having patients sign a blanket consent form upon introduction into the practice. Blanket consent forms have several problems, however. The primary problem is a general consent is unlikely to provide any legal protection in the face of a lawsuit. This is because a general consent does not provide patients with explicit details that would permit them to knowingly consent to a specific procedure. Informed consent is a process not a piece of paper. It involves communicating, listening and understanding. But informed consent is about more than protecting yourself. Studies have demonstrated that patients with more information about a particular procedure have less anxiety and may recover more quickly. The purpose of this article is to provide you with an informed consent checklist to ensure your patients understand the medical procedures to which they are subject and may provide some legal protection. You can add this checklist to the patient’s medical record, providing the name of the procedure at the top. The list does not require the patient’s signature, although it would be helpful. Dialogue One of the first steps is to discuss with your patient the following with regard to a specific procedure: n The patient’s diagnosis or current medical status n The likely prognosis without medical intervention n The patient’s treatment options n The likelihood of success of each option n The material risks of each option n Your recommendations The dialogue must be with you, and not delegated to another member of the staff who may not be as knowledgeable as you. It’s important for you to describe any permanent scarring or disfigurement, the discomfort or the temporary or permanent disability that may result. You may be required to indicate your level of expertise in performing a certain procedure. In this dialogue, you are not required to disclose any remote risks of the procedure; risks generally known to the public; or, risks about which a physician cannot be reasonably aware. There are, for example, extremely remote risks of sepsis associated with any surgical procedure. But unless the risk is significant, a patient need not be informed about it. Likewise, you are not required to identify medication risks that are unknown at the time they are prescribed. You are required to inform patients of risks that you know or should become aware of after dispensing medication that thereafter is found to have significant risks. It is also important to assess your patient’s level of understanding and comprehension about the proposed procedure, and listen and tailor the process to meet the patient’s needs. Additional Mechanisms of Providing Information on Informed Consent Studies have demonstrated that patients with ample information about a procedure have levels of anxiety, recover faster from surgery and tend to be more adherent to certain treatment regimens. Although other mechanisms of providing information do not take the place of dialogue with you, they may be used as a beneficial ancillary tool to provide information for a truly informed consent. Video and audiotapes are wonderful ways of providing information to a patient. Handouts are, too. It is important to document not only your interactions with the patient but also any ancillary tools used to provide information to the patient about the procedure. Have All Questions Been Answered? Well trained staff should relay to you any additional patient questions. At the end of your discussions with the patient, staff can ask him or her: “Have all of your questions been answered?” If the answer is “yes”, staff can check the box on the informed consent checklist. If the patient answers “no”, then additional discussion is necessary. CALIFORNIA ACADEMY OF FAMILY PHYSICIANS

Is an Independent Interpreter Needed/Used? When treating a patient who prefers to receive health information in a language other than English, avoid the temptation of using a family member to interpret. Although it may add time, an independent interpreter is important to ensure your communications are reliably transmitted to the patient. It is also important that the person you use is trained in medical interpretation as opposed to simply being bilingual. That interpreter can be a member of your medical staff or the hospital’s staff. Clear communication is vital for informed consent. In the case of a later dispute over whether consent was informed, an independent interpreter may be a godsend. If an interpreter is required, the staff should ensure that the interpreter signs the informed consent form indicating they have accurately translated the communications between the patient and physician on the contemplated procedure. The interpreter should also ask the final question: “Have all of your questions been answered?” Does the Patient Have the Mental Capacity to Give Consent? There is a presumption that adults are competent and able to freely consent to their medical care. Mental illness alone does not overcome this presumption. In most cases, this box may be checked off and nothing further is required. However, in the case of children, the elderly or patients who do not have the mental capacity to give consent to a procedure, it is important to ensure that the proper party is providing consent. In such cases, staff should review the following: 1. Power of Attorney. An adult may have been legally appointed by the patient to make health care decisions through the power of an attorney. The Power of Attorney should be kept in the medical records. Is it present? 2. Conservator or Guardian. This individual has been appointed by a court to make health care decisions for the patient. The court order appointing the conservator or guardian making clear that the order extends to health care decisions should be kept in the patient’s medical records. Is it present? 3. Parent of minor. If parents are divorced, the physician should determine which parent may consent to medical care for the child. Is it documented? Generally speaking, treating a patient without obtaining any consent is a battery. There are four exceptions: 1. You may provide treatment without informed consent in a medical emergency. For example, when the patient is not capable of giving consent, a delay to obtain consent might result in severe disability or death to the patient and where there is no credible information to suggest the patient would not consent. In such a case, consent is implied. 2. Consent also is implied where an unanticipated life threatening event occurs that is beyond the scope of the consent given. You may proceed to treat the unanticipated event. Such events should be rare, however. The informed patient should be aware of most potential risks of a procedure and have consented to treatment if the risk manifests. 3. There is the “therapeutic privilege” which allows you to withhold information from the patient if, in your view, the information may endanger the health of the patient. Therapeutic privilege never should be invoked unless you are prepared to see your patient in court. Believing that you know better than the patient could end up with you facing with a jury of “patients.” That jury will have little sympathy for the physician. 4. You may also be faced with a patient who tells you that he/she doesn’t want to participate in the informed consent process or would like to operate with his or her “head in the sand.” If a patient makes such a request, you should obtain the written, informed consent of the patient to remain ignorant of medical care. That consent should be added to the medical record and revisited (and reauthorized) on each subsequent visit by the patient to your office. Keep in mind that I am unaware of any documented case where a patient recovered a judgment against a physician because the physician provided information the patient did not want to hear! The articles provided in Practice Management News are general. They do not constitute legal, practice management or coding advice in any particular factual situation or create an attorney‐client relationship. Consult your attorney for advice in your particular situation. 48

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Read Carefully Before Signing Barbara Hensleigh

June 2008

You have had problems with managed care agreements before. For example, gag clauses were designed to prevent you from discussing all possible treatment options with patients. You obtained legislation outlawing the clauses in some states, including California. Physicians also addressed systematic delays in collections from certain managed care organizations in the landmark federal Racketeering Influenced and Corrupt Organization Act (RICO) case brought against a number of for‐profit HMOs by the California Medical Association and other medical societies. But the problems aren’t over. Blue Cross, a defendant in the RICO case, continues to attempt to impose onerous burdens on physicians through changes to its agreements. Recently, Blue Cross has proposed to amend its Prudent Buyer Plan Participating Physician Agreement. The amendment requires the following: n The physician cannot close his/her practice to new patients from the plan unless he/she closes the practices to all other plan patients. n Physicians are prohibited from disclosing or discussing the terms of the amendment with anyone, including their attorneys and business managers. Doing so constitutes a material breach of the agreement and Blue Cross may unilaterally and without notice reduce compensation levels to previous contract amounts and take legal action against the physician. n The agreement is for a two‐year term, without the ability to renegotiate. At the end of the two years, the agreement automatically renews for another year, unless the physician provides 120 days notice of an intention to terminate the agreement or to renegotiate. The purpose of this article is to discuss the practical, legal and ethical issues involving these three terms.

A. A Physician May Not Close His/Her Practice to Patients of the Contracted Plan Unless the Practice Is Closed to All Patients of Other Plans Arguably the provision violates the cannons of medical ethics promulgated by the American Medical Association. It also may be illegal. A physician has an absolute right to choose the patients in his or her medical practice. Patients also have a right to access treatment. A patient of yours may want her elderly mother, now living with her and who is also insured by Aetna, to see you for treatment. You would like to see the patient. You should be entitled to do so. Unethically, the amendment attempts to prohibit treatment of the Aetna patient if you have closed your practice to Blue Cross patients. The provision may be illegal in any event. I may be stretching here, but the language may illegally restrain competition. Under California law (and perhaps in other states), every contract by which one is restrained from engaging in a lawful profession, trade, or business of any kind is, to that extent, void. The Blue Cross provision appears designed to remove the incentive of competition among managed care plans. For example, Aetna may pay more to encourage good physicians to take as many Aetna patients as possible. If you obtain a lucrative contract with Aetna, you would be willing to close your practice to patients of other plans, including Blue Cross, so you can fill your practice with Aetna patients. The amendment attempts to avoid your preference for Aetna patients by forcing you to see Blue Cross patients, regardless of Blue Cross’ poor contract rates. Aetna may not be willing to increase rates if it knows you must see Blue Cross patients at poorly reimbursed rates.

B. The Requirement that the Physician Cannot Discuss the Amendment With Anyone Well, we are discussing it here! A contract containing a blanket provision prohibiting a party from discussing its terms with others (including the lawyer representing the signing party) faces practical and legal obstacles. First, there are practical problems with enforcement. It is elemental that a party is not bound by an agreement unless the CALIFORNIA ACADEMY OF FAMILY PHYSICIANS

party signed it. A physician may distribute the unsigned draft amendment of the Blue Cross Prudent Buyer Plan PPA to anyone she or he pleases, without running the risk of incurring any potential liability for breach of the confidentiality provision in the agreement. Second, from a legal standpoint, the clause may be unenforceable. It is not the standard, legal confidentiality clause. All of us have seen those. The standard clause is designed to prevent the leaking of competitively sensitive information. Generally it contains four exceptions, for a spouse, accountant, lawyer and those necessary to ensure enforcement of the agreement. Despite this, the Blue Cross clause has no exceptions even though there appears to be no competitively sensitive reason for the provision. Generally and in California, provisions of contracts that violate public policy are not enforceable. The Legislature typically determines what constitutes enforceability. Courts may find a clause unenforceable as against public policy even where there is no statute on point. The closest example is a case involving a confidentiality clause contained in a securities brokers’ contract with his customer. That clause prohibited the client from discussing any illegal conduct of the broker with regulatory authorities. After the broker was investigated and cited as a result of a complaint from a customer, the broker sued the customer for violating the confidentiality provision. The court refused to uphold the provision barring the customer from reporting the illegal conduct to the government, as it went against public policy. The court weighed the value of enforcing contracts against the value of enforcing the confidentiality clause. The court found that declining to enforce the provision merely declined assistance to the dealer's concealment of his wrongdoing. Enforcing the provision would have undermined the public need for oversight in the securities arena. The same analysis could be applied to the provision at issue with the Blue Cross amendment. Here, a proposed clause, written by lawyers for a managed care corporation, prevents a physician's lawyer from reviewing the contract (or a portion of it). The clause silences the physician from making a complaint about the contract (such as in the RICO lawsuit) because it prevents an analysis of the provision by an expert in legality, a lawyer. That silence not only potentially harms the physician, but also potentially harms the public, whose medical treatment may be affected by the agreement. A clause claiming that a breach of a confidentiality provision would permit the managed care company to “unilaterally and without notice reduce the physician’s fee schedule, terminate the agreement, and/or take action against the physician” likewise is legally problematic. The clause appears designed to penalize the physician for showing the amendment to her lawyer. Penalty clauses, too, are generally illegal. I am reasonably confident the penalty provision is unenforceable. Blue Cross, with its bevy of lawyers, probably knows this as well. The point of the clause may not be its enforceability, but rather the chilling effect it may have on the willingness of physicians to provide it to counsel.

C. No Ability to Renegotiate the Agreement For Two Years While there may be no legal prohibition to a two‐year term, physicians should think long and hard about a lock‐in. If you are willing to agree to it, calendar 120 days from the date it is set to expire so that you can provide proper legal notice of the expiration and your intent to renegotiate the provision. This notice should be in writing. Conclusion There are three options if you are faced with the Blue Cross amendment. First, you can simply refuse to sign the amendment to the agreement. If you do, the burden is on Blue Cross to terminate the agreement due to your failure to sign. Second, you can simply mark a large “X” through the offending provisions, initial the “X,” sign the amendment and return it to Blue Cross. The burden is then on Blue Cross to either accept the amendment as you modified it or to attempt to force you to sign the original agreement. The last option is for you to sign the amendment “as is.” If a dispute later arises, you can then argue that the provisions related to closing your practice to Blue Cross patients and confidentiality are illegal. 50

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Medical Malpractice Insurance – Traps and Tips Barbara Hensleigh

September 2009

Health insurance coverage and its labyrinth is the subject of current political debate. But what about the complexities of medical malpractice liability coverage for physicians? The purpose of this article is to provide information for sorting through the maze of liability coverage. Policy Types There are two major types of coverage: 1. Claims‐made 2. Occurrence The more common claims‐made policy comes in two, significantly different forms. Both types require that the claim, a written demand on the physician to pay money as compensation for damages or to perform free services, be made within the policy period. The less restrictive of the two, commonly called a “claims‐made policy,” also provides coverage when a claim is made to the physician but not reported to the carrier until after the policy period has expired. In contrast, the more restrictive claims‐made policy, commonly called a “claims made and reported policy,” requires the physician to report a claim to the carrier within the same policy period the claim was made. Under this policy, a physician is not entitled to coverage if a claim is made within the policy period but isn't reported to the carrier until after the policy has expired. Claims‐made coverage is generally inexpensive at first and then becomes more expensive over time. Claims‐made policies generally require the purchase of tail coverage to provide coverage for a claim made after the policy lapsed which was not reported to the carrier during the policy period. Tails are especially important to consider if an insured physician moves to another carrier or changes place of employment. Claims‐made policies can further be distinguished by what triggers coverage. Some policies allow coverage to be triggered only upon the presentation of a claim (usually defined as a written demand for money or services). Other policies also trigger coverage when a physician reports an incident he or she believes may result in a claim. A physician purchasing a claims‐made policy should ensure that any policy under consideration is the least restrictive form (i.e., a simple claims‐made policy). Ideally, the policy should trigger coverage in the most expansive of circumstances, including coverage for incidents reported during the policy period even when a claim has not yet been made. A physician also should be wary of any policy requiring the report of an incident be made within a specific time period (e.g., 30 days of the incident) in order to trigger coverage. Such a restrictive reporting period may result in coverage denial. In contrast to claims‐made policies, occurrence policies are rare. They are the Cadillacs of professional liability insurance and are priced accordingly. Claims‐made premiums, however, increase in cost as the policy matures and may become comparable to occurrence policies when considering the cost of tail coverage. Occurrence policies cover incidents or claims occurring during the coverage period regardless of whether the claims were reported during the period. Tail coverage isn't necessary because the physician is covered for all incidents occurring during the coverage period, regardless of when reported. A physician with an occurrence policy need not worry about insurance to cover claims after retirement because the he or she is covered by the policies in place when in practice.

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The Application Process A physician may obtain insurance by application submitted through a broker or directly to a carrier. The cost, or premium, varies, based upon “credits” (i.e., decreases to premiums) or “debits” (i.e., increases to premiums). Credits are typically offered to a physician who: n Is claim free for a certain period of time; n Maintains certain risk management standards; n Practices only part time or is new to the practice; n Maintains membership in certain practice associations; or has other reasons. Debits may increase the cost of insurance for physicians who have: n A better‐than‐average number of claims; n A claim with a better‐than‐average payout; n A practice performing certain procedures (e.g., deliveries, c‐sections); or n An audit revealing certain internal control procedures are missing (e.g., routine review of lab results). A physician may obtain a credit by participating in a risk management program offered by the carrier. Look for a carrier offering Continuing Medical Education (CME) seminars, on‐call risk consultants to provide personalized train‐ ing and assistance, litigation support programs providing education during ongoing litigation, and publications by the carrier (e.g., newsletters, recommended reading, etc.). The Fine Print The review of a prospective liability policy does not stop with a claims‐made/occurrence analysis. There are several other policy components a physician should review and understand. Consent to Settle Clauses A consent to settle clause gives the physician the right to reject any proposed claim settlement, even when the carrier or physician's counsel recommends it. The clause is important because, by law, certain settlements must be reported to the National Practitioner Data Bank or state medical board. The reporting may result in an administrative action against the physician. Some policies also contain a time period (e.g., 30 days) in which the physician must reject a settlement offer or be deemed to have consented to it. The physician should retain the sole option to reject a proposed settlement. While the imposition of a time limit to reject a settlement is not a reason to reject a policy, a physician should be aware of the time period. The physician should refuse a policy that contains a “hammer clause.” A hammer clause permits the carrier to reduce the limits of a policy to the dollar amount of a settlement proposal rejected by the physician. For example, a policy providing $1 million per occurrence may be reduced to a limit of $50,000 if the physician refuses a demand to settle for $50,000. Right to Purchase Tail Coverage A claims‐made policy should contain a right to purchase tail coverage. Tail coverage can be expensive, although it is often offered at no charge by a carrier at the retirement, death or permanent disability of a physician. Limits of Liability Many hospitals and health care plans require a physician to provide proof of liability insurance within certain coverage limits. Typically, coverage is provided with both a dollar limitation on an individual claim and an aggregate amount for the policy period. The limits are commonly written as, for example, $1 million/$3 million. The first number reflects the limits of the amount a carrier will pay on an individual claim. The second number reflects the total limit the carrier is obligated to pay out, if there are several claims, within the policy period. Some

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policies include a provision permitting the carrier to deduct defense costs (e.g., attorneys’ fees) from agreed upon limits. This is known as an “exhausting limits policy.” Policies permitting the carrier to deduct from the limits and the costs of defense (i.e., the costs of paying a lawyer to defend the case) should not be purchased. Other Exclusions A physician should carefully review policy exclusions. For example, the physician should determine if the policy excludes the defense of Medical Board actions. Some policies provide a dollar limit for the defense of such actions. Also, some policies may exclude coverage for medical care provided outside the geographic location of the physi‐ cian's identified practice location or for volunteer work. Choosing a Carrier Any liability coverage purchase involves an analysis of the company offering the coverage. A policy is worth little if the company issuing it goes belly up. One of the most important indicators of the financial well‐being of a carrier is its rating. A.M. Best independently analyzes the financial and operating strength of carriers. It rates companies from A++ to F. Other raters include: Standard and Poor's, Duff & Phillips, Moody's and Weiss Research. A physician should review carrier ratings by at least two of these organizations. Some carriers are highly regulated, others are not. An admitted carrier is subject to the rules, regulations and oversight of the state to which it is admitted to do business. Because of the high level of scrutiny, an admitted carrier (with a high rating) is the safest bet. An unadmitted carrier might still be an option based upon, among other factors, the rating of the carrier. There are other types of insurance carriers as well, including a Risk Retention Group and a Mutual Company. Both may require the insured to be a part owner of the company. How the carrier operates in a claim situation is also an important factor. Try to review the following: n Information about the carrier's win rate; n The percentage of claims closed without payment over the past few years; n The average number of years of experience of the carrier's claims personnel; and n The number of claims the carrier has defended in the past few years. Finally, the length of time the carrier has operated is important. Has the carrier weathered financial storms? Has it stayed in the market during the rough times, or has it exited the market and re‐entered it when times are “good?” A stable company is a better choice. The articles provided in Practice Management News are general. They do not constitute legal, practice management or coding advice in any particular factual situation or create an attorney‐client relationship. Consult your attorney for advice in your particular situation.

