A HealthLeaders Media publication - HCPro · According to Terri Levine, president of Comprehensive Coaching U in North Wales, PA, there are six basic rules for managing conflict:

don’t ring up the right order. In a physician’s office, you can be dealing with serious life-and-death issues. And the other thing is that most physicians are Type A personalities. Just by the nature of who they are, they can create stress even if they don’t open their mouths.”

“�Even�though�I�understand�my�job�is�to�do�X,�I�am�still�a�human�being�bringing�my�own personal stuff into the workplace.”

—Terri Levine

continued on p. 2

Some practices handle conflict better than othersby John Commins

Spend enough time in a physician office—either as an employee or a patient—and you’re going to encounter conflict and tension.

For patients already anxious about their health, even during well visits, it can be partic-ularly unsettling to hear voices raised or accu-sations flying. It may be a receptionist dealing with a patient who has just been informed that his copay was raised. It could be an office manager confronting a billing clerk over a documentation error. It could be a physician assistant’s personal troubles spilling into the workplace. Whatever the reason, conflict is a cancer in the healing environment. It must be contained.

For years, Terri Levine, president of North Wales, PA–based Comprehensive Coaching U, has parachuted into stressed-out physician offices to negotiate an end to hostilities.

Conflict is part of humanitySo how’s business? “I’ve never seen a busi-

ness, a corporation, a physician office that doesn’t have conflict,” Levine says. “People are people. There is conflict in our experi-ence. It’s part of humanity.” By far, she says, the most prevalent form of conflict is among coworkers.

Because of the serious nature of the work in physician offices, stress—even on the best of workdays—will always be present. “There is more stress that we find particularly in medical doctor practices than in any others,” Levine says. “In a retail store, you mess up, you

A HealthLeaders Media publication

Conflict isn’t always about screaming matches at the front desk. “Sometimes one employee could be angry with another and could be with-holding information, being quiet, not giving them everything they need, forgetting to give important data and messages,” Levine says. “Anger. Talking behind the other employee’s back. Sarcasm. Those are the warning signs that something needs to be handled. Usually it is underneath the surface, and you have to look for it because it can become a shouting match.”

(For more help keeping the peace, see “Six rules for managing conflict” on p. 2.)

Zero tolerance

Paula M. Comm, practice administrator at PRA Behavioral, LLC, serving the northwestern suburbs of Chicago, says the head psychiatrist

INSIDE

April 2010 Vol. 29 No. 4

Security 3How to prevent medical identity theft at your practice.

Recruitment 5Reaching out to physicians in the digital age.

Compliance 7Must-have members of your RAC team.

Healthplans 9How to keep CDHPs from hurting your revenue stream.

TheBreakroom 12Physicians making progress on EHR adoption.

Conflictcontinued from p. 1


For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, please contact the Copyright Clearance Center at www.copyright.com or 978/750-8400.

2 The Doctor’s Office April2010 © 2010 HCPro, Inc.

at the practice has a zero-tolerance policy toward workplace conflict. “He hates conflict, and he really practices what he preaches,” Comm says. “Especially in a psychiatric practice, you don’t want someone coming to the window and feeling the tensions that are going on within the office because it’s so apparent.”

Comm says she is very aggressive in sniffing out work-place tension. And an effective way to do that, she says, is to get out of your office and stand in the hall and listen.

“I go up there and just stand. I can get a feel for what is going on immediately. I can tell by the tone, by the attitude. I have an office manager beneath me who isn’t attuned,” Comm says. “So I will go in and stand up there and go to her office and say, ‘Do you know that it’s tense up there?’ And she will say, ‘What do you mean?’ ”

Manage different personalitiesLevine says one major reason for conflict is personality dif-

ferences. “We have different beliefs and different philosophies. We have different stories and programs based on our past experience,” she says. “Even though I understand my job is to do X, I am still a human being bringing my own personal stuff into the workplace. I’m not going to like everybody else’s personality, and I may not understand exactly what I need to be doing, or there might not be the same communication style between a couple of employees.” (To determine what personality types make up your office, see “Five kinds of employees” below.)

Levine says personality profiling plays a prominent role when she coaches employees at physician offices. “Let’s say I find out somebody is a director type. They give quick infor-mation; they don’t like to converse. If I understand that per-son’s style, I can use behavioral flexibility and talk to them in that way,” she says. “If someone is more of a relater, they like to socialize, chit-chat. Then again we teach how to be more behaviorally flexible in that area.”