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Ten Tips for Choosing a Lawyer Barbara Hensleigh

November 2009

the Area in Which You Need Advice 1 Identify The first step in choosing a lawyer is identifying the area in which legal assistance is needed. Like physicians, lawyers specialize. A lawyer experienced in drafting real estate documents may not be the best lawyer to litigate a fee dispute between a physician and a health plan in court. Bear in mind that in law, as in medicine, preventive measures may save significant costs in the long term. For example, hiring a health care transactional lawyer to prepare a written agreement for a new physician hire will reduce the possibility of a later lawsuit about the terms of an oral agreement. Paying a lawyer to draft a written agreement is likely far less costly than paying a lawyer to defend a lawsuit over the terms of a disputed oral agreement. Around for a Referral 2 Ask Ask friends and colleagues for names of attorneys in the particular area in which you need advice. Lawyers are good referral sources as well. For example, a lawyer specializing in probate may know, by word‐of‐mouth in the legal community, a reputable real estate lawyer. Professional associations often keep lists of lawyers to whom they refer members. The California Academy of Family Physicians and the American Academy of Family Physicians both have referral databases of attorneys specializing in health care law. Both organizations require some vetting of the lawyers on their lists. Due Diligence on Prospective Lawyers 3 Conduct Investigate prospective lawyers. Bar associations may have a lawyer search function on their websites. In California, the state bar association provides information on any prospective lawyer, including whether the lawyer has been disciplined by the state bar. See: http://members.calbar.ca.gov/search/member.aspx. The law school an attorney attended is only one factor to consider. As with physicians, long‐term experience is more important than formal education. Through additional testing and practice requirements, some state bars also certify attorneys in specialized practice areas. In California, the practice areas listed on the bar’s website include family, tax, estate planning and bankruptcy law. Investigate certifications claimed by a lawyer from organizations other than the state bar association. Those certifications sound good but, in reality, may be meaningless. Alternative sites may also provide information about prospective lawyers. For example, a site may discuss a case handled by the prospective attorney, contain interviews with the attorney, published reference papers, or presentations given by the attorney. That information may be invaluable in informing you of the attorney’s perspective. If, for example, you find the attorney represented a large hospital against a physician, you may not want to retain him or her to represent you in your potential case against a hospital. On the other hand, if you find the attorney has successfully prosecuted cases against the very hospital with which you have a dispute, that attorney may be the right one for you. The lawyer’s membership in professional organizations also is important. A health care lawyer for physicians typically will not be a member of a hospital lawyers’ group or a wills and estate planning professional society, for example.

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and Talk to the Prospective Lawyers 4 Meet After narrowing your choices through investigation, meet prospective counsel. Some lawyers will charge a fee for an initial meeting. Others won’t if the meeting is short. The meeting should not be for obtaining legal advice; in fact, the lawyer may not be able to provide advice without an opportunity to review paperwork. The purpose of the meeting is to obtain additional information about the lawyer’s background, determine how the lawyer would manage your case, and decide whether the lawyer fits your case and personality. To prepare, you should make a list of questions for the lawyer to answer. The lawyer should be able to forthrightly explain his or her experience and outcomes in particular cases. The lawyer should be able to explain how your potential case would be staffed (i.e., the level of the lawyer’s involvement in the case vis‐a‐vis associates and paralegals). Associates or paralegals may be less expensive; however, they also may take longer to perform assignments because of their lack of experience or understanding of the important issues. Look for a personality that fits yours and for straightforward answers to your questions. the Fee Arrangement 5 Determine Discuss the potential fee arrangement. Will the lawyer charge a flat fee to draft an employment agreement? If so, what is the fee? Or will he or she charge by the hour? If so, what is his or her hourly rate (and the hourly rate of associates and paralegals)? Can potential litigation be managed on a contingency fee basis or a blended contingency/ hourly fee basis? Will there be an up‐front retainer that is depleted as the case advances or retained until the case ends? There are myriad fee arrangements. The fee arrangement must be one that works for both you and your lawyer. An Estimate of the Potential Legal Fees 6 Get The lawyer may be able to provide a rough estimate of the potential cost to do the work. In transactions such as drafting an agreement, it’s much easier to gauge the potential cost. Don’t retain a lawyer who cannot estimate the cost for drafting general agreements. It’s more difficult to gauge the cost of litigation. There are variables beyond the control of the lawyer, such as additional requirements imposed by the court or the aggressiveness of opposing counsel. Nonetheless, the anticipated cost of litigation should be discussed. You may also discuss methods to reduce costs. Can you or your spouse do some of the organizational work? For example, a physician recently attended an initial meeting at my practice. She brought an organized notebook of all documents associated with the case, a list identifying the important witnesses and their association with the case, and other relevant information. She saved several hours of billable work to organize the documents and to create a “cast of characters” identifying potential witnesses. I welcomed her effort for many reasons. Among other things, the client’s work demonstrated how serious she was about her case and her attention to detail, both good attributes for a witness in litigation. (Yes, in initial meetings, lawyers evaluate prospective clients, too.) Clear and Honest about Facts and Goals 7 BeYourPractical, conversations with potential counsel are protected by the attorney‐client privilege even if you decide not to retain the counsel. Accordingly, you should be candid about the facts and your goals. It’s important to be completely forthright with the facts, even ones you believe might cast you in a bad light or hurt the case. Forewarned is forearmed. The lawyer may be able to blunt the impact of negative facts, but only if she knows them from the outset. Moreover, knowing all of the facts permits the lawyer to properly evaluate a case. A lack of candor damages the case and the relationship.

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If the lawyer knows your goals, she can gauge whether she can deliver the results you seek. We have had cases where the potential client informed us up front he or she anticipated the recovery of a certain sum we deemed unrealistic. We did not take these cases because of the potential for friction and unhappiness. But we did refer the potential clients to other lawyers who may have evaluated their cases differently. for Malpractice Insurance 8 Check An attorney who does not carry malpractice insurance likely will not have the resources to pay for any damage done as a result of any negligent representation. As difficult as the question may be, ask. Say you read an article that said you should. for References 9 Ask Attorneys are happy to give references for their work. They are usually proud of their accomplishments. Feel Pressured 10 Don’t Once you have interviewed at least two potential lawyers, you should sleep on your decision. Run from any lawyer who attempts to pressure you into making an immediate decision. The articles provided in Practice Management News are general. They do not constitute legal, practice management or coding advice in any particular factual situation or create an attorney‐client relationship. Consult your attorney for advice in your particular situation.

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You and Your Hospital – The Ins and Outs of Hospital Contracting Barbara Hensleigh

August 2010

California and a minority of other states bar hospitals from directly employing physicians unless the employment relationship fits into one of a few legal exceptions. Faced with economic stressors, however, hospitals are attempting to increase revenue by offering services rendered by physicians. In some cases, hospitals have created ways to circumvent the prohibition against the corporate practice of medicine while, at the same time, using it as an excuse to pass on expenses and potential liabilities to the physicians with whom they contract. This article provides guidance in reviewing hospital/physician contracts for physician‐led services and in limiting expenses and liabilities. The Physician as an Independent Contractor There are exceptions to the prohibition against the corporate practice of medicine. Certain hospitals in rural areas can employ physicians, for example. If a physician were employed by a hospital, the hospital must pay withholding taxes, malpractice insurance, benefits, vacation pay and the like. Some physicians may prefer to be employees of a hospital because of such benefits. The hospital’s evaluation of the relationship may differ from that of the physician. Regardless of whether or not the hospital can legally employ physicians, it may desire to contract with a physician as an independent contractor to save money. The hospital is not required to offer benefits to independent contractors as it would to employees, including vacation pay, medical insurance and retirement programs. Furthermore, as an independent contractor, the physician will likely be required to pay his or her own medical malpractice insurance. Finally, physicians are liable for any professional negligence because they are not hospital employees and the hospital may rely on the general prohibition against the corporate practice of medicine to avoid entering into an employment relationship with physicians. Independent contracts between physicians and hospitals are not particularly physician‐friendly for more reasons than the fact that physicians do not receive the same benefits as hospital employees. These contracts are typically written by hospital legal counsel and have become more advantageous to hospitals in recent years. It seems as though each hospital attorney is trying to outdo the other in transferring costs and liabilities to the physician. At the tipping point, it is inadvisable for a physician to enter into such a one‐sided agreement. This is particularly true for contracts with large hospital chains, both for‐ and not‐for‐profit. Occasionally, a hospital chain will refuse to negotiate a decidedly inequitable arrangement citing the need for uniformity of contracting. A take‐it‐or‐leave‐it agreement probably should be left. At a minimum, before entering into a hospital contract, physicians should review the proposed agreement and assess the following: n Is the relationship truly that of an independent contractor, or does it seek to circumvent the prohibition against the corporate practice of medicine or pass on certain operating costs of an employer onto the physician? If the hospital is controlling the physician's work hours, providing equipment and supplies, prohibiting the physician from working elsewhere and exerting general control and supervision over the physician, the agreement may be more of an employment agreement, regardless of how it is worded. n How much will an independent contracting arrangement cost the physician? The physician must pay for his or her liability and health care insurance, taxes, disability insurance and vacation, among other things. If the physician intends to enter into an independent contracting arrangement with a hospital, those costs should be recouped by the physician in the form of payment for his or her services. In other words, an independent contracting CALIFORNIA ACADEMY OF FAMILY PHYSICIANS

arrangement paying $140,000 per year is not the equivalent of an employment agreement for the same amount. n Is the hospital requiring the physician to create a separate corporate entity to enter into the agreement? At least one major hospital chain requires a physician be incorporated before entering into a contract to provide services on behalf of the hospital. Such a requirement is nothing more than an effort to circumvent the bar on the corporate practice of medicine by making an employment agreement appear more like an independent contracting arrangement. While protecting the hospital chain, this requirement costs the physician money. The physician is required to pay the costs of incorporation as well as the corporation’s annual taxes. These costs should be passed on to the hospital. n Is the hospital requiring the physician to carry general liability insurance? There is no reason for a physician, without an existing medical practice, to carry general liability insurance. However, one major hospital chain routinely requires its contracting physicians to purchase general liability insurance, naming the hospital as an additional insured. Before signing such an agreement, a physician should determine whether he or she can even obtain such insurance. If so, the cost of that insurance should be passed on to the hospital. n Is the hospital attempting to require the physician to indemnify the hospital? One large hospital chain in California attempts to include a contractual requirement that physicians indemnify the chain in the event it is 1) charged by the Internal Revenue Service for taxes not paid by the chain for the physician because the chain has intentionally misclassified the physician as an independent contractor rather than an employee; and 2) sued for work performed by the hospitals' employees under supervision of the physician. As openly acknowledged by the chain's legal counsel, a physician's malpractice carrier typically will not provide coverage for either situation. Accordingly, the physician could be personally liable for these inequitable indemnification provisions. Indemnification and the risk of liability may be too great for a physician to enter into such an arrangement. Notably, when one physician client refused to agree to indemnify the chain under these circumstances, the chain relented and changed the provisions. But the change did not occur without the willingness of the physician, in the face of personal pleas by the hospital's CEO, to walk away from the contract. n Does the proposed agreement provide the hospital with the right to settle a lawsuit on behalf of the physician? One hospital chain provides the contracting physician with a modicum of insurance under that system's self‐insur‐ ance policy. However, the same provision gives the system the right to settle any lawsuit brought against the physi‐ cian. The provision is as unacceptable in the proposed hospital contract as it would be in an insurance policy per‐ mitting the carrier to settle an action without the physician's consent. Any settlement may be reportable to the National Practitioner Data Bank or Medical Board. Moreover, the chain may not have the physician's best interests at heart in settling and it would be beneficial to remove the provision from the agreement. The Shadow Physician Practice A major hospital chain has another method of circumventing the prohibition against the corporate practice of medicine. The process involves: 1. Creating a medical group; 2. Locating a titular physician owner of the practice; 3. Causing the group to enter into a long‐term management agreement with a hospital‐owned management group for significant management fees; and 4. Causing the group to enter into an employment agreement with the physician providing him or her with a percentage of the revenue from the practice. Under this paradigm, the hospital controls the medical group; the group and the practice are owned in name only by the physician. If the physician terminates his or her employment agreement with the group, ownership in the group immediately terminates. The arrangement poses significant potential liability for the physician. As the sole shareholder, the physician is subject to liability for actions by the management group or hospital of which he or she may not be aware. For

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example, if the hospital chain does not properly incorporate the group or does not maintain corporate formalities (e.g., maintain bylaws, annual shareholder meetings and corporate taxes), the physician may be personally liable to third parties to whom the group owes money. Since failing to maintain corporate formalities poses little or no liability to the hospital chain, there is a possibility the formalities may not be maintained. Moreover, the bylaws of the group, if there are any, or the management agreement may require the group to indemnify the management group for any actions it has taken on behalf of the group. If the group has not observed corporate formalities, then the physician may be personally liable and may be forced to indemnify the hospital chain or its management organization for acts it took on behalf of the group. Finally, even if the management group agrees to indemnify the physician for its actions, the indemnification is only as good as the financial viability of the management group. If they are insolvent, the indemnity provision may be meaningless. There are other reasons to be concerned about the de facto control by a hospital/management group of a practice legally owned by a physician. The physician is ultimately responsible for the activities of the group, regardless of whether he or she controls it. To the degree the management group engages in billing irregularities, the physician maybe legally responsible, even if he or she did not know about the irregularities. The paradigm also raises troubling kickback and fee splitting issues. California law, for example, prohibits the formation of a professional corporation for the purpose of causing a violation of the law relating to fee splitting, kickbacks or similar practices by physicians. Violation of the law may result in a referral by the Department of Managed Health Care to the Medical Board for termination of the involved physician's license. If a court were to see through the shadow physician practice, it might find that the hospital has violated the prohibition against the practice of medicine AND that the arrangement violates the prohibition against fee splitting and kickbacks. The articles provided in Practice Management News are general. They do not constitute legal, practice management or coding advice in any particular factual situation or create an attorneyâ&#x20AC;?client relationship. Consult your attorney for advice in your particular situation.

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Quality Improvement and Practice Redesign Getting Started With Planned Care Where to Start with Improvement Do Patients Belong on YOUR Care Team? Mapping Your Way to Leaner Workflows Strategies to Improve Access and Make Office Visits More Patientâ&#x20AC;?Centered

February 2006 February 2007 April 2007 February 2009 August 2009

Getting Started with Planned Care Sue Houck

February 2006

Do you have 825 hours to care for your patients with chronic disease? That’s the amount of time it would take to provide care as advised in national guidelines for well‐controlled patients with the top 10 chronic diseases for a panel of 2,500 patients. That’s three‐and‐a‐half hours a day. When requirements for uncontrolled disease are factored in, time demands more than tripled, according to a 2005 study. 1 This study concluded that alternative service delivery methods are needed to meet care guidelines. As participants in CAFP’s New Directions in Diabetes Care (NDDC) Collaboratory and others have found, planned care is an effective way to integrate alternative approaches. The Chronic Care Model, developed by Dr. Ed Wagner at the McColl Institute, is a system of evidence‐based, planned care for patients with chronic diseases. The model includes: n n n n

Self‐management support for patients; Decision‐support tools to assist physicians and staff; Clinical information systems to track patient care; and Productive interactions between physicians and patients, such as planned one‐on‐one and group visits.

The model was developed because processes for acute conditions are poorly designed for chronic illnesses. Planned care will help you take a proactive vs. reactive approach to caring for your patients. And although this discussion will focus on diabetes, the concepts can be applied to any chronic illness. Case Study Frustrated with trying to provide optimal care for patients with chronic illness, Family Physicians of Western Colorado identified a physician champion — a key prerequisite — to launch planned care. They started by providing patients with a one‐page Patient Care Report which graphs blood pressure, HbA1c, lipids, weight, and other data over time. Patients were encouraged to post the report in a prominent place in the home, such as their refrigerator, to remind them of their progress. Three years later, physicians in the group overwhelmingly concluded that planned care greatly increased both their satisfaction with caring for patients with diabetes (86%) and the overall quality of care they provided to patients with diabetes (79%). What did they accomplish? Measurable improvements included a drop in average HbA1c and blood pressure measurements as well as more patients taking aspirin. 2 Key steps to effectively implementing planned care are: 1. Develop a method to track patients with diabetes 2. Use a team approach in designing planned care 3. Initiate planned care activities and track results Develop a method to track patients with diabetes First, identify how many of your patients have diabetes from billing and/or payer data. Front desk and medical records staff should flag patient charts to ensure that everyone gets identified. Next, establish either a paper or electronic registry of these patients. The registry should include demographic data, as well as key health information, so that care can be monitored and planned over time. While electronic health records (EHRs) make identifying patients with diabetes easier, many require software enhancements, like templates, to do registries. If you don’t have an EHR, a registry can be as simple as an Excel spreadsheet. More information on registries can be found here. 62

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Use a team approach in designing planned care Next, include staff in designing planned care. Attention to teamwork, including cross‐training and delegating, helps to spread responsibility and reduce bottlenecks. Some practices have trained non‐physician staff to do foot checks, track lab results, and teach self‐management skills. In addition, nurse‐led planned care visits have been shown to reduce HbA1cs. 3 Teams may spend a minimum of two to four hours to identify where to start with planned care. Regular team meetings also help build ongoing learning. Case Study: Several years after “work harder/smarter” improvement efforts, Plymouth Family Physicians concluded that, left solely to the physician, any Planned Care Activities gains to be made were modest. The group expanded the roles of non‐physician staff who willingly Estimated Effort took on new tasks when they Required Item believed that interventions were 1 Identify patients with diabetes in the practice in the patients’ best interest. 2‐3 Develop a registry to track care of patients with diabetes Staff appreciated being respected Nursing staff asks patients with diabetes to remove shoes and socks at as problem‐solvers with insight 1‐2 each office visit equal to others. 1

Support staff began to help develop and reinforce shared care plans with patients, as well as explain labs and procedures. The results? Operational and financial performance improved, staff satisfaction went up and turnover dropped.

2‐3 2 2‐3

3‐4 3 Initiate planned care activities 2 and track results 3‐5 Where to start with planned 3 care? Solicit staff input regarding 3‐5 characteristics of the ideal visit 3 for patients with diabetes and 2 ask yourself these questions: 2‐3 n Is documentation for HbA1cs, 2 serum creatinine, fasting lipid 3 2 panels, and other lab work 1‐2 current and easy to find in

patient charts? n Would a diabetic flow sheet make ongoing documentation and patient interactions more productive? n Which staff members might expand their roles? n Should lab work be done before visits to reduce

1‐2

Post signs in all exam rooms asking patients with diabetes to remove shoes and socks Initiate regular planned care team meetings Identify average HbA1cs of patients with diabetes Select monitoring activity as well as goals and metrics (e.g., update or reduce HbA1c, check for microalbuminuria, complete depression screening, or foot checks for a specific percentage of patients with diabetes) n Implement monitoring activity Develop a shared plan of care with individual patients with diabetes Develop diabetes flow sheet that incorporates care guidelines n Implement diabetes flow sheet Develop a plan to do group visits n Initiate group visits Initiate nurse visits to monitor lab values and promote self‐management Develop diabetes foot screen form n Implement using diabetes foot screen form Train MAs or nurses to do foot checks n MAs or nurses complete foot checks Schedule lab work before physician sees patients Identify and share information regarding community resources for patients with diabetes Enhance self‐management information for patients with diabetes (e.g., share diabetic flow sheet contents, practice Website and Familydocs.org materials, handouts, etc.)

This table lists sample planned care activities and the estimate of required effort, including time estimates, on a scale of 1 to 5 (1 = small effort, 5 = significant effort). Time estimations may vary due to variations in practice patterns, resources, and readiness to adopt change.

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frustrating bottlenecks? Planned care decision support tools include diabetic flow sheets that provide prompts and reminders with treatment guidelines at the point of care. In addition, most EHRs include decision support tools. Planned care innovatively spreads time‐intensive care among physicians, staff, and even patients. Begin with simple process changes like asking diabetic patients to remove their shoes and socks. Consider other changes, such as launching group visits, setting goals to reduce average HbA1cs, and making information available on community resources for chronic illness care. Tracking the results of planned care activities facilitates shared learning while building teamwork and momen‐ tum. As detailed in the Winter 2006 issue of California Family Physician, the Plan‐Do‐Study‐Act (PDSA) cycle tool enables users to plan tests of change and document results. In NDDC, they are known as Small Tests of Change. This simple tool has been widely used by physician groups and hospitals. The goal is to make incremental changes and test them in small ways to see what’s working. A detailed description of how to use PDSAs to improve care of patients with diabetes can be found here. Planned care isn’t for everyone. As the name states, it takes planning. In practices willing to commit the time and resources, however, physicians, staff, and patients will notice the positive results. As David K. McCulloch, MD, from Group Health Cooperative of Puget Sound says, “A big fear when we proposed doing this six or eight years ago was that they would have to call in people for additional visits and look in their eyes and at their feet and have to give treatments; providers were concerned that people would end up coming in more often, and it would cost them. It’s not true. You will find that if you have an organized system, people come in and get everything dealt with much more efficiently.”

1 T. Ostbye et al., Annals of Family Medicine. May/June 2005; 8:3. 2 P. Mohler, N. Mohler. Improving Chronic Illness Care: Lessons learned in a private practice. Family Practice Management. November/December, 2005. 3 Peters and Davidson, Diabetes Care. 1998;21:1037. Aubert et al. Annals Intern Med 1998; 129:605.

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Where to Start With Improvement Sue Houck

February 2007

It’s Monday morning and the phones at Dr. Artoro’s office are ringing nonstop. His first patient is concerned about the results of her recent colonoscopy, but there are no procedure results in her chart. Dr. Artoro’s nurse manager mentions that Cindy at the front desk has just resigned. When asked why she was leaving, Cindy replied that she was tired of being “out of the loop” about what’s going on at the office. Dr. Artoro’s day is topped off with a visit with Frank Sweet, a 72‐year‐old diabetic who’s new to the practice and needs a foot exam. Completing a thorough history on Frank takes 13 minutes. Driving home at the end of the day, Dr. Atoro feels frustrated. Like many physicians, relationships with patients are among the most satisfying aspects of his work.1 However, waits, delays, and busy work seem to be constantly getting in the way. Sound familiar? The thought of starting to improve may be far down on your list of things to do on a day like the one above; but think again. Would it be helpful to get rapid relief from such distracting hassles? To free up more time to be with patients? If you’re feeling overwhelmed about where to begin, start by simply writing on sticky notes the top things that bother you as you care for patients tomorrow. Getting Started Assume that Dr. Artoro’s sticky note list of complaints looks like this: 1. MA Andrea gets so busy with phone calls that sometimes she’s unavailable when I need assistance. 2. I had to leave the exam room to get needed information that was missing from charts during two office visits. 3. I’m tired of staff complaining that they’re out of the loop about what’s going on. 4. I was interrupted twice by a staff member needing clarification about some of the appointment types and lengths. 5. History taking consumes so much of my time. I’ve had to rush through explaining findings and planning care with patients twice. 6. I don’t have a simple way to thoroughly document diabetic foot exams, and even when I think I need to do a foot exam, often a monofilament isn’t in the exam room. Do any of these issues ring true for you? They’re common complaints that we hear from family physicians nationwide. Cumulatively, they zap energy, frustrate, and even cause burn‐out. Practical Solutions Based on experience with hundreds of practices, we’ve found the following solutions work for the problems noted above: 1. MA Andrea gets so busy with phone calls that sometimes she’s unavailable when I need assistance. Before hiring more staff to answer phones, conduct a simple audit of phone calls. Save all messages for one week. Next, divide them into categories e.g., advice, refills, referrals, etc. Count volume of messages by category for each physician. A group on the East Coast found that an average of six calls per day were requests for the group’s fax number. Simply adding the number to the automated voice recording heard by all callers eliminated the requests. A group in California found that 80 percent of message volume in a small group was for one physician who routinely told patients at the end of a visit to call her to report on “how things are going.” After

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reviewing the data, the physician decided to ask only those patients needing follow‐up to call. In addition, patients were allowed to directly call her clinical team, eliminating handoffs from the front desk. The result? Call volume dropped by 30 percent. In addition, patients were delighted to speak directly with staff already familiar with their clinical needs. If you think you are too busy to take the time do the audit, consider how much time you and your staff are already spending on calls that don’t add value to the patient experience. 2. I had to leave the exam room to get needed information that was missing from charts during two office visits. Have clinical support staff review patient records for needed documentation the day before scheduled appointments. If needed, calls can then be made to specialist physicians or labs so that reports are available on the day a patient is seen. If you have a patient registry, consider doing this even farther ahead to ensure needed labs get done before the visit. 3. I’m tired of staff complaining that they’re out of the loop about what’s going on. Dr. Artoro does not have regular staff meetings. But weekly or even biweekly staff meetings can avoid communication lapses that are common in a busy practice. Structure your meetings to maximize their effectiveness, participation, and attendance. Read the December 2006 edition of Practice Management News, “Making Staff Meetings Work.” Regular staff meetings are essential to improving patient, staff, and provider satisfaction and the smooth operation of your practice. If finding the time for a biweekly meeting doesn’t seem possible, consider a weekly “huddle” with your staff. 4. I was interrupted twice by a staff member needing clarification about some of the appointment types and lengths. Lots of appointment types and lengths result in long queues of patients waiting to be seen in some appointment categories, like physicals and new patients. In addition, complicated appointment rules create significant frustration for scheduling staff that can contribute to high turnover. Standardizing appointment types and lengths can significantly reduce physician interruptions for staff needing clarification about scheduling rules. It also reduces the hassle factor for appointment staff and patients who must wait in queues for a specific type of appointment. In our experience, so‐called hidden capacity can be freed up and visit volume increased up to 10 percent when appointment types and lengths are reduced and standardized. Consider standardizing all appointment lengths to be either 20 minutes or 15 and 30 minutes. In addition, if you’re considering a move to open access scheduling, standardizing appointments is an important first step. 5. History taking consumes so much of my time. I’ve had to rush through explaining findings and planning care with patients twice. History taking can consume significant amounts of visit time. In addition, extended general discussion of medical history is negatively related to patient satisfaction.2 In fact, patients are most satisfied with medical visits in which they talk about their specific therapeutic interventions, are examined, and receive health education. More than simply documenting the reason for a patient’s visit, consider having nurse or MA staff enter in‐depth interval histories as well as previous medical histories. Better yet, have patients complete a checklist form that documents previous medical history or even interval history. Some practices ask new patients to download a history form from the group’s Web site to be completed and brought in for their visit. Other sites have patients complete a history directly into their electronic health record on a secure practice Web site. 6. I don’t have a simple way to thoroughly document diabetic foot exams, and even when I think I need to do a foot exam, often a monofilament isn’t in the exam room. Using information from the American Diabetes Association and other resources, develop a simple form for completing foot exams. Be sure to view the US Department of Health and Human Services’ monofilament foot examination page, and check the new Practice Resources section of www.familydocs.org at the end of February 66

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when we’ll have a comprehensive list of other resources available. Consider Small Test of Change (STOC) cycles (also known as the Plan‐Do‐Study‐Act cycle) to plan and implement the form (discussion follows). If you have a patient registry and can determine in advance which diabetic patients you will be seeing that day, your MA can put a monofilament in the chart. If you don’t have a registry, there are other ways to delineate diabetic patients, such as with a colored sticker on the outside of the chart, so your staff can appropriately prepare the room for your visit needs. Several teams in CAFP’s New Directions in Diabetes Care initiative have found the “sticker” method to work well; office staff figured out the best place on the outside of the chart to put a sticker, and now the MA knows to ask the patient to take off his or her shoes and socks when roomed, and a monofilament is placed in the chart so it’s easily accessible to the physician. Other teams are working on implementing patient registries, electronic or paper, so they can more easily identify their diabetic patients. Use STOC Cycles to Document Improvement Activities Assume Dr. Artoro decided that a form would help to document diabetic foot exams. STOC cycles are a proven, simple way to both test potential changes to office operations and document progress regarding the desired changes.3 They’re also a useful communication tool for staff participating in improvement, and help engage them in the process of change. Staff must be involved in trying out new ways to improve practice operations; often they know best what tweaks to the system will result in improvement. Objective

To find or develop a simple form to document diabetic foot checks.

Plan

Consider what you’ll do and predict your results Dr. Artoro will itemize what to include in foot exam checklist and approve final form (estimate 30 minutes this week). MA Lucia will do an Internet search for forms (estimate 20 minutes this week). Mary at front desk will format a checklist from Lucia and Dr. Artoro’s info (estimate 30 minutes this week). We predict that we can easily develop or adapt a practical foot exam form to use with diabetic patients. This will be an improvement from current haphazard documentation of foot exams, and that staff will agree on what this form should look like.

Do the activities Dr. Artoro itemized what to include on the checklist: sensation, ulcers, calluses, elevated skin temperature, proper fit of shoes, pedal pulses, foot deformity, swelling, risk categories (actual time 15 minutes, less than 15 minutes planned). Lucia did not find any forms, but she did find additional parameters to consider for the form e.g., muscle weak‐ ness, ingrown toenails (actual time 20 minutes, same as estimated). Dr. Artoro reviewed the additional parameters and decided to also include them (time 10 minutes — not planned). Mary made the form in Microsoft Word (actual time 30 minutes, same as estimated). Staff had a quick “huddle” to look at the final form. Two formatting changes were recommended – the font was too small to read and the “check boxes” on the list didn’t line up to the items (actual time — 10 minutes). Mary made the changes to the form (5 minutes).

Study

Review what happened Some tasks took longer; others took less time than estimated. In addition, Dr. Artoro spent an additional 10 minutes reviewing and selecting parameters and a few additional minutes were spent to make sure all staff felt that the form was usable. Total time for all participating was one hour and 30 minutes. Staff did not find the extra work to be a problem. Dr. Artoro and the staff are happy with the results.

Act

Test the form for two days with diabetic patients to see how it’s working. If the form is working well, continue use for one week and then study and discuss the results.

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The key to making STOCs practical is to break down a number of changes or even one big change into separate small tests of change. For example, assume that Dr. Artoro would like to not only find and use a form for diabet‐ ic foot exams but also to delegate foot exams to his nurse, Maria. The first STOC might be to find out if an acceptable form already exists or develop a form or to see if Maria has any interest or time to do the foot exams. See also Table 1. Sample STOC Develop Diabetic Foot Exam Form. A second STOC would be to test the form. Subsequent STOCs might include devising steps to train and observe nursing staff completing the checks. Conclusion There’s never a perfect time to begin improvement. But small changes over time can chip away at inefficiencies that sap satisfaction for physicians and staff. To make it meaningful, start by documenting annoyances for a day. Consider STOC cycles to simply document and test incremental changes and make certain that a change is also an improvement.

1 Suchman AL, Roter D, Green M, Lipkin M. (1993, December). Physician satisfaction with primary care office visits. Medical Care, 1083‐ 92. 2 Robbins JA, Bertakis KD, Helms LJ, Azari R, Callahan EJ, Creten DA. (1993, January). The influence of physician practice behaviors on patient satisfaction. Family Medicine, 25(1):17‐20 3 Langley, G.J., Nolan, K., Nolan, T. Norman, C., Provost, L., (1996). The Improvement Guide, San Francisco: Jossey‐Bass.

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Do Patients Belong On YOUR Care Team? Sue Houck

April 2007

This article focuses on patients with diabetes; however, many of the care concepts can be used with your patients who have other chronic illnesses. Forty‐five‐year‐old diabetic patient Clarissa Martinez has an appointment today. It’s only April, but she’s had five office visits this year, most for minor problems. She’s also called the office four times, each time generating a message, chart pull and return call. Her complaints today are many, from a sore throat to a small ulcer on her right foot. After the visit, MA Robin and RN Maria commiserate regarding Clarissa’s poor adherence to their repeated advice about foot care and proper diet. But maybe the answer lies beyond better adherence. When caring for patients like Clarissa, ask yourself these questions: n What are your goals for patients like this over the next year? Lowered blood pressure? An A1c that’s below seven and no hospitalizations? Fewer calls and visits for minor problems that your patient may be able to handle herself? n Whose actions will have the most impact on achieving these goals? Isn’t your patient the central producer of clinical results by changing behaviors and partnering with you to achieve goals you have set together? If so, doesn’t it make sense that she should be knowledgeable and skilled in producing those results? If providers and staff are willing to view Clarissa as a member of the care team, who could manage more of her own care, would staff frustration drop? Could outcomes improve? One study found that collaborative vs. didactic educational interventions may be more effective in improving glycemic control, weight and lipid profiles in diabetic patients. 1 Beyond patient education, self‐management builds patient problem‐solving skills. Patients learn to interpret and manage symptoms and maintain daily activities. Central to self‐management is self‐efficacy – patient confidence to carry out activities necessary to reach a desired goal.2 But embracing and implementing patient self‐ management often takes time. Why? It may seem counter‐intuitive to physicians and staff whose experience and training have led them to think that they bring value by giving advice. A site in Michigan that embarked on improving care for patients with chronic illness found that, “We have learned over the years at our center that effective chronic illness care requires two things. First, it requires a team with the patient at the center. Second, it requires active, involved participants — especially an active, involved patient.”3 Teams in CAFP’s New Directions in Diabetes Care initiative have also found that training on patient self‐management has been critical to activating patients. For example, our family physician teams have learned the keys to motivational interviewing, such as letting the patient identify the goals he or she thinks can be achieved. This training has been essential in changing the visit from one where the physician gives her “canned” lecture on nutrition or exercise or smoking cessation, to one where patients are engaged in identifying even the smallest changes they feel confident they can achieve, therefore building confidence to address larger behavioral change.

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How might an active approach to self‐management be different from the status quo? Table 1 contrasts the two states. Table 1. Status Quo vs. Self‐Management Status Quo

Active Self‐Management

Traditional compliant patient role the norm.

Collaborative goal setting builds confidence, engagement and responsibility (e.g., “What would increase your confi‐ dence in managing your diabetes from a rating of 5 to 7?”).

Care for chronic illness is provided in one‐on‐one physician Group visits are conducted with patients with chronic ill‐ nesses, reducing the number of times physicians must office visits. repeat the same advice. Mid‐level, nurse and/or pharmacist visits enable patients to manage medications. Patients receive encouragement for achieving their goals, peer sup‐ port and learn successful tactics when dealing with the challenges associated with their condition. Education materials are often distributed as an afterthought Consistent, coherent self‐care information and decision sup‐ during acute care visits. port are available via practice Web site and printed materi‐ als. Links to Web sites with additional self‐management information are also provided. See also: http://familydoc‐ tor.org/785.xml Visits look like they always have.