Levine says that many of the employees she coaches are surprised to learn of their personality type, but their co-workers aren’t. “I was with a group last month, and one

Six rules for managing conflict

According to TerriLevine, president of Comprehensive

Coaching U in North Wales, PA, there are six basic rules for

managing conflict:

1. Makesureyoutreatotherstaffmembersorpatients

calmly. “ ‘Calm’ is a word I teach. The second word I teach

is ‘mutual respect,’ even under pressure,” Levine says.

2. Keeppeopleandtheirproblemsseparate. If a person is

being difficult, it doesn’t mean he or she is a bad person.

It’s just a behavior that is being manifested.

3. Deeplytunein.Instead of thinking about what you want to

say, truly listen to the other person; pay attention to subtext.

4. Speakfromthecharge-neutralplace.After you have

thoroughly listened, which means you have to be quiet (a

difficult effort for most people), be objective.

5. Lookforcommonground.Levine suggests asking your-

self, “How can we mutually agree on something, even if

we mutually agree that you have an opinion and I have

an opinion?”

6. Exploreoptions. Take a look at your options to determine

the best way to solve the conflict.

Five kinds of employees

Different personality types can lead to conflict in the work-

place. “Once we understand how people respond, then we can

teach them how to resolve conflict,” says TerriLevine, presi-

dent of North Wales, PA–based Comprehensive Coaching U.

Levine identifies the following prominent personality types:

1. Thecompetitor.This personality type feels that he or she is

always right and does not back down.

2. Thecollaborator. This person uses a cooperative approach.

3. Thecompromiser.The compromiser tries to reach a

middle ground.

4. Theaccommodator.These personality types yield to others’

demands, even if they think they are right.

5. Theavoider. “This person totally avoids conflict but keeps

it within,” says Levine. “This is the person who could be

exploding at a patient at the front window.”



© 2010 HCPro, Inc. April2010 The Doctor’s Office 3

Educate staff members, patients in fight against medical identity theft

Educate your patients about playing an active role in fight-ing medical identity theft, make your policies tougher, and take a proactive approach to minimize the increasing risk, experts say.

Booz Allen Hamilton, a McLean, VA–based firm that was commissioned in 2008 by the Office of the National Coordinator for Health Information Technology to research medical identity theft in the United States, says all facilities can adopt the following strategies:

» Integrate identity theft into staff training. Organiza-tions should incorporate medical identity theft prevention into existing training and awareness programs, says Dan Steinberg, associate at Booz Allen Hamilton and coauthor of the Medical Identity Theft Final Report.

“A major step toward preventing medical identity theft is to be sure that staff are familiar with it and will have rea-son to suspect something is not quite right if the patient presents with conditions or demographics that don’t match their records,” says Steinberg. Make medical identity theft a separate discussion during training and orientation, and use friendly reminders to let staff members know that it remains an organizational concern.

In addition to giving tips on how to spot suspicious activity, educate staff members about what to do with that information. “If a provider discovers an identity theft, it must take immediate action to prevent further unlawful disclosures and should contact its legal counsel concerning

how best to notify affected patients,” says Bill Roach, JD, healthcare attorney at McDermott Will & Emery in Chicago.

» Educate consumers. Patients need to take a more pro-active approach to protect their personal information. But organizations must also teach patients about the risks, says Steinberg.

“Hospitals can also educate consumers about the value of ensuring the information in their records is accurate and up to date,” he says.

Develop educational material that urges patients to pay attention to personal information to which they have easy access.

Few patients, for example, actually read and understand the explanation of benefits notices that many insurers send consumers shortly after using medical services, says Steinberg. “It’s unfortunate because this is a mechanism already in place that can help detect medical identity theft,” he says.

» Verify patient information thoroughly. In the past, organizations did not often go the extra mile in order to verify each patient’s identity. Doing so is a challenge for staff members, particularly those in patient access, who may see dozens of patients each shift. Previously, organiza-tions simply took the patient’s word for it. Now, many

continued on p. 4

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person came out to be a director,” she says. “The rest of the group was all saying, ‘Yup!’ and the person said, ‘I didn’t think I was like that.’ Then as we went through spe-cific examples of how a director behaves, she said, ‘Yes, that is me.’ ”

Levine says the way to reduce conflict in the physician office is not to hire the same types of people, but rather to make sure each employee understands one another’s person-ality traits.

“We need a combination of personalities in the office. It’s better to have all different personalities. If you’ve got a

patient who needs TLC, get the relater out there, not the director,” she says. “If you understand how your coworkers function in the world, you can have some behavioral flexi-bility toward them and some more understanding of who they are.” H




organizations ask patients to present a form of picture identification.