Details regarding needed testing, specialist visits, and results are discussed as time permits.

Visits look different. Patients may peruse their own records during group visits. Wall signs remind patients to ask for a printout of today’s visit (if EHR). Physicians invite patients themselves to answer questions that come up regarding self‐care in group visits. Wallet cards and printed registry reports are routinely dis‐ tributed indicating results, as well as schedule for lab tests. Patients can track their progress over time and keep these results in a convenient place, such as attached to the refrig‐ erator.

In addition to home‐grown self‐management activities, the peer‐led Chronic Disease Self‐Management Program (CDSMP) is a seven week, 17‐hour, small group intervention for people with different chronic conditions. The program emphasizes problem solving, decision making and confidence building. A one‐year outcomes study found a 0.97 day reduction in hospitalization, and 0.2 fewer ED visits and fewer outpatient visits. There were also statistically significant improvements in seven of nine health status measures, including illness intrusiveness and pain.4 One site found that simply sending a pre‐planning letter reminding patients to get recommended lab work and bring all medications and current blood sugar and blood pressure readings added significantly to the efficiency of office visits.5 Shared graphed patient registry reports are now posted on patient refrigerators and even taken to ophthalmologist visits. Providers find that these “reports appear to engender a sense of personal responsibility. They [patients] now arrive at their diabetes visit with the anticipatory question, ‘What’s my latest A1c?’” Results include improved process (percentage of patients taking aspirin and receiving nephrology and eye screening) and outcome measures (e.g., percentage of patients with blood pressure, A1c and LDL). Physicians report that the effort has made life easier and that they “wouldn’t go back” to the old way. 6 The natural combination of self‐management activities with planned visits is likely to yield more complex visits than a hit‐or‐miss approach to completing needed prevention, advice and monitoring during acute care visits.

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Table 2. Results of Group Visit Self‐ Management Program Outcome Group visits (CHCC) 2 years later ADL Loss

‐58%

Satisfaction Hospitalizations

+8% ‐19%

While no comprehensive studies exist to date, it’s reasonable to assume that such visits could be legitimately billed at higher rates. A review of results from a group visit self‐management program found reduced Activity of Daily Living (ADL) loss and increased satisfaction in the group visit participants. See also Table 2 Results of a Group Visit Self‐Management Program.

Self‐management support is a key component of the Chronic Care Model, which has been shown to improve care and outcomes for Source: Holman, H., Lorig, K., A. (2004, patients with chronic illness. See also: http://improvingchronic‐ May/June) Patient Self‐Management: A Key To care.org/change/model/components.html. Effectiveness and Efficiency in Care of Chronic Disease. Public Health Reports. (118) 239‐243.

For a free, downloadable video providing excellent training for providers, visit the California Healthcare Foundation’s Web site for a session with noted diabetes expert, Bill Polonksy, PhD, CDE. While Medicare covers some types of diabetes self‐management training, individuals or entities must meet several conditions and the beneficiary receiving the training must also qualify. For more information, go to www.aafp.org/fpm/20010400/14bill.html. For resources on patient self‐management, including group visits, please visit the Academy’s recently updated New Directions in Diabetes Care Resource Center. In particular, you will find information on how to properly code for group visits, an action plan development guide, and a sample diabetes progress report that you can use with your patients. The demands of caring for patients with chronic illness generate a significant workload for physicians and staff. Why not consider patients as members of your care team to improve outcomes and satisfaction?

1 Norris, S.L., Engelgau, M.M., Narayan, K.M. (2001, March). Effectiveness of Self Management Training in Type 2 Diabetes: A Systematic Review of Randomized Trials, Diabetes Care. 24(3):561‐87. 2 Bodenheimer T, Lorig K, Holman H, Grumbach K. (2002, November). Patient Self‐Management of Chronic Disease in Primary Care. JAMA. 288(19):2469‐75. 3 Funnell, M. M., (2000, March). Helping Patients Take Control of Their Chronic Illnesses, Family Practice Management, Vol. 7, No. 3, pages 47‐51. 4 Lorig, K.R., Sobel, D. S., Ritter, P.L., Laurent, D., Hobbs, M., (2001, November‐December). Effect of a Self Management Program on Patients With Chronic Disease. Effective Clinical Practice, 4, 256‐262. 5 Mohler, P.J., Mohler, N.B., Improving Chronic Illness Care: Lessons Learned in a Private Practice. (2005, November‐December) Family Practice Management.10, 50‐56. 6 Ibid.

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Mapping Your Way to Leaner Workflows Sue Houck

February 2009

We define workflows as the individual processes (e.g., office visits, refills, scheduling) that collectively get the job done and create value for patients. The process of workflow mapping can help you and your staff visualize the sequence of steps involved in each workflow function. Mapping is valuable for a number of reasons, including evaluating whether a process can be optimized to decrease non‐value added time spent doing routine office functions and clinical activities. Metrics, such as the time it takes to complete a given process, will help you assign values to compare effectiveness. In addition, mapping can also identify opportunities to reduce unnecessary variation in how work is completed, for example, relying on so many different types of patient visits that scheduling and rescheduling take far more time than necessary with little added value. Mapping Tools A variety of tools can be used for mapping, including flow charts, spaghetti diagrams, and value stream mapping. Originally developed for information technology projects, flow charts utilize shapes (e.g., rectangles, diamonds, arrows) to identify the sequence of all activities for a given process. Spaghetti diagrams use free‐form lines to visualize movement and activities of individuals (e.g., providers, patients) as well as use of objects (e.g., flow sheets). A simple hand or computer‐generated drawing can be used. So‐called lean management strategies utilize value stream mapping to compare current state against ideal workflows. While similar to flow charting, value stream mapping can also be used as a foundation for fixing bro‐ ken processes. Value stream mapping is easy and requires minimal training. Using value stream mapping and spaghetti diagrams in the process of renovating their office, one group found physicians were traveling up to 48 steps multiple times each day to reach exam rooms from their offices. After lengthy discussions over a number of months, providers decided to move into a common area surrounded by exam rooms. The result? Better access to staff and less messaging. The group also enjoyed more collegial discussions about treatment strategies. This is not to say moving office space and making radical shifts are the only ways that value stream mapping can be useful. Start small and see if you and your team can identify a change that would reduce unnecessary actions or activities. To get started, consider asking everyone in your office to submit a list of the top three workflow processes they find cumbersome and a brief explanation of why. If you see an item that's mentioned on more than one list, consider inviting each person involved in that process to participate in a value stream mapping exercise during lunch or after a staff meeting. Lean thinking has enabled Toyota and others to significantly improve manufacturing workflows and reduce errors. The concepts are being utilized increasingly in health care to improve efficiency and access to care, including offering patients same‐day appointments. Central to the lean concept is identifying and eliminating waste (e.g., interruptions, waiting) so that value (care) flows continuously throughout a process. Primary processes are those that serve external customers (patients); internal processes serve internal customers (e.g., staff and physicians). Processes that create value are those for which an external customer would be willing to pay a fee. A perfect process: 1) creates value for those experiencing it; 2) is easy to manage; and 3) is satisfying for staff to perform.1 Where to Start Using index cards or Post‐it notes, identify each step for a given process in the sequence that it occurs. Getting your staff to complete this activity builds teamwork and ensures that every step is noted. It can also help to physically walk through each step in a process. To create a value stream map, line up activities from left to right; be sure to jot the amount of time it takes to complete each step of the activity. 72

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One practice used value stream mapping to help them visualize potential changes they could consider as they tried to improve the patient‐centered focus of their practice. Figure 1 shows a current state value stream map of activities completed during a typical office visit. Time spent on each activity is noted in parentheses with totals at the top of each column. The site identified 16 patient activities during an office visit. In addition, 24 of the 69.5 minutes of patient time on site was spent waiting, clearly an activity that does not add value. Figure 2 is a spaghetti diagram of their current state value stream.

What do patients value during an office visit? An article in Family Medicine indicates patients are most satisfied with visits in which they “talk about their specific treatment, are examined, and receive health education. Patients view time spent on history taking negatively.”2 Replacing some of the time (six minutes) spent taking a patient’s history (items 6 and 9 in Figure 1) with time discussing their needs could result in increased patient satisfaction. After each step is mapped, briefly note problems related to it in a separate process box. Figure 3 shows a process box for an office visit check‐in. A practice used this opportunity to identify the average time to complete a process and so‐called lead time (i.e., the total time to complete a step, including wait times). Once common problems are identified and visually sequenced, priorities can be set on when and how to solve them. Problems with check‐in at this site included provider complaints regarding waits and Internet connection downtime. In addition, registration forms weren’t well designed; the form included three different demographic data requests. Workflow Activity Activity #2. Front desk checks in patient and collects co‐pay. n

Providers complain check‐in delays keep them waiting. n Patient age and address data collected multiple times on forms. n No Internet access 1 hour, Tuesday and Wednesday Process time = 6 minutes Leads time = 15 minutes CALIFORNIA ACADEMY OF FAMILY PHYSICIANS

Perfect state value stream maps answer this question: what needs to change in the next 12 to 18 months for this process to be perfect, and deliver high value to the customer? The perfect state value stream map (Figure 4) and spaghetti diagram (Figure 5) show reductions in the steps taken to complete a visit (from 16 steps to nine steps). The practice set a goal of reducing non‐value added wait time from 45 minutes or more. They identified several ways to accomplish this: 1) helping patients make online appointments; 2) take vital signs and check patient in the exam room to reduce travel time; and 3) have patients check‐in and provide history information at electronic kiosks to free‐up staff time and allow the provider to focus on other patient information during the visit, such as discussing treatment options.

While some may contend patients would not value completing visit activities usually done by staff, the opposite is likely the case. Winning the Service Game by Schneider and Bowen describes how consumer involvement in service delivery can actually enhance satisfaction. “Perhaps the thought of making customers serve themselves seems out of step with these times in which businesses are constantly chided to pamper and delight their customers. Yet customers can obtain delight from serving themselves if it provides them with a greater sense of control over the service production process.” 3 Improved processes that have an “owner” who takes responsibility for knowing and monitoring it are more likely to be sustained over time. An owner should be someone who has familiarity with a process in the course of his or her daily work. Keep in mind the examples in this article may not represent the changes that would work in your office. The important part of this exercise is to bring your staff together to discuss changes that everyone agrees would add value and increase the satisfaction of office staff and your patients’ experience. Work flow mapping provides a practical way to visualize processes and guide desired change. But mapping and subsequent process improvement is not sustainable if physicians and staff don’t believe in it. Make sure there’s enough motivation and buy‐in from those who will need to make the change happen. Finally, be sure site leadership is committed to take needed action for as long as it takes so improvement can be achieved. 1 Getting Lean in Health Care Edited by Diane Miller, Institute for Healthcare Improvement, Innovation Series, 2005. p.5. 2 Robbins, J.A., Bertakis, K.D., Helms, L.J., Azri, R., Callahan, E.J., Creten, D.A. (1993, January).The influence of physician practice behaviors on patient satisfaction. Family Medicine, 25(1):17‐20. 3 Schneider, B., & Bowen, D. (1995). Winning the Service Game. Boston, MA: Harvard Business School Press. 74

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Strategies to Improve Access and Make Office Visits More Patient‐Centered Sue Houck

August 2009

The Patient Centered Medical Home (PCMH) model appropriately emphasizes the importance of improving patient access and patient experience. In addition to activities such as group and electronic visits that leverage physician office resources, there are strategies to improve office visit access once patients arrive by streamlining patient workflows. Many family physician offices are so busy that meeting the current patient demand may be the top priority. Taking time to measure non‐clinical activities, then meeting with your staff to make a plan for improvement, may fall so low on the list that it’s never done. Despite all this, it’s probable the practices that cause bottlenecks and delays in your office are the same as those that limit access and adversely affect patient satisfaction. The good news is while taking steps to improve workflow can take extra time at the outset, they can also improve revenue and your patients’ experiences as they move through the different steps in an office visit. For example, on a recent site visit, we found physicians at a southern California group wringing their hands in frustration about a longstanding problem; patient check‐in lines that stretched out the door. But it wasn’t just the patients waiting. Physicians also found themselves with time they could not fill productively because their schedules were not coordinated with those of the staff and patients. Automating, delegating and even removing steps that don't add value can eliminate office visit delays that reduce physician‐patient time. Identify Value vs. Non‐Value Activities We’ve identified eight steps typically required of patients for office visits. These include: n Make phone call for appointment n Check in upon arrival n Report vitals and history n Wait to be seen by provider n Undergo physical examination by provider n Discuss diagnosis n Receive relevant health education n Check out upon visit completion Patients report that three key activities actually create value for them during office visits: being examined by their provider, discussing their diagnosis and receiving health education.1 Surprisingly, detailed history taking is not perceived as adding value. Delays associated with non‐valued activities, such as waiting to check in, extend overall visit time, leading to frustrated patients and reduced physician productivity. Streamline or Remove Non‐Value Activities Why not delegate, automate or even remove activities that don't generate value? Except for patient wait time, most activities that patients don't value can't be removed. Some practices have moved to automate certain activities, such as online appointment systems, check‐in, and history taking. In addition, patients who choose to participate complete the data entry for these activities, saving staff time and expense. See Table 1, next page. Online Appointment Scheduling With costs beginning at $50 per month, Web‐based appointment software can remove barriers and facilitate scheduling. You choose whether to allocate all or only a small portion of available appointment slots. Scheduling can be customized according to type and length of visit. Pediatrician Herbert Bravo said he'd have to hire at least two more staffers without his online appointment system. 2 After checking out practices using the soft‐ CALIFORNIA ACADEMY OF FAMILY PHYSICIANS

Table 1. Automate, Delegate, or Remove Non‐Value Activities; Maximize Value‐Added Activities 1. Make appointment 2. Check in 3. Vital signs and history 4. Wait 5. Undergo examination 6. Discuss diagnosis 7. Receive health education 8. Check out

No Automate and delegate to patients

Yes

Automate and delegate (some) history taking to patients Remove with streamlined workflows Maximize time and resources here

Minimize waits with streamlined workflows

ware and taking advantage of a free trial, a group with which we worked in Maryland implemented online appointments and found the process reduced no‐shows. Family nurse practitioner Carla Gibson found: “So far, patients absolutely LOVE the scheduler ... one month in, 80‐percent‐plus are using it. I love it as well ... patients describe why they want an appointment in much better detail ... they choose EXACTLY the right time block for their visits 99.99 percent of the time! ... and many of them will “wrap up” their own visits ... One more example of eliminating barriers resulting in more efficient and satisfying care for patient and provider.” 3 While some may raise concerns about conforming to patient privacy protections in the Health Insurance Portability and Accountability Act (HIPAA), violations are avoided because patients see only available appointment times, not other patients' names. If you already use an electronic health record (EHR), a number of systems include online appointment modules. Other online appointment vendors include: n www.appointmentquest.com n wwww.web‐appointments.com n www.eppointments.com Some services require a software interface and others require only a link to your practice website. Automated Medical History Automated medical histories can also be completed by patients at a waiting area kiosk or from home using the Internet. They’re HIPAA compliant and can be customized for individual practices. Costs begin at $50 per month depending on the vendor and plan selected. After observing that her level of detail in history taking often waned later in the day, a family physician in solo practice with whom we worked found that documentation thoroughness and consistency increased once automated. In addition, the increased level of detail enabled her to code at a higher level for some visits. Consider the following practice example: n 18 patients per day are seen n Average history taking time of four minutes n Average visit slot of 20 minutes Assuming you take an additional minute to wrap up an automated history, by implementing the new software you would still have freed up three minutes per appointment. This translates to 54 minutes per day. This amount of time would allow 2.7 additional 20 minute visits per day. Assuming $100 net revenue per visit, you could increase revenues by $270 per day, and $59,400 per year, assuming 220 work days a year. Given that many family physicians see far more than 18 patients per day, the effect of automation would be even more 76

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Assuming you take an additional minute to wrap up an automated history, by implementing the new software you would still have freed up three minutes per appointment. This translates to 54 minutes per day. This amount of time would allow 2.7 additional 20 minute visits per day. Assuming $100 net revenue per visit, you could increase revenues by $270 per day, and $59,400 per year, assuming 220 work days a year. Given that many family physicians see far more than 18 patients per day, the effect of automation would be even more significant. If you’re interested in more information, the following vendors offer such software: n www.Medicalnetsystems.com n www.Medicalhistory.com n www.Medisolve.ca Automated Check‐In While currently used more by larger medical groups and hospitals, automated check‐in kiosks are HIPAA‐ compliant, reduce paperwork and allow for co‐pays. How much does check‐in cost you per patient now? If your compensation costs for a front desk staffer total $35,000 per year and a .3 FTE is required to complete all patient check‐ins, your annual costs would total $11,550. Kiosk costs vary, but begin as low as $50 per year. Recent California HealthCare Foundation research found that 90 percent of Kaiser members were able to use kiosks without assistance, and 75 percent believe checking in via kiosk was faster than via receptionist.4 Kiosks also had a higher co‐pay collection rate than that of the average staffer. We studied three family medicine practices that automated certain tasks. Documenting baseline data on appointment completion costs and patient histories before and after automation, we found that automation was cost‐effective. In addition, if you decide to use kiosks, designate a staff member to greet and assist patients for the first month or more if you think it would be useful. You should also provide an alternative for patients who are not comfortable with this technology. Before you implement, consider how your office staff will work together on a plan to implement. It's important to get input from each member of your team who would be involved in this change. Each of your team members is an expert on their respective workflow segments, but may not know all the details of others' on the team. You might also consider inviting several of your patients to provide feedback; given that one of your ultimate goals is to improve their satisfaction, it can be helpful to get their input into the process. And finally, consider how you will evaluate the effectiveness of any changes. Do you already measure patient experience or patient satisfaction? Does your IPA or medical group have these data? Do you already have meas‐ ures of patient cycle time to use as a baseline? Knowing the specific measures that you would like to improve will help you determine if a change actually results in improvement. Automated check‐in vendors include: n www.Phreesia.com n www.Mckesson.com A Word about Waits While neither staff nor patients value waiting during office visits, it is an unhappy reality for most practices. General strategies to reduce waits include standardizing high volume staff tasks such as rooming, and synchro‐ nizing activities such as appointment times so they mean the same for everyone (e.g., a 9:00 am appointment time means when the physician enters the exam room, not when a patient checks‐in). See also the March edi‐ tion of Practice Management News for resources on how to map your way to leaner workflows. Conclusion Automate, delegate and even remove tasks patients don't value during visits. Patients comfortable with self‐ service and appreciative of privacy and convenience may welcome these innovations. Meshing improvement strategies to enable activities patients do value also increases satisfaction and controls costs. CALIFORNIA ACADEMY OF FAMILY PHYSICIANS

1 Robbins, J.A., Bertakis, K.D., Helms, L.J., et al. (1993, January). The Influence of Physician Practice Behaviors On Patient Satisfaction. Family Medicine. 25(1):17‐20. 2 Medical Economics. (2006). Let Patients Book Their Own Appointments?http://medicaleconomics.modernmedicine.com/memag/arti‐ cle/articleDetail.jsp?id=329097&pageID=1&sk=&date=. Retrieved July 19, 2009. 3 Ideal Medical Practice. Appointment Software. (2008).http://idealhealth.wikispaces.com/Appointment+software. Retrieved July 20, 2009. 4 Rhoads, J., Drazen, E. (2009). Touchscreen Check‐in Kiosks Speed HospitalRegistration. Oakland: California HealthCare Foundation.