“This measure can backfire, however, if staff [members] are not well trained on its purpose and use,” Steinberg says. He cites an incident involving a woman who tried to address a medical identity theft occurrence but was rebuffed. The woman was later able to prove that someone stole her license and health insurance information at the same time. “The intake specialist must not have challenged the woman who presented it as her own, despite the fact that the picture

on it was clearly not of her,” says Steinberg. Teach staff members the importance of examining the types of identifi-cation your organization requires. Doing so will go a long way toward preventing medical identity theft and catching criminals. H

Source

Adapted fromBriefingsonHIPAA,January 2010.

Medical identity theftcontinued from p. 3

Red flag notification procedure

Editor’s note: Use this policy as a template for your organiza-

tion in order to prevent identity theft. It is a sample from the

HCPro, Inc./Columbus Healthcare & Safety Consultants’ Red

Flag Manual and Training CD Package, a comprehensive training

package designed to help healthcare providers comply with the

Federal Trade Commission’s (FTC) Red Flags Rule. The FTC’s new

enforcement date is June 1. For the full template and to learn

more about the book, go to www.hcmarketplace.com/prod-8205.

The established chain of command for this policy is to imme-

diately notify your supervisor, who will bring it to the appropriate

member of the medical identity theft team.

The dedicated medical identity theft team members will consist

of the chief of staff, patient access administrator, practice manage-

ment administrator, practice management staffing coordinator,

patient financial services (PFS) director, PFS manager, HIM director,

privacy officer, risk management, and security officer.

Prevention of medical identity theft procedure 1. During preregistration, all intake departments will request per-

sonal identifying information from the patient. If electronic veri-

fication of patient registration reports a discrepancy or if other

identifying information is suspicious, it should be reported to

the supervisor. If an employee believes this key information is

assigned to another patient’s name in the system, immediately

notify your supervisor, who will bring it to the appropriate

position: the patient access administrator or the privacy offi-

cer. The patient access administrator or privacy officer will

decide, in consultation with the director of risk management

and/or security, the appropriate and necessary steps for this

patient registration.

2. Request identification at registration/admission/point of service:

a. All intake departments should request and review govern-

ment-issued photo identification (driver’s license, military ID,

or passport) at the time of registration or admission. If the

patient does not have photo identification, ask him or her

for two forms of non-photo identification (Social Security

card, school identification, utility bill, company ID, birth cer-

tificate, etc.).

b. If the patient is under 18 or is being admitted for emergen-

cy care services, the responsible party’s identification should

be requested.

c. Each time a patient visits, validate that the patient’s iden-

tification is official and record on the proper registration

screen that the validation was completed.

d. During the registration process, does the admissions screen

have a red flag alert? If so, contact a person on the dedi-

cated team. The patient access administrator or the privacy

officer will contact the patient’s physician and risk manage-

ment department on an as-needed basis.





© 2010 HCPro, Inc. April2010 Private Practice Success 5

“In terms of physician tech adoption, there is this percep-tion out there that new young kids coming out of medical school are really active in technology and older physicians are holdouts. But what we’ve seen in our studies is, over the past two to three years, that divide is shrinking,” Abreu Ressi says. “Older physicians are integrating that technology into their everyday practice.”

continued on p. 6

Recruitment

Use digital communication to reach physicians of all agesby Marianne Aiello

The idea began as a joke. Mary Thomson, vice president of marketing and PR at Abington (PA) Memorial Hospital, was talking to a specialist about the difficulties of contact-ing referring physicians to thank them for sending new patients. “You should have your top five referrers as your fab five in your phone,” she laughed. Her quip then sparked an idea.

“Specialists really should have the numbers in their phone, so when they’re coming out of the OR they can click a num-ber and even just leave a message,” Thomson says. “That goes a long way between physicians and relationship building and referral development.”

So Thomson and her team set about creating a smart-phone application that will allow physician leaders—all of whom have smartphones at the 504-bed hospital—to reach a referring physician’s back-office line in just a few clicks.

This example is simply one of the many ways that hos-pitals are turning to digital channels to enhance their phy-sician referral and recruitment communication strategies. Currently, 99% of physicians use the Internet and 64% use a smartphone—a number projected to jump to 81% in 2012, according to Manhattan Research’s 2009 Taking the Pulse study. And as physicians’ means of communicating change, practice recruiting methods must evolve along with them.