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Staffing Issues Making Staff Meetings Work The Value of Teams Hiring and Training Medical Assistants

December 2006 July 2007 January 2008

Making Staff Meetings Work Sue Houck

December 2006

Physicians and staff who are busy seeing many patients a day find it hard to carve out time from patient care for regular staff meetings. But being busy may not equate with being effective. In addition, staff meetings pro‐ vide time for collective input into issues facing your practice. Individual versus collective attempts to fix a prob‐ lem can have unintended negative consequences for others who are part of the process being changed. For example, a physician in Oregon found that implementing his criteria regarding when physical appointments could be made increased patient wait times, confused appointment staff, and increased interruptions during office visits with requests from staff to clarify or waive the rules. Meeting with staff before implementing the change might have identified these potential problems before the changes went into effect. Why have Staff Meetings Ask yourself the following questions about your practice: n Do discussion and needed action regarding ongoing issues get postponed again and again? n Do some staff complain about being “out of the loop” regarding decisions? n Could discussion about issues benefit from a variety of experience and points of view? Staff meetings enable you to solve problems as a group, building teamwork and shared learning. In addition, discussing issues, taking action, and being accountable for results can energize staff and reduce burn‐out. In fact, Roger, Shenkel, MD, of Primary Care Partners has found, “a well run meeting is a thing of beauty and a highly effective management tool.”1 Format To optimize their usefulness, make every minute count at staff meetings. Avoid using the time to make minor announcements. To inform staff about a new copier, use e‐mail or memos, not meeting time. Once an issue is identified and discussed, solution ideas can be generated, and decisions made as a group regarding what actions to take. Finally, actions and due dates are assigned to staff. (See Table 1) For complex or detailed issues that take up a lot of meeting time, form a small sub‐group of individuals to consider alternatives and recom‐ mend solutions to the rest of the staff within a set period of time. Table 1. Staff Meeting Format Consider automating some decision making, 1. Identify and discuss issue once discussion is 2. Generate solution ideas complete. Want to 3. Decide on needed action/s survey staff regarding a 4. Assign actions and due dates final selection of equipment or even an EHR, but dread taking up more staff meeting time? With surveymonkey.com or zoomerang.com, or any other survey software program, you can easily design surveys of up to 10 questions and get up to 100 responses for free. A questionnaire regarding EHR training took me less than forty minutes to develop. Once your survey is done, simply e‐mail staff a link to complete the survey, thus freeing up hours of your time as well as staff meeting time. This also allows staff to answer anonymously, which might provide further insight into a problem or issue facing your office.

Planning and Ground Rules To stay on time, agree to no interruptions except for emergencies. Include snacks if it won’t break the budget and include an agenda for each meeting. Office visits that run overtime are more likely to result in physician 80

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and staff being late to noon meetings, so I recommend morning meetings. To protect family time, avoid staff meetings at the end of the day. Limit meeting duration to no more than one hour. Meeting frequency varies from once a week to once a month, depending on the volume and complexity of issues requiring attention. Groups undergoing major change such as implementing an electronic health record may need to meet weekly; if issues needing group input are few, meetings can occur biweekly or even monthly. It’s a good idea to establish ground rules at the first few meetings. These may include agreements about being on time, respecting others input and avoiding side conversations. Including established ground rules on the meeting agenda and status report form serves as an ongoing reminder to participants. (See Table 2, next page.) Staff Meeting Status and Agenda Template.) One of CAFP’s New Directions in Diabetes Care collaboratory practices uses a very simple agenda that includes the following items: old business; new business; pet peeves; and, opportunities for excellence. The only caveat is to be sure that “pet peeves” include system issues, like problems with office equipment, rather than personality issues. Have a “scribe” briefly document issues, key discussion points and decisions, as well as actions to be taken by whom. Report status and update activities during each meeting. Be sure someone takes responsibility and that the group agrees to a due date for each action item. The scribe function and meeting leader can be rotated among attendees. Facilitation Matters Effective facilitation greases the wheels for successful staff meetings. Activities include reviewing the agenda and making sure the meeting begins and ends on time. In addition, to make sure sufficient time is spent on them, the facilitator should put discussion of controversial issues in the middle not at the end of meetings. Waiting for tardy attendees penalizes those who are punctual, so be sure to start and end on time. If a significant number of staff or physicians can’t attend, it’s better to cancel. To counteract so‐called dominators, solicit input from other participants with comments such as, “let’s hear from someone who hasn’t spoken yet.” If a participant regularly creates problems, speak with him or her in private about the issues. In addition, avoid any discussion regarding the job performance of staff members at staff meetings. A common cause of meeting burnout is too much discussion. Facilitators must strike a balance between details and general discussion and set limits to avoid rambling. Make sure everyone has had a chance to contribute and then firmly focus on solutions and action. Initially a manager or physician may assume the role of facilitator; however, after meetings are established and running smoothly, it’s a good idea to rotate facilitation responsibilities among staff. Many organizations involved in improvement work highly recommend that staff take turns serving as the meeting facilitator, rather than physicians. This helps to reinforce the notion that staff input matters. A common problem at meetings is that some staff defer to physicians, impeding frank sharing and resolution of problems. In directing group meetings at Dana‐Farber Cancer Institute in Boston, Charles Borden has found that, “the more level the playing field, the better the participation and results. So, one of the ground rules that gets set is ‘leave all hats at the door.’ Everyone’s knowledge is critical in analyzing problems as well as in designing solutions that work.” 2 Candid discussion also helps to prevent “us versus them” attitudes even in a small group. Conclusion Carving out time to meet as a group, to have concerns heard and participate in solutions, sends a message that staff input is valued, even in a small practice. In addition, focused dialogue and shared accountability can pro‐ duce more robust solutions than solo efforts to resolve common issues. Over time, the synergy and common purpose of well‐run meetings can create an effective force for smooth operations. CALIFORNIA ACADEMY OF FAMILY PHYSICIANS

Table 2.

Staff Meeting Status and Agenda Template

Our Ground Rules

1. Genuinely listen to what others have to say 2. Avoid side conversations and interruptions 3. Show respect for others by being on time

Issue and Discussion 1. There’s frequently a lack of complete information regard‐ ing assessment and treat‐ ment of patients referred to specialists. Calling to com‐ plete information causes delays and frustration for physicians, staff and patients.

Summary Develop a simple form to accompany referrals for spe‐ cialists to complete and return.

Decisions 1. Dr. Nevus will develop a form and have Dr. Sanchez and staff review before 11/20. 2. MAs Robin and Lynn will test out the new form by using it with two different types of specialist physicians with referrals on 12/4 3. At the next staff meeting, we will discuss if any revi‐ sions need to be made. 4. Once made, nurse Anne will discuss how to incorpo‐ rate form into EHR with EHR planning group on 12/15

Action Status 1. Completed 11/19 2. Pending 3. Pending

2. Some staff are consistently late for staff meetings. Starting late penalizes those who are on time.

Tardy staff will put 50 cents for every minute late in a “snack jar”. Money will be used to buy snacks for staff meetings.

1. Clerk Anne Franklin will collect, communicate amounts collected, and use for snacks beginning 11/15

1. Completed 11/15 ongoing

3. The refill process takes up to two days and involves many steps. One local prac‐ tice uses nurse protocols to streamline the process.

Need to itemize steps in refill 1. Anne will itemize steps in 1. Completed 11/10 2. Pending process and identify ways to refill process by 11/10 streamline. 2. Dr. Francisco and MA Robin will review and identify potential ways to streamline and report back by 12/1

4. Patient allergies are recorded in several locations in the chart. Recording the same information more than once is rework and increases the likelihood for error if not current in all locations.

Need to select and use only one location to record aller‐ gies, e.g. problem list.

1. MA Robin will identify where allergies are now recorded, seek input regard‐ ing one place to record, and report back by 12/5. 2. Physicians will decide when to begin recording in one place. After testing the use of the new recording

1. Pending 2. Pending

New agenda items 1. Demographic data, e.g., patient phone numbers, are not current in some charts 2. Patients are asked to bring superbills to front desk after visits and sometimes they don’t get there. 1 Shenkel, R. (2003) How to make your meetings more productive. Family Practice Management, Vol. 10, No. 7, 59‐60. 2 Silversin, J., Kornacki, M.J., (2000). Leading Physicians Through Change. Tampa, Florida: American College of Physician Executives.

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The Value of Teams Sue Houck

July 2007

A health care team could be described as “a group with a specific task or tasks, the accomplishment of which requires the interdependent and collaborative efforts of its members.” 1 Teams can play a central role in your office, particularly when undertaking quality improvement efforts. In effective teams, each member understands his or her role and is appropriately trained to carry out that role. When thinking about who should be included on your team, consider the size that would make your team most effective and determine who the key players are. Key players would be those who are either directly involved in the patient encounter or who have a significant impact on the delivery of care to your patients and the patient’s experience. The most likely candidates for your team include your medical assistant or other clinical support staff, and front office staff where appropriate. Developing a Team — Where to Begin While challenging to develop, the benefits of highly functioning formalized teams are many. Findings at a Kaiser Permanente site found that teams with greater collaboration, delegation of tasks and patient familiarity had greater patient satisfaction as well as improved quality measures for diabetes and asthma care.2 Another study found fewer hospitalizations and surgeries, and more visits for health supervision among providers who worked in care teams.3 When developing your team, consider the following4: n Define the goal of your team — does your team have a mission and objectives as to what you want to accomplish? Is there a way to measure this? n What are the office systems that affect your team? Do you have a patient registry that can support your team’s activities? What are the capabilities of your practice management system? Do your systems support your team’s objectives, and if not, how can they be modified? Or, do your objectives take these limitations into consideration? n What is the division of labor among team members? Does each team member know his or her role? Are the tasks (both for the team and for the individual) clear? Is there a need to shift roles and responsibilities of team members both to offload physician responsibilities and to allow each member of the team to practice to the limit of his or her licensure? n What training can help support your team? This training can be formal or informal. n Communication — what are the primary methods for team communication? Do you have team meetings? Do you have a predictable way for team members to communicate? Make Time for Your Team Among the challenges in developing truly effective teams is finding protected time to meet as a group (often done at lunch to avoid loss of revenue) as well as strong leadership and clear work roles. You may find yourself wondering when you’ll even have time to meet and whether it is worth it, given all the other things you have to accomplish in any given day. But experts in quality improvement advise that you don’t have the time not to meet. They say that regular team meetings are so important that making time is essential; team meetings can also reduce time spent in non‐value‐added activities, such as looking for lab results, waiting for patients to take off their shoes and socks so you can conduct foot exams, and other activities. In addition, since the typical medical practice has physicians making most decisions, offering your team members a chance to participate in decision making and express their thoughts can improve their productivity and satisfaction. You may also hear ideas that will improve your office — ideas that would not have been voiced without a platform to do so. CALIFORNIA ACADEMY OF FAMILY PHYSICIANS

Dr. Charlie Burger in Bangor, Maine has spent many years perfecting systems for team development, from formalized training to standardized communications, to prominent posting of the latest team improvement metrics on a data wall. Productivity is high — each provider (two physicians and a nurse practitioner) sees approximately 25 patients each day. Even those staffing the phones perform at a high level, using robust electronic algorithms to screen patients. Some CAFP members have also developed such a data wall, posting it in a break room or kitchen, to excellent effect. Observing and working with hundreds of practices nationwide, several elements of high functioning teams are clear: these teams communicate frequently, often minute‐to‐minute, with a high degree of mutual trust, respect and appreciation. Encouraging staff and physicians to use first names during team meetings helps level the playing field among physicians and staff, promoting collaboration versus top‐down relationships. Delegating Improves the Bottom Line A higher level of functioning for team members and delegating can also positively affect the bottom line. For example, assume the average revenue per office visit is $90. Assume also that you spend four minutes or 20 percent of your time during a visit documenting the patient history. If you could delegate that function to an appropriately trained team member, you would save four minutes or $18 per visit. If you average 4,000 encounters per year, you would save $74,000 — an amount that would more than pay for additional support staff to perform that function. This is just one example; other activities, such as having your medical assistant perform foot exams on your patients with diabetes, can also be an outgrowth of your successful team. The increasing demands of chronic illness care make delegating some of the work to team members imperative. You know — and we know — that you can’t do it all. And the research supports this. For example, it takes an estimated 3.5 hours a day or 825 hours per year to provide care as advised in national guidelines for well‐controlled patients with the top 10 chronic diseases (with a panel of 2,500 patients). Time demands more than triple when requirements for uncontrolled disease are factored in.5 Standardized, robust work processes that enable effective teamwork ensure the right information and people are in the right place at the right time. Risk is also reduced since most errors are caused by missing or overlooked information. Plan Your Day’s Workflow Beyond regular team meetings, huddles are another way to ensure smooth communication among your team members. Huddles also have the advantage of being much shorter than a team meeting. A huddle provides a simple, regular structure for teams to build cohesiveness while improving care. Usually conducted in the morn‐ ing for 5‐10 minutes, every team member can contribute to planning the day’s workflow while reviewing the schedule. For example, the medical assistant can look for potential bottlenecks in the schedule, e.g., two high‐ needs patients back to back. He or she can also set up procedures, do chart prep and request outstanding labs and reports. The nurse can look for patients who could have nurse visits and identify potential slots for double booking if needed. The physician can review his or her list of scheduled patients, help the nurse and MA plan flow and anticipate patient needs. Physician team members can also request needed lab, procedure, or emer‐ gency department reports and let staff know of any potential for double‐booking. Do Patients Belong on Your Team? Don’t underestimate the potential of patient self‐management. A recent study found that type 2 diabetes patients taught to titrate their own insulin dose may equal or exceed the results that physicians achieve.6 Why not think outside the box in sharing clinical information with patients? Dr. Charlie Burger provides every patient with a copy of his or her visit note. The notes are also written in a more friendly tone, using the second (you) versus third (he or she) person to engage patients.

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Centralize Your Office’s Strengths Tired of feeling overworked and inefficient, Dr. Christine Sinsky of the Medical Associates Clinic in Dubuque, Iowa decided to redesign her operations with a strong care team at the center. Working with two nurses, visits are planned before Dr. Sinsky enters the room. A standardized worksheet facilitates the visit and dictation. Nurses do the initial review of labs with patients, initiating symptom‐driven tests, completing foot checks and eye exam referrals for patients with diabetes. The nurse then “presents” a given patient to Dr. Sinsky who says, “I make decisions about treatment and the nurse operationalizes them. Nurses are the nexus of the organization at the practice.” As a result, Dr. Sinsky is able to minimize the work that physicians do that is within the skill set of other team members. This ensures that all staff members are performing up to the level that their licenses allow. Nurses prefer the higher level of functioning, and Dr. Sinsky is free to do medical decision making and relationship building, not information mining. Productivity is up significantly, with an average of 25 patients seen within five hours. Relevant articles and x‐rays are shared with the nurses, and a strong sense of collegiality prevails at the site. Build a Better Team; Create a Better Outcome Effective teamwork in a practice enables coherent versus haphazard adjustments to variations in workflow throughout the day. While a willingness to get along at work may promote some level of unstructured teamwork, teams built intentionally around interdependence and collaboration can improve patient care, outcomes and job satisfaction.

1 Wise H, Beckhard R, Rubin I, et al. (1974). Making Health Teams Work. Cambridge, MA: Ballinger Publishing Co.. 2 Roblin DW, Kaplan SH, Greenfield S, et al. (June 23‐25, 2002). Collaborative clinical culture and primary care outcomes. In: program and abstracts of the annual meeting of the Academy for Health Services Research and Quality: Washington, DC,. 3 Jones RVH: Teamworking in primary care: How do we know about it? Journal of Interprof. Care. 1992;48:107‐117. 4 Adapted from a June 22, 2007 presentation given by Kevin Grumbach to CAFP’s New Directions in Diabetes Care teams. 5 Ostbye T, Yarnall K, Krause K, Pollack K, Gradison M. Is there time for management of chronic diseases in primary care? Annals of Family Medicine. May/June 2005; 8:3: 209‐14. 6 Meneghini L, et al. (2007). Efficacy and safety of insulin determine in a large cohort of patients with Type 2 diabetes using a simplified self‐adjusted dosing guideline: Results of the predictive 303 study. American Diabetes Association meeting: Abstract 197‐OR.

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Hiring and Training Medical Assistants Sue Houck

January 2008

We’ve all been there. An efficient, hard working medical assistant (MA) who’s a great team player decides to move out of town and submits his or her two‐week notice. Almost immediately the time‐consuming scramble to recruit a replacement begins. From recruiting to training, why not develop a systematic approach that’s also imbued with the values of your practice? You’ll save time and increase the likelihood of hiring candidates who are a good match. Steps include: clearly differentiating your practice among applicants, effective screening, building employee motivators into the job, and standardized training. Clearly Define and Communicate Who You Are First, be sure you’ve identified and can communicate specific characteristics that define your practice. Why? A clear identity will help you stand out in a look‐alike market among prospective applicants. In addition, applicants who are not a good match can self‐select out of the application process, saving you time and resources. Specific characteristics might include a high rating among consumer groups, guaranteed same‐day patient access, staff longevity (a practice in Maine has an average staff tenure of nine years; a site in Colorado has staff regularly return after leaving to work elsewhere), an effective team that meets regularly, an electronic medical record, NCQA certification, working with the same provider vs. floating, permission to test out new ideas, academic affiliation or active self‐management programs, such as group visits. Screen Effectively and Save Time Make the best use of time with effective screening techniques. One site on the East coast videotaped daily MA activities. The video communicated practice values via brief interviews with leadership and staff using a question‐and‐answer format. Enabling candidates to get a real‐world sense of what it’s like to work at your practice helps identify those who are more likely to be a good fit as well as those who aren’t. Save time by faxing or e‐mailing a basic application, or even posting one for download from your website. A sample generic application form is available at http://medicaleconomics.modernmedicine.com/memag/data/articlestandard/memag/332004/113350/article.p df. 1 For candidates who “pass muster” with your generic application, pose questions to probe deeper into an applicant’s values and experience (e.g., perceived challenges of a job and hallmarks of a successful practice). See Table 1 for an interview questionnaire. Remember to avoid questions about age, national origin, marital status, and whether a candidate has children. When someone looks like a good fit, be sure to get permission to contact their previous employers. A so‐called “always and everywhere” hiring mentality helps build an ongoing list of potential candidates. Remember, like attracts like, i.e., friends and colleagues of outstanding staff may also be excellent employees. Interview good candidates regardless of your current need. This can help you to prepare for the inevitable challenges of quickly filling a position. In addition, team interviews, where one or more candidates are interviewed by several staff members, can save time. Team interviews also provide a context for observing how candidates interact in a group setting. Finally, while more costly, using a temp agency provides hands‐on experience for both the applicant and the practice to see if there’s a good match before committing to permanent employment. What Employees Want What helps attract and retain employees? First, make sure that your MA pay scales are within the average range for similar jobs in your community. In addition, studies by the Families and Work Institute find that 86

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flexibility is critical. They’ve found flexibility to be just as important as challenging and meaningful work, learning opportunities, job autonomy, input into management decision‐making and supervisor and coworker support for job success. In fact, flexibility to manage home and work responsibilities was found to be more valued by employees than money and advancement. Finally, employees in effective and flexible workplaces are more likely to be engaged in helping their organizations succeed, more likely to be satisfied with their jobs, more likely to stay with their employer and more likely to be in better mental health.2 Ad Advice When placing an ad, avoid overused terms like “great location,” “great working conditions” or “friendly work environment.” Do include work hours and days, including weekends if required, as well as location, specialty, whether experience is required or preferred, and if the job is a career opportunity. With the exception of excluding salary and benefits information, be specific. Let potential applicants know if you’re willing to be flexible regarding work and home responsibilities, such as job sharing. In addition to local newspapers, post openings on Monster www.monster.com or Absolutely Health Care www.healthjobsusa.com to spread your reach to prospective applicants. Systematize Training To systematize MA training, first review and compare current job descriptions with how staff actually does the work. Are there significant inconsistencies (e.g., refill process responsibilities) that have changed or been removed since EMR implementation? If so, be sure to update current job descriptions. Build institutional knowledge by developing systematic training that sets standards and clearly explains how to do high volume processes. These can include: n Codified rooming protocols; n Flow sheets for patients with chronic illness; and n Standing orders. Standardizing these processes can reduce the potential for error, provider interruptions, delays and frustration. Decide how many times a new MA must be able to do a given activity (e.g., rooming patients, referrals, diabetic foot exams) before he or she is “certified.” Cross‐training staff enables staff to quickly adapt to changes in workflow. For example, an MA who also knows how to greet and register patients can help with check‐in as well as rooming if providers are waiting. Use regular staff meetings to celebrate and reinforce progress regarding training milestones. Counteract the frequent complaint about lack of career opportunities in medical office jobs by incorporating redesign concepts into training and job design. Build in permission to question and even change the status quo via small tests of change. Why? Encouraging redesign creates a sense of possibility. Examples include encouraging staff to try new ideas and look for ways to delete, delegate or automate steps in a given work process. MAs at one site removed requirements for duplicate approvals in their referral process. Streamlining the process reduced workload and expedited refills for patients. Don’t forget to include managing the patient service experience in your training. Keep it simple with a few rules that are consistently implemented. Standards include stopping conversations when a patient approaches, giving priority to an arriving patient versus a ringing phone, and standard protocol for resolving patient complaints. Other strategies include greeting patients when they are within five feet of a staff member. Finally, take time to assess the social “glue” that binds relationships among staff by tuning into casual conversations. Are discussions generally positive or full of complaints and “not my job” defensiveness? Address negativity and poor performance quickly. Why? Unfortunately, many physicians and managers are CALIFORNIA ACADEMY OF FAMILY PHYSICIANS

uncomfortable with conflict and the time‐consuming aspects of dealing with poor performance. As a result, incompetence frequently gets ignored, particularly among loyal staff. The cumulative effect is to reward loyalty at the expense of competence. Instead, as one manager remarked, “hire slow and fire fast.” Effective hiring and training of MA and other staff is crucial to the smooth running of your practice. A systematic approach that reflects the unique characteristics of your practice will save time and resources and ensure a good match. Table 1. Interview Questionnaire Questions Tell me what interested you in this position.

Interview Comments

What was most satisfying about your last position? If we asked folks with whom you worked with last what it was like to work with you, what would they say? What have been your most satisfying work accomplishments? What was most challenging about your last job? If we were sitting here one year from today and you could say that this job worked out perfectly, what would that be like for you? What were the best and worst characteristics of your most recent supervisor? What do you think are the hallmarks of a successful medical practice? What is the best way to deal with conflicts with co‐workers? Unhappy patients? Uncooperative physicians?

1 Weiss, G. (July, 2004). Starting a practice: 3‐4 months out: hiring staff. Medical Economics, 81:34. 2 Backon, L., Galinsky, E. When work works. Making Work “Work”. (2007). Retrieved December 19, 2007, from: http://familiesand‐ work.org/site/research/reports/3wbooklet.pdf

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Technology Leverage Registries to Improve Chronic Illness Care The Dos and Donâ&#x20AC;&#x2122;ts in Selecting and Contracting for an EHR System Is There a Patient Portal in Your Future?

October 2006 May 2010 September 2010

Leverage Registries to Improve Chronic Illness Care Sue Houck

October 2006

A registry is a practical tool that enables you to manage the care of populations of patients versus reactively trying to recall what interventions are due when a patient arrives for an office visit. Registries organize information in one place for tracking and monitoring the care of a group of patients. They generate reminders and feedback for providers to facilitate care planning. Why Use a Registry? Only 56 percent of recommended care is being provided for patients with chronic illnesses in the United States. Research indicates that when used effectively, registries can improve outcomes for patients with diabetes. In addition, pay‐for‐performance programs are carving out portions of reimbursement for effectively managing the care of patients with diabetes and other chronic illnesses. While the focus of this discussion will be on registries for patients with diabetes, the concepts can be used for any patient with a chronic illness. Do You Need a Registry? Ask yourself the following questions: n How many patients with type 2 diabetes are in my practice? n How many are overdue for an HbA1c? n Does my staff know which patients have diabetes so they can ensure labs have been completed before the visit? Successful implementation of a registry requires active support from physician and administrative leadership. Why? You’ll need to free up resources to document registry information, as well as to generate and act on reports. In addition, physician consensus is needed to make decisions regarding what interventions will be tracked, e.g., blood pressure, lipid panels, A1cs, foot checks, and how registry reports will be shared with physicians. Five Steps to Building an Effective Registry Step 1: Make Sure It’s Practical A registry should include timely and clinically‐useful information. It should be easy to use and integrated into daily clinical activities. For example, a summary report of the most recent results and reminders of required tests should be easy to generate and made available at the point‐of‐care, either attached to the paper chart or integrated into an EHR. Entering and extracting data should be easy. If effective, the registry should help — not hinder — the organization’s daily clinical work flow for providers and staff. Step 2: Decide on a System to Build Your Registry Registries are commonly developed using one of four methods: a. Desktop database or spreadsheet programs like Microsoft Access or Excel Many practices will have at least one of these programs already installed on an office computer or network. While Excel is an easier program to learn, Access offers more robust features. However, due to its complexity, Access is also more likely to require professional IT staff to develop and maintain. Get tips on using Microsoft Excel to develop a patient registry here. b. Chronic disease management systems (CDMS) CDMS are software products that are free in the public domain or available for purchase. Data are entered from the patient chart into the software from which reports and reminders are generated. For an overview of computerized registries, download an information sheet and specific product reviews. 90

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c. Electronic health record software Some EHRs include registry functions or they can work with other registry programs. Consult individual vendors for product specific features. A note of caution: current EHRs vary significantly in their registry capabilities and many are limited. Just because you already have an EHR does not mean it can provide the same functionality as a registry. Be sure to have staff for a given vendor demonstrate step‐by‐step how to build a registry from their EHR. Download a comparison of EHRs vs. chronic disease management system software products at http://www.aafp.org/fpm/2006/0400/p47.html . d. Paper‐based filing systems This is the simplest way to build a basic registry. For tips on developing paper registries, go here. Step 3: Decide What You’ll Track and How Before developing your registry, you should decide what to track and how frequently, based on care guidelines. Registries include two types of information: demographic and clinical. Demographic information includes patient name, sex, payer, account number, and date of birth. Clinical information should include values and dates for interventions so patients who need monitoring can be identified. A site in Washington divides tracked clinical information into three categories: glycemic control, coronary risk factors, and microvascular end organ disease data. Glycemic control data may include HbA1c results as well as results of home glucose monitoring and current medications. Coronary risk factor data may include blood pressure, lipids, smoking status, and medications. Microvascular end organ disease data may include microalbumin screening, monofilament test for neuropathy, dilated retinal exam, and a measure of renal function for those with albumin/creatinine greater than 30. Start with entering data on 15‐20 patients. Next see if the process works. Can the information be easily retrieved from your registry? Are the data accurate? See Table 1 below for a sample layout of registry information that has been adapted from Clinica Campesina in Colorado. Step 4: Maintain Accurate and Current Identification of Registry Patients Agree on a common definition of patients with diabetes to be tracked, e.g., patients with CPT code documentation of 250 who have not left the practice and had at least one visit to the practice in the last 12 months. Registry patients are most commonly identified from CPT data and chart audits. Accuracy is essential to ensure provider buy‐in and the usefulness of the registry. You can also determine patients with diabetes through medication refills or from your billing records. Decide also on a process to update the registry for new and departed patients.

Table 1. Sample Diabetes Registry Data Last Name

First Name

Payer

DOB

Acct. #

Last Visit

BP Sys

BP Dia

Cortez

Mary

Medicare

9/15/37

123456

10/10/05

102

Smoker

Last Eye Exam

Last Self‐Management Goal

Last Foot Exam

Foot Risk

Lipid Panel

Last A1c

Never

11/30/04

10/10/05

Low

10/10/05

9.5

Use color‐coded flags instead of “diabetes labels” to identify paper charts of patients with diabetes. Flagging charts also reminds staff to print out current registry reports before office visits of individual patients.

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provider buy‐in and the usefulness of the registry. You can also determine patients with diabetes through medication refills or from your billing records. Decide also on a process to update the registry for new and departed patients. Use color‐coded flags instead of “diabetes labels” to identify paper charts of patients with diabetes. Flagging charts also reminds staff to print out current registry reports before office visits of individual patients. Step 5: Define Staff and Physician Participation Decisions will need to be made regarding who will assume responsibility for registry activities. While physicians are responsible for clinical results, support staff can complete many registry functions. Responsibility for clinical data entry is usually assumed by clerical or clinical support staff. For example, can your front desk staff review registry data and make referrals for patients due for an eye exam? Don’t forget to include patients in the process. Some sites distribute wallet cards to patients with timelines and reminder letters for needed interventions. One study of three registry strategies found that an implementation strategy, which included direct letters to patients, showed significant improvement across a number of measures. The measures included percentage of patients completing glycosylated hemoglobin (Hbg) testing within 6 months and low‐density lipoprotein (LDL) within 12 months. Registry reports can be printed and shared with individual providers on a monthly or quarterly basis. Use comparative registry reports for each physician to identify top performers and coach under‐performers. Utilizing registries takes effort, particularly from nursing staff. See also Table 2. However, they also enable physicians to conduct more thorough visits for patient with chronic illnesses, some of which can be billed at a higher level of complexity. In addition, physicians Table 2. Registry vs. Non‐Registry Facilitated Office Visit (Registry‐facilitated visit is noted in italics) 1. Nursing staff prepares chart for office 1. Nursing staff prepares chart for office visit. Noting that patient has diabetes visit. due to color‐coded flag on chart, nursing staff prints patient’s current registry information and attaches it to front of chart. Noting also that patient is due for a foot check, nurse attaches foot check form to chart for physician and patient is instructed to remove their shoes and socks once roomed. 2. Nursing staff rooms patient, complet‐ 2. Nursing staff rooms patient, completing vital signs. Noting that patient is due ing vital signs. for a HbA1c from registry printout, nursing staff draws blood and reminds patient about importance of exercise and proper diet in managing diabetes. HbA1c results and notation about advice are documented in chart. 3. Physician sees patient, notes that he’s 3. Physician sees patient and reviews HbA1c which has gone up to 8 from previ‐ a diabetic on problem list, and orders ous reading of 7. Physician documents foot check and advises patient on how to HbA1c. Physician reviews HbA1c after reduce HbA1c. visit and asks nursing staff to schedule follow‐up appointment to discuss HbA1c results and review management of dia‐ betes. A foot check will also be done at that time. 4. Chart is returned to medical records.

4. HbA1c results and foot check are documented in registry from medical chart by nursing staff. Chart is then returned to medical records if practice is still using paper charts.

are able to delegate less complicated tasks to nursing staff and provide care that is better planned, timely, and likely to improve clinical outcomes. Bringing together data from a variety of sources, registries are effective tools to remind providers about needed care, monitor progress, and plan needed interventions. Used effectively, reg‐ istries provide the foundation for improving the care of patients with chronic illnesses.

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1 McGlynn, E.A., Asch, S.M., Adams, J., et al. (2003). The quality of health care delivered to adults in the United States. N Engl J Med., 348:2635â&#x20AC;?45. 2 Renders, C.M., Valk, G.D., Griffin, S., et al. (2001). Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings. Cochrane Database Syst Rev., (1), p. CD001481. 3 Hummel, J, (Summer 2000). Building a computerized disease registry for chronic illness management of diabetes. Clinical Diabetes, Vol. 18, No.3. 4 Stroebel, RJ, Scheitel SM, Fitz JS, Herman RA, Naessens JM, Scott CG, Zill DA, Muller L. (2002). A randomized trial of three diabetes registry implementation strategies in a community internal medicine practice. Jt. Comm J Qual Improv. (8):441â&#x20AC;?50.

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The Dos and Don’ts in Selecting and Contracting for an EHR System Barbara Hensleigh

May 2010

We hope every practice will ultimately have an electronic health records (EHR) system and meet the federal standard of “meaningful use.” While final regulations to establish meaningful use criteria have yet to be finalized, we believe three major areas will be addressed: n Use of EHR in a meaningful way, including e‐prescribing n Connection from the EHR for a health information exchange (HIE) n Reporting clinical quality measures for a significant percentage of the patient population A new EHR system comes with a contract required to obtain the software to provide the technical and service components for your practice. Providers should personally test EHR software to determine whether the software fits the need of the practice and physician. What is a self‐evident software function to one physician may not be to another. Since some vendors are reluctant to demonstrate their products in physicians’ offices, attending conventions that include software demonstrations may be one good way to test out products. Many vendors also provide web‐based demonstrations for their EHR systems. An Application Service Provider (ASP) system, providing off‐site storage and retrieval of medical records, is usually less expensive than a Client/Server (C/S) system, where the data remains on a server at the practice location. An ASP system typically takes less technical support, and support can be provided remotely. The ASP system is only as fast as the transmission capabilities of the medical office. Those capabilities should be assessed before purchasing a system. It would be frustrating to purchase an ASP system only to discover accessing records takes a long time and reduces office efficiency because available Internet connectivity is slow. A C/S system, while usually more expensive, provides greater flexibility in configuring the system for your specific office needs. It has the advantage of maintaining medical records on site with less concern over transmission of records over the Internet. The hardware purchase and upkeep, however, costs more than an ASP model; maintenance and software upgrades may require technical support beyond that of the medical office staff. After selecting the software most compatible with your practice, you must execute a contract for software, installation, training and technical services of the product. What are some things you should look for in a contract? ASP Contractual Issues: The contract should clearly indicate that the data located offsite belongs to the practice. The contract should not permit the vendor to have a lien on the medical records or limit access to the data stored offsite in the event of a dispute with the practice. In the event of non‐compliance, the contract should provide for significant liquidated damages (e.g., if the vendor cuts off access to data due to a payment dispute). Data Security:

The contract must provide security of the data when it is stored off site. Where is the data warehoused? Is there a redundant (backup) site for your data in another state? What warranties are in the contract regarding system down‐time? Ideally, you want to have warranties that the software system will be operational no less than 99 percent of the time.

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C/S System Contractual Issues: Because the C/S system maintains medical records in a server at the physician’s office, the system will require more technical support and training. A contract for the C/S system should contain dates by which training will occur, problem solving and specific turn‐around times for service of the system (e.g., the vendor must provide service calls within 24 hours of receiving notice that the provider's system is malfunctioning). EHR Certification:

The Office of National Coordination of Health Information Technology (ONC) issued a set of standards, implementation specifications, and certification criteria for EHRs. A provider will not receive a HITECH incentive payment without a certified system. Historically, the Certification Commission for Health Information Technology (CCHIT) has been the entity certifying EHRs. Newly proposed rules, however, leave the ultimate issue of the certifying entity in doubt. Accordingly, any contract must require the vendor to supply a certified EHR within the meaning of HITECH and any other laws, rules and regulations.

Interoperability Standards: The vendor must provide that the system meets the requirements for achieving “meaningful use.” The final definition and regulations for implementation of “meaningful use” are still in development. Requirements for interoperability, the ability of any provider to send clinical data to other providers for purposes of coordinated quality care should be included. EHR vendors must contractually agree to meet all interoperability standards, both currently and in the future. At a minimum, the software must be at Health Level 7 ("HL7") standard of data models, and preferably able to push a “CCD” (Continuity Care Document). Any interfaces or interoperability charges or conditions must be detailed in the contract. Privacy and Security Standards: Privacy and Security Standards were developed, and continue to be developed, at both the Federal and state levels. The vendor must warrant that its software and system will meet all current and future privacy and security standards and laws at both the Federal and state levels. Cost of Upgrades:

The vendor should typically incur the cost of any upgrades to the software during the term of the contract. If the provider is required under contract to pay for upgrades, the contract should state the cost.

License Ownership:

The contract should unambiguously state that, at the conclusion of the contract, the license for use of the software belongs to the provider. A statement that the vendor “may” transfer a license makes license transfer permissive. The statement that the vendor “shall” transfer license makes it obligatory. Obligatory language clearly requires the transfer of the license.

Additional Providers:

The contract must address the cost for adding other physicians/users to the system. A contract stating, for example, that the vendor is “authorized” to adjust fees to take into account additional providers using the software" is not acceptable.

Assignment:

The contract must require that the physician approve (in writing) of any assignment of all or part of the contract. The physician has selected the vendor after conducting due diligence. Assigning the contract to another vendor without his or her express consent defeats the physician’s efforts to select a known high quality vendor.

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Indemnification:

There should be a provision requiring the vendor to indemnify the physician for actions brought against him or her arising out of the breach of the agreement by the vendor or any other actions by vendor.

Limitation of Liability: The agreement should not contain a provision limiting the liability of the vendor or limiting warranties implied by law. Dispute Resolution:

Preferably, the contract should contain a provision permitting a speedy resolution of any dispute arising out of the agreement through mediation or arbitration.

Transfer of Data at Contract Conclusion: The contract should specifically address the transfer of the data back to the physician, in useable form, at the conclusion of the contract. If the vendor intends to charge for the conversion of data into useable form, the charges must be delineated in the agreement. It is unacceptable for the contract to state “charges will be paid by the physician” or the physician will pay all "reasonable" charges associated with the transfer of the medical records back to him or her, unless the contract specifically states that any disputes over charges will not delay the transfer of the medical records in usable form back to the physician.

PRACTICE MANAGEMENT NEWS: COMPENDIUM

Is There a Patient Portal in Your Future? Sue Houck

September 2010

Your practice implemented an electronic health records (EHR) system and your team has worked together to stabilize workflow. Despite all of the work your team put into the EHR, you find that workflow efficiency has not changed. Your support staff continues to play phone tag with patients throughout the day managing appointments, prescription refills and simple inquiries. If this scenario sounds familiar, you may want to consider implementing a patient portal for your practice. This article will help you weigh the pros and cons of this technology and determine if it is right for your practice. Patient portals are secure, web‐based tools that enable around‐the‐clock email communication between patients and their care team. Patient portals are perfect for appointment, refill and referral requests. Portals can also be used internally to provide reminders, lab and procedure results, self‐management tools and more. In addition, all communication through the portal can be stored in the EHR. CAFP past president Joseph Scherger, MD, MPH, now Vice President at Eisenhower Medical Center’s Primary Care 365 in Rancho Mirage, CA calculated that an average of two to three minutes is needed to complete one email communication. Dr. Scherger added in that order to be successful, a patient portal requires a physician to champion its benefits with patients, staff and other physicians in the practice. Dave Ehrenberger, MD, Medical Director of Broomfield Family Practice, also uses a patient portal and said it improved staff efficiency in making appointments and messaging. According to Dr. Ehrenberger, the practice benefits because there is “no more phone tag and staff time spent listening to voicemail messages now that we're using the portal.” Some of Dr. Ehrenberger’s colleagues vowed never to use email for patient communications, but that vow quickly changed when they used the portal. The same colleagues now request immediate access to the portal because they realize how much time it saves them in documentation as well as responding to patient voicemails. The software can be seamlessly integrated into an EHR product or interfaced with the EHR via vendor products. In addition, a variety of vendor portal demonstration videos can be found via Internet search with the key words “patient portal” and “video.” Portals can also be used by family members who have “proxy access” to manage care. For example, parents can request an appointment on behalf of a child or review a child's medical record with proxy access. Family members with proxy access can also better understand and manage the care of the elderly. Dr. Ehrenberger found that 80 percent of his patients have registered for the portal and use it. An additional 10 percent registered, but do not use the portal and the remaining 10 percent did not register because they did not have email access. In order to pay for the service, the practice paid a one‐time fee of $2,000 plus an ongoing fee of $40‐$50 per provider per month for service charges. The costs were offset by the time staff saves through the use of the portal. Instead of negotiating appointment times via phone, patients simply indicate their reason for a visit as well as first and second choices for appointment dates and times. One study of patient portal use found that up to 77 percent accessed the portal at least monthly, most commonly for laboratory and radiology results and sending clinical messages to their providers. Portal users were younger and more affluent and had fewer medical problems than non‐users. 1 The portal has been an “incredible crowd pleaser” for patients at Dr. Ehrenberger’s practice. In addition, since implementing the portal three months ago, phone communication dropped by 20 percent and is predicted to drop by 50 percent. At each visit, nursing staff asks new and existing patients if they would like to receive CALIFORNIA ACADEMY OF FAMILY PHYSICIANS

email communications; patients who choose to use the portal get a print‐out with instructions. All routine communications are then sent via email to participating patients. Incoming patient messages can be routed to clinical support staff, which most sites recommend, or go directly to the physician. Based on his experience, Dr. Ehrenberger said many physicians find it easiest to respond directly to patients instead of routing responses through support staff. Effective implementation also requires training physicians and staff about the key distinctions between written and oral patient communication. There is no need for correct punctuation and spelling on the phone, but there is on the portal. It is also important to avoid medical terminology and jargon. For example, “sore throat” and “itching” are more likely to be understood by patients than the terms, “dysphagia” or “pruritis.” Patients, of course, should be warned that with emergent issues such as chest pain, email is not appropriate. While many care teams respond sooner, 24 hours is a common response time and patients should be made aware of the possible delay. Dr. Scherger finds that portals enable self‐management by patients seeking more immediate access to lab and procedure results, as well as self‐care information, including videos. Some portals enable direct medical record access for patients. Dr. Scherger cautions that while many think of portals as an “add‐on,” they are actually a new communication platform enabling care to be continuous and proactive rather than episodic and reactive. In a randomized controlled trial with 606 patients from an academic internal medicine practice, 44 percent of portal user patients reported that communication improved with the clinic vs. 12 percent of controls. In addition, 59 percent of portal user patients described care as very good or excellent versus 48 percent of controls. Physicians received one portal message per day for every 250 portal patients. Patients were also more likely to send informational and psychosocial messages by portal than by phone. 2 Enhanced email communication may reduce office visits. Kaiser Permanente has seen a 25 percent drop in visits following implementation of its portal and EHR. Reductions may, however, indicate that some visits are unnecessary visits or that some care is better managed via electronic communication. At GreenField Health in Portland, OR, physicians use patient emails, e‐visits and aninteractive website to communicate with patients. The innovative internal medicine practice now does 40 percent of all patient interactions through web messaging, 35 percent via telephone and only 25 percent via traditional one‐on‐one office visits. Most of the physicians’ time is spent answering questions and resolving issues such as interpreting test results or adjusting medications. GreenField physicians are paid for this work through an annual “retainer fee,” from $350 to $650 depending on the patient's age, as payment for this work is not currently covered by insurance plans. Email communications can also be leveraged to improve care and outcomes. In a randomized clinical trial, William Lester, MD, MS of Massachusetts General Hospital, found that a simple email to primary care physicians resulted in a clinically significant reduction in LDL levels in high‐risk patients.3 Patient portals are a way to improve connection and access for patients, bringing providers closer to patients in a way that is familiar to them. We hope this article provides you with practical information that will help your practice decide whether a portal will work for you and your patient population. 1 Weingart, S.N., Rind, D., Tofias, Z., Sands, D.Z. (2006). Who Uses the Patient Internet Portal? The PatientSite Experience. Journal of the Medical Informatics Association, Volume 13, 91‐95. 2 Lin, C., Wittevrongel, L., Moore, L., Beaty, B.L., Ross, S. (2005, Jul‐Sept). An Internet‐Based Patient‐Provider Communication System: Randomized Controlled Trial.,Journal of Medical Internet Research, 7, 4. 3 Lester, W.T., Grant, R.W., & Barnett, G.O. (2006, January). Randomized Controlled Trial of an Informatics‐based Intervention to Increase Statin Prescription for Secondary Prevention of Coronary Disease. Journal of General Internal Medicine, 32, 1, 22‐29.

Additional Topics The Patientâ&#x20AC;?Centered Medical Home: Fad or Key to a Sustainable Future? Panel Management News New HIPAA Privacy and Security Requirements

April 2008 May 2009 October 2009

The Patient Centered Medical Home: Fad or Key to a Sustainable Future? Sue Houck

April 2008

At first glance, the Patient‐Centered Medical Home (PCMH) may look like another laundry list of practice redesign strategies. Further examination, however, reveals a comprehensive roadmap to a sustainable future for family medicine and primary care. In fact, the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians and American Osteopathic Association issued Joint Principles of the Patient‐Centered Medical Home in 2007. 1 These principles focus on seven components outlined later in this article. Another indication of its staying power is the fact that AAFP President Jim King, MD plans to base arguments for higher rates for payment on the PCMH. 2 In addition, a number of health plans and employers are planning projects to compensate practices with PCMHs. The National Committee for Quality Assurance (NCQA) Physician Practice Connections ‐ Patient‐Centered Medical Home (PPC‐PCMH) program recognizes practices that adopt the PCMH. The program focuses on measurement and accountability, including 10 priority criteria, and is supported by the AAFP. While some of the required activities are discussed here, see www.ncqa.org/tabid/631/Default.aspx for a thorough description of the NCQA program. Given the associated costs, fair payment is essential to all family medicine practices, but particularly for solo and small offices that may not have the resources associated with larger systems. Physicians can achieve one of three levels of PPC‐PCMH recognition, depending on the practice's infrastructure and how well physicians can meet the NCQA criteria. In terms of technology, the first level requires only an electronic practice management system, so most practices could be eligible for this level without electronic health records (EHR) or patient registry adoption. That said, with or without an EHR, patient registries are key to managing and improving the care of patients with chronic diseases. While the seven PCMH components overlap and vary in their complexity, this article will discuss core concepts as described in the Joint Principles as well as practical strategies to begin implementation. Personal Physician An ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care describes this element. Having a regular source of care and continuous care with the same physician over time is associated with better outcomes and lower costs. 3 Practical strategies include ensuring patient continuity and right‐sizing patient panel sizes. Is it an ongoing struggle to see all your patients who request care? If so, your panel size may be too large. According to the Medical Group Management Association, the median number of patients on family medicine panels is 2,016. 4 To preserve continuity, consider teaming with a mid‐level provider who can perform less complex tasks or even closing your practice to new patients. Given that larger panels may be necessary for practice overhead, other options include enhancing your entire team's role in patient care (described in more detail in Item 2). CAFP offers several resources on the team approach to care on its website http://www.familydocs.org/new‐direc‐ tions‐in‐diabetes‐care/tools‐and‐resources/team‐meetings‐and‐team‐care.php. Measure panel size by counting the number of so‐called unique patients or individuals who have had a visit with a given provider in the last 18 months. Be sure the name of each patient's primary care physician is documented and accurate in your practice management system to ensure that patients are matched with their own physicians when making appointments.

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Physician‐Directed Medical Practice The personal physician leads a team at the practice level that is responsible for the ongoing care of patients. A team approach enables flexibility to match the complexity of patient needs. Freeing up physicians to lead the team requires delegation of complex tasks to other members of the team, such as medical assistants, front‐ and even back‐office staff. If a significant amount of your visit time is spent collecting information instead of making decisions and planning care, consider delegating some information gathering to clinical support staff (e.g., patient history, prevention and current meds as well as the patient's biggest concerns and goals for each visit). Want to promote greater teamwork? Begin with three‐ to five‐minute team huddles each morning to check in, review the schedule and plan work for the day. If your practice has a Web site, consider directing patients to programs such as “How’s Your Health” http://www.howsyourhealth.com/ or “Instant Medical History” http://www.medicalhistory.com/home/index.asp to collect some of this information in advance of the visit. Whole‐Person Orientation Whole‐person orientation includes care across all stages of life: acute and chronic care as well as preventive services and end‐of‐life care. Practical activities include implementing patient registries to monitor and treat patients with chronic illness as well as making sure patients feel understood and resolving their concerns. NCQA's medical home program requires the use of evidence‐based guidelines for at least three conditions. Care Is Coordinated and Integrated Practical strategies include avoiding hand‐offs and tracking referrals. For example, a practice in the Midwest had implemented an EHR but was using a blended paper and automated system for processing external labs. After documenting the 11 steps and costs required to complete a CBC, the practice decided to automate bi‐directional lab reporting and reduce the number of labs with which it worked. Results included fewer errors and lower costs. In addition, a local hospital assisted with implementation costs. Quality and Safety The foundation of quality and safety is a partnership between patients and physicians, including joint decision‐making, as well as feedback to be sure that expectations are being met. Dr. John Wennberg notes that the PCMH confronts a cultural bias that “more care is better and that physicians must know best.” 5 On a practice level, frank discussion among physicians and staff is important to acknowledge and deal with potential cultural resistance to meaningful patient partnerships. Practical strategies include systematically tracking referrals and tests, including following up on abnormal results. Don’t forget to leverage your use of existing technology. A small practice on the East Coast was completing school and sports physicals, as well as other permission forms on paper, despite existing EHR capability to generate and electronically sign the forms. After documenting the completion of an average of six to eight forms a day, physicians automated the process‐including electronic signatures‐despite concern that some might not be accepted. Two months later, none have been returned and physicians estimate staff and provider time savings of more than an hour a day. If you’re considering the purchase of an EHR, recommendations are available from peers in Edsall and Adler’s survey of 422 family physicians. 6 Enhanced Access Enhanced access includes open‐access scheduling, expanded hours and new ways to communicate, including email. Consider the goal of having at least 60 percent of appointments open at the beginning of each work day. While this strategy requires working down the backlog of existing appointments, it can significantly improve patient satisfaction, continuity and outcomes. 7 If you have a Web site, including robust self‐management information for patients who need it 24/7 can also be valuable. NCQA requirements also include written standards and documentation for patient access and communications. As discussed earlier, be sure to adjust lopsided panel sizes as needed, or efforts to enhance access will only frustrate physicians and staff.

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Payment System From joint decision making with patients to coordination of care and technology, the PCMH will require more time and resources from family physicians. Proposed payment reform would compensate physicians for their value to patients who have a PCMH including: the value of care by non‐physician staff, non‐face‐to‐face encounters including secure e‐mail and phone consultations, and payment for care management including coordination and support for the use of technology. PCMH models could also pay physicians for achieving measurable quality improvement. CAFP recognizes that there are barriers to meeting the NCQA criteria and strongly supports fair and appropriate payment in order to encourage the adoption of medical home features. In what is hopefully the beginning of a national trend, a coalition of self‐insured employers including General Electric, IBM and Verizon Communications is launching an initiative to pay bonuses to physicians who create PCMHs via the Bridges to Excellence Program. Participating physicians can receive annual bonus payments of up to $125 for each patient covered by a participating employer, with suggested maximum yearly incentives of $100,000. We are hopeful that this trend will encourage California health plans to recognize the significant time and effort that family physicians must allocate toward providing a PCMH. Where to Start Overall, PCMH enables comprehensive reform and is gaining broad support. An outdated payment system that rewards face‐to‐face, episodic, procedurally‐based acute care versus comprehensive, longitudinal and coordinated care, however, makes meeting all PCMH criteria a mighty task. In fact, PCMH’s payment reform component will likely be required for comprehensive, sustainable implementation. But it’s not too soon to begin matching your practice improvement efforts with the PCMH. In fact, you may have a number of the components already in place. Start with what matters most to you. And what may reduce the biggest day‐to‐day frustrations you and your staff experience. Consider what energizes you to take action. For example, begin with pre‐visit planning to be sure needed lab and procedure results are available or undertake development of a robust Web site with in‐depth self‐management advice that you and your staff find yourselves repeating often to patients. Get in the habit of measuring and sharing even simple changes. Finally, moving beyond the status quo requires regular meetings to plan, measure and report desired changes.

1 Joint Principles of the Patient‐Centered Medical Home, 2007, http://www.medicalhomeinfo.org/downloads/pdfs/jointstatement.pdf 2 Measure Your Practice's Medical Home Fitness Level, (2008, January 16). AAFP News Now. 3 Starfield, B., Shi, L., Macinko, J. (2005). Contribution of primary care to health systems and health. Milbank Quarterly, 83(3):457‐502. 4 Medical Group Management Association. (2006). Cost Survey for Single‐Specialty Practices. 5 Wennberg, J.E. (2004). Practice variations and health care reform: connecting the dots. Health Affairs. Suppl Web Exclusives: VAR140‐ 4. 6 Edsall, R. L., Adler, K.G., (2008, February). User Satisfaction With EHRs: Report of a Survey of 422 Family Physicians. Family Practice Management, 15(2): 25‐31. 7 Murray, M., Bodenheimer, T., Rittenhouse, D., Grumbach, K., (2003). Improving timely access to primary care: case studies of the advanced access model. JAMA, 289 (8), 1042‐6.

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Panel Management News Sue Houck

May 2009

Panel management is emerging as an important strategy for monitoring and improving patient care. It can be particularly useful if you participate in pay‐for‐performance or are considering National Committee for Quality Assurance (NCQA) recognition as a Patient Centered Medical Home. Panel management is defined here as care that's applied systematically to a specific population of patients (e.g., patients with diabetes, asthma, or hypertension) and is based on established standards, including monitoring and follow‐up. We will also discuss "financial" panel management in light of the impact of contracts with different payers. Identifying Your Panel Size The typical family medicine practice averages 2,000 patients. To determine which patients can be considered part of your panel, count the number of individual patients you’ve seen in the last 18 months. This can usually be extracted from your billing or practice management system. If your system doesn't have this capability, total patients can be estimated by counting the number of active charts. This method is far less accurate, however. While you may be tempted to request this information from the various health plans with which you contract, be warned. Mary Jean Sage, a consultant with The Sage Associates and regular contributor to Practice Management News, reports that payer‐generated lists are typically not reliable or current. Instead, estimate your panel size by dividing the total number of your annual encounters by the average number of visits per patient per year. If your practice management system can't extract the average number of visits per patient per year, estimate it by taking a sample of 50 charts and counting the number of encounters for each patient in a given year. Medical Group Management Association (MGMA) data indicate the average number of annual encounters for a family physician (without OB) totals 4,336. 1 This means if you have 4,400 encounters per year and three visits per patient per year, your estimated panel size would be 1,466 patients. Dr. Mark Murray has developed several tools to adjust panels for patient acuity as well as the so‐called four cut method for assigning individual patients to individual provider panels. 2 Why does panel size matter? The medical director of a small primary care group in Southern California has a panel of 1,934 patients. He spends one day a week on administrative duties and sees patients the other four days. Assuming an average panel size of 2,000 patients and his .8 FTE status, an appropriate panel size for him would be 1,600 patients (i.e., his panel should have 334 fewer patients). If your panel size far outpaces the average, it may result in frustration for you, your staff, and patients who face long waits or delays in available appointments. Solutions include closing the practice to new patients who are not family members of existing patients and adding a part‐time nurse practitioner to “level the load” for this physician. Getting Started With Panel Management First, identify one or more groups of patients from within your panel who would benefit from additional monitoring and care management. Typically these are patients with diabetes, hypertension, or depression. Next, determine the number of patients for whom you provide care with the selected diagnoses; again this can usually be extracted from your practice management system. If the patient group(s) you've selected aren't already in a disease registry, consider establishing one for them. Registries organize and track data, as well as needed care for patients with chronic illnesses. They can be as basic as a filing card system or Excel spreadsheet, or as sophisticated as a Web‐based application with reporting and tracking functions. See also Practice Management News, October 2006, for practical patient registry strategies.

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UCSF’s Center for Excellence in Primary Care reports that one key to successful panel management is to systematically track and review a population of patients with chronic conditions. Each provider takes 15 minutes of protected time twice a week to review the status of 20 diabetes/cardiovascular patients. The physician indicates needed care or follow‐up (e.g., medication change or adjustment) for each patient as well as when the physician wants to review the patient's status again. Clinical support staff then implements physician orders. Another strategy is to expand the role of your care team. For example, are there activities that medical assistants or front or back office staff can do as well as you can? Training MAs to complete and document dia‐ betic foot checks, as well as sharing the schedule of care and prevention guidelines with patients are examples of how such activities could be delegated. Agreeing on standardized processes among providers regarding work that's delegated establishes consistency, reduces potential for error, and smoothes workflow. For example, if you decide to delegate foot checks to MAs, agree on training steps and required documentation for each MA to achieve competency. Do spot‐checks in the future to ensure quality. A number of small practices in Colorado have adopted a simple tool for front desk staff to review care guideline schedules to make appointments for patients with diabetes. The Diabetes Planned Care Ruler (See Table 1) is matched and overlaid onto registry printouts from their electronic health record (EHR). The ruler indicates care needs and timing of appointments as well as follow‐up for patients with diabetes. The ruler frees up provider time that formerly was spent coordinating follow‐up care. In addition, most front desk staff appreciate the expanded responsibility. Table 1. Diabetes Planned Care Ruler Name: ____________________________________________________________ Visit BP/Syst BP/Dias Tobacco Eye Exam SM Goal Foot Exam LDL Date LDL A1C Date Value

If >6 mos, make appt. otherwise see BP, LDL & Alc rules If >130, appt every month If >80, appt. every month If current smoker, case manager reviews for tobacco cessation counseling If not within 1 yr, put on list of DM eye exam group visit If not within 1 yr, case manager to set goal w. patient If not within 1 yr, make appt. If not within 1 yr make appt. If >130, appt every month; if 100‐130, appt. every 3 mos. If not within 3 mos. make appt. (6 mos okay if last value <7.0) If above 9, appt every month. If 7‐9, appt every 3 mos. If below 7, appt every 6 mos

Ruler columns are lined up with registry print‐out to determine needed action based on current patient data. Robust information technology (EHRs and patient portals that enable bi‐directional communication with patients) combined with payment based on quality vs. visit volumes are enabling innovations such as e‐visits, group visits, and even scheduled phone visits. One 1999 study found office visits accounted for 99.6 percent of all ambulatory care contacts at Kaiser Permanente Medical Group site. By 2007, they represented 66 percent of patient contacts. Scheduled phone visits accounted for 30 percent and secure messaging accounted for the remaining four percent. 3

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To estimate the number of office visits you can accommodate per year (also known as visit capacity), multiply the number of days worked seeing patients in the office minus days spent on administrative tasks and non‐visit clinical work by a provider's average number of visits per day. (Table 2) Table 2. Estimating Provider Office Visit Capacity Number of working days in the office per year Deduct number of days spent in administrative work Deduct number of days spent on non‐visit clinical work, e.g., e‐visits, phone visits Total number of clinical office work days How many office visits do you average per day? Multiply number of provider days per year x number of visits to determine visit capacity

Example 240 days 20 days 10 days

Totals 240 ‐20 ‐10 _______ 210

18 days 210 x 18

18 3,780

Don’t Forget Financial Aspects On the financial side, manage your panel by understanding the revenue effect of each payer's contract. This can be done by comparing total and average revenues and encounters for each payer. To accomplish this, consider the following steps: 1. Tabulate all of the encounters rendered to patients over a given period of time for each insurer. If you can’t access this from your practice management system, ask for help from your vendor. If your system cannot extract the data, look at your superbills over a given time period; count the number of encounters and the total revenues by each payer. 2. Divide your total revenues by revenues for each payer to get a percentage breakdown of revenues by payer. The higher a given payer's revenues in relation to its percentage of encounters, the better. For example, a payer that accounts for 18 percent of your total encounters but 25 percent of total revenues generates better income to your practice. On the flip side, a payer providing only 18 percent of revenue but accounting for 25 percent of total encounters is a contract that could benefit from re‐negotiation. Physician’s Practice has a useful tool to compare payer revenues. 3. When negotiating, use your data to help build your case. In this age of take‐it‐or‐leave‐it contracts, small practices may have the hardest time changing contract terms. You should then determine if your practice can sustain ending that contract. As physician pay is increasingly related to quality, the unit of productivity will become panel size, not number of visits. Active panel management can organize and systematize population‐based care.

1 Medical Group Management Association. (2008). Physician Compensation and Production Survey. Denver: Medical Group Management Association. 2 Murray, M., Davies, M., Boushon, B., Panel Size: What is it, why is it important, what is the ideal panel size and is there a limit to panel size? Internet Group. Retrieved April, 27, 2009 from the source. 3 Chen, C., Garrido, G., Chock, D., Okawa, G., Liang, L., (2009). The Kaiser Permanente Electronic Health Record: Transforming and Streamlining Modalities of Care.Health Affairs, 28, no 2. 232‐333.

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New HIPPA Privacy and Security Requirements Mary Jean Sage

October 2009

The American Reinvestment and Recovery Act (ARRA), signed into law in February 2009, includes significant expansion of privacy and security requirements of the Health Insurance Portability and Accountability Act of 1998 (HIPAA). HIPAA affects both covered entities (e.g., health care providers, plans, clearinghouses) and business associates. In particular, the new provisions: n Impose breach notification requirements; n Make business associates directly responsible for complying with HIPAA privacy and security rules; and n Provide for increased enforcement activity and penalties for non‐compliance. Most changes take effect in February 2010. Two provisions have already gone into effect, however: increased penalties and new breach notification requirements. HIPAA Privacy and Security Requirements Expanded The original HIPAA Privacy and Security Regulations applied only to covered entities (e.g., providers, plans). Covered entities were required to enter into Business Associate Agreements with those to whom they provided protected health information (PHI). Examples of such entities include billing and/or collections agencies, consultants, and technology vendors. ARRA modified these regulations so they now apply directly to business associates. This means companies that fit the definition of a "business associate" are required to do the following: n Conduct a formal risk assessment; n Appoint a security officer; n Implement safeguards to protect electronic PHI (i.e., encrypting emails and computer files, limiting access to PHI); n Develop written security policies and procedures; and n Train employees on HIPAA and how to protect PHI. HIPAA requirements must now be incorporated into the covered entity's business associate agreements. Business associates will now be subject to the same civil and criminal penalties for noncompliance as covered entities. STEPS TO COMPLIANCE: Review your business associate agreements. You will likely need to amend those agreements. You may want to take steps to assure your business associates are in compliance. New Requirements in the Event of a Breach Previously, HIPAA generally did not require covered entities to notify individuals or the Secretary of Health and Human Services (HHS) of a PHI privacy or security breach; business associate agreements only required business associates to report such breaches to the covered entity. Under the new requirements, HIPAA‐covered entities that have a breach with respect to unsecured PHI, or those that reasonably believe a breach has occurred, must notify each affected individual without reasonable delay and no later than 60 days after the discovery. Similarly, business associates with a breach must notify the covered entity within 60 days, identifying each individual whose unsecured PHI was, or is reasonably believed to have been, accessed or disclosed. In addition, if 500 or more individuals are affected, covered entities must also notify HHS. If the breach involves more than 500 residents of a geographic area, notice is to be provided to “prominent media outlets” servicing the region or state. Covered entities must also maintain a log of any 106

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breaches involving less than 500 individuals; this log must be provided to the Secretary annually. As defined by ARRA, unsecured protected health information is: health information not secured through the use of a technology or methodology specified by the Secretary in guidance. On April 17, 2009, the HHS Secretary issued guidance identifying two methods to render PHI unusable, unreadable, or indecipherable. The methods are encryption and destruction. These should provide safe‐harbor protection from notification requirements. This guidance is available on the HHS website. Breach notifications must contain the following: n n n n

Brief description of what happened, including the breach date and discovery date (if known); Description of the types of unsecured protected health information involved; Steps the affected individuals should take to protect themselves from potential harm; Brief description of how covered entity is investigating the breach, mitigating losses and protecting against further breach; and n Contact information (e.g., toll‐free phone number, email address, Web site, mailing address) to help affected individuals follow‐up. STEPS TO COMPLIANCE: 1) Review your practice’s policies and procedures to confirm they assure the security of PHI, including all billing information (e.g., insurance identification numbers, patient credit card information); and 2) update your office’s HIPAA policies and procedures to include the required breach notification. Access to Electronic Health Records (EHR) and Disclosures When PHI is maintained by a covered entity such as an EHR vendor, the new law gives individuals the right to request their information in electronic format from that entity at a reasonable cost. Covered entities may not charge a fee that exceeds the labor costs of responding to an individual request (as opposed to copy, labor and postage costs which are allowed under current guidelines). Most importantly, patients who have fully paid for a health care item or service out‐of‐pocket can prohibit disclosure of PHI to his or her health plan for payment or health care operation purposes (but not for treatment purposes). Existing law allows individuals the right to an accounting of certain PHI disclosures for up to six years, but not to otherwise permissible disclosures for treatment, payment or health care operations. Under the new provisions, individuals will also have the right to receive an accounting of all EHR disclosures made to covered entities or their business associates during the three years preceding the request for an accounting, even those for treatment, payment or health care operation purposes. This requirement will apply to disclosures for current EHR users beginning in 2014. For those not currently using EHRs, it will apply when the covered entity acquires an EHR or by January 1, 2011 whichever date is later. STEPS TO COMPLIANCE: This requirement will be particularly burdensome as it dramatically increases the records that will need to be kept and monitored by covered entities. Review your procedures for record keeping now. The sale of EHRs or PHI obtained from EHRs is prohibited unless the covered entity obtains a valid HIPAA authorization from the individual. The authorization must specifically permit such disclosure and should also specify whether the entity receiving the PHI can further exchange it for remuneration. Minimum Necessary Information HIPAA generally requires that covered entities limit PHI to the “minimum necessary” when using or disclosing PHI for purposes other than treatment. ARRA mandates that HHS issue guidance on what constitutes “mini‐ mum necessary” by August 2010. In the meantime, covered entities and business associates should reexamine their procedures for use and disclosure of PHI and limit the data set (i.e., excluding identifiers such as names, street addresses, social security numbers, telephone numbers) to the extent practicable.

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Expanded Enforcement and Penalties HHS has been the primary agency tasked with enforcement; few penalties have been assessed for violations. The new law will likely change this pattern substantially by increasing penalties for noncompliance. In certain circumstances, penalties will be mandated. ARRA also established tiered civil monetary penalties for violations occurring after February 17, 2009, including: n Minimum penalty for a violation where the person did not know and would not have known by exercising reasonable diligence: $100 per violation, not to exceed $25,000 per calendar year. n Minimum penalty for a violation due to reasonable cause: $1,000 per violation, not to exceed $100,000 per calendar year. n Minimum penalty for a violation due to willful neglect that is timely corrected: $10,000 per violation, not to exceed $25,000 per calendar year. n Minimum penalty for a violation due to willful neglect that is not corrected: $50,000 per violation, not to exceed $1,500,000 per calendar year. What Steps Should You Take Now? 1. Review your existing HIPAA privacy and security policies to determine where revisions will be necessary. 2. Identify areas where breaches of information have occurred in the past or could occur in the future. Determine what steps could reduce the risk of a breach. 3. Review your practice's HIPAA Notice of Privacy Practices and, if necessary, revise it. 4. Revise all Business Associate Agreements to incorporate the new HITECH requirements. Updates for the Billing Department ICD‐9 for 2009/2010 is here! ICD‐9 updates are effective as of October 1, 2009. If you haven't already updated your diagnosis list, NOW is the time. The existing ICD‐9 code set expansion and new code creation will help you report a range of conditions more specifically (and help get you ready for the transition to ICD‐10). Changes include: n n n n n n n n n n n n n

Well‐child and pre‐birth codes Immunizations Laboratory examinations Problems in newborns and children Colic and other gastrointestinal problems Conjunctivitis Gout Embolisms Peurperal infection Inconclusive mammogram Emotional signs and symptoms Speech disturbances H1N1

For a detailed discussion of the new codes, read the September/October issue of Family Practice Management at www.aafp.org/fpm. “ICD‐9 Codes for Family Medicine: The Short List” has been updated and is available along with and the “Long List” at http://www.aafp.org/online/en/home/publications/journals/fpm/icd9.html.

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New Codes for H1N1 Vaccine and Administration The first supplies of H1N1 vaccine are being shipped. Most plans will pay for the H1N1 vaccine administration, but will not pay for the vaccine itself because it is being provided free of charge by the federal government. CMS has created a HCPCS codes for vaccine administration (G9141) and the vaccine (G9142). Familiarize yourself with these codes and make sure to use the correct diagnosis code (V04.81: need for prophylactic vaccination and inoculation against certain disease, other viral diseases, influenza). Sample Medicare Claim Diagnosis Date of Service V04.81 MM/DD/YY

Place of Service 11

CPT / HCPCS G9141

Many commercial plans recognize HCPCS codes; but private insurers are not required to use G codes. Check with your respective carriers to see how they would like the administration billed (HCPCS (G) code or CPT code (90465‐90468 for children or 90471‐90474 for adults) for vaccine administration before submitting claims. Access the AAFP News Now article on getting paid for H1N1 vaccine administration. Check out these AAFP links for current procedural terminology codes: AMA Fact Sheet: http://www.ama‐assn.org/ama1/pub/upload/mm/362/ama‐fact‐sheet‐h1n1‐reporting.pdf http://www.ama‐assn.org/ama1/pub/upload/mm/362/ama‐fact‐sheet‐h1n1‐reporting.pdf H1N1 CPT Codes (AMA): http://www.ama‐assn.org/ama/pub/h1n1/resources/cpt‐codes.shtml

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