Everyone is on e-mailDigital communication, once thought to be primarily

effective among younger doctors, is now common among all age groups, says Meredith Abreu Ressi, vice president of research at the New York research firm.

“�Everybody�now�at�this�point�is�somewhat�computer�savvy�and�has�e-mail�addresses.�...�Even�physicians�who�have�been�in�the��practice�20-plus�years still respond to e-mail blasts and Internet job boards.”

—Rob Rector

Rob Rector, senior vice president of recruiting at Atlanta-based Pinnacle Health Group, says he has noticed universal e-mail adoption among the physicians he works with.

“Everybody now at this point is somewhat computer savvy and has e-mail addresses,” Rector says. “At one point I would have said [some generations are less tech savvy], but I think everything has caught up. Even physicians who have been in practice 20-plus years still respond to e-mail blasts and Internet job boards.”

Ways to connect onlinePhysician recruiters at Memorial Healthcare System,

located in Hollywood, FL, amped up their online presence



6 Private Practice Success April2010 © 2010 HCPro, Inc.

Rector suggests practices purchase lists from organizations such as:

» The AMA » Medical societies and associations, many of which can be

found on LinkedIn » Resident databases

“The biggest thing is trying to find the best list, because if you don’t get the correct list with the up-to-date e-mails, you’re going to get a lot of bounce back and a lot of blocks that aren’t doing any good,” Rector says. “When you’re purchasing a list, you should ask, ‘How did you get these and when was the last time you talked to them?’ A lot of the companies we get our lists from will call physicians and do a prescreen and get their information and e-mail address. If they do that and make con-tact with the physicians, we know that those lists are good.”

Looking past e-mail blastsThe next phase in digital communication as a referral and

recruitment tool will likely be online social networks, Abreu Ressi says. Physician-only networks, such as Sermo and Medscape Physician Connect, are continuing to grow.

“The other one to remember is Facebook, because last year we saw about one-third of physicians are using it in some capacity,” she says. “I expect it to be at least half when we do the [Taking the Pulse] study this year. They’re on there to con-nect with old friends, colleagues, and family members—but more and more are joining professional groups.”

Although digital communication is growing in popularity, recruiting via print hasn’t gone away just yet. “The outreach that we do for candidates has to be multipronged,” Dilts says. “The environment is very competitive, so we really utilize all resources, with electronic media being just one of those.”

Although it will be interesting to see how medical journals evolve as e-readers and other devices grow more prevalent, print is still a useful communication medium, Abreu Ressi says.

“Most physicians are doing both online and print in some capacity, so to cover your bases, you have to be sure you’re in both places,” she says. H

when they realized the growing importance of the Internet among physicians. They advertise on medical journal Web sites, subscribe to an online physician-only job search net-work, and post employment opportunities on the health sys-tem Web site. They, too, have noticed that digital adoption among physicians is now widespread.

“Technology has become pervasive in the industry, and most physicians, just like other walks of life, have some technical prowess,” says Sandra Dilts, administrative director of busi-ness development and physician relations at the seven-hospital system. “Whether it be responding by e-mail or text messaging, I think that it’s not entirely segmented. However, five years ago I would say that those that responded to online sourcing were the physicians that were newer in their careers.”

Just a few years ago, Memorial recruiters received the major-ity of résumés by mail or fax. Now, they receive about one fax every three months and receive the majority of résumés via e-mail. “We have an opportunity to be able to reach more people at a faster speed than ever and for them to respond just as quickly,” Dilts says. “It’s made it a 24-hour-a-day industry.”

The key to a successful integrated recruitment campaign is to ensure that snail mail and e-mail address lists are up to date, Rector says.

“Part of our strategy for reaching out to physicians is direct mail, which is still very good,” he says. “We are also listed on several different job boards and we have our own job board for Pinnacle Health Group. We also have started doing mass e-mail campaigns where we will get an AMA list or different lists you can purchase, and send e-mails with our direct mail piece images to all these physicians.”

Recruitmentcontinued from p. 5

Useful links for connecting with physicians

» Sermo: www.sermo.com

» Medscape Physician Connect: www.medscape.com/connect

» Facebook: www.facebook.com

» LinkedIn: www.linkedin.com

» AMA: www.ama-assn.org






© 2010 HCPro, Inc. April2010 Private Practice Success 7

Include specific departments when forming a RAC teamby Kimberly Anderwood Hoy, JD, CPC

The Recovery Audit Contractor (RAC) program has caused a lot of apprehension in the provider community. In response, many providers have elected to develop RAC teams to assess the risk to their organization prior to the beginning of the program and to handle requests once the program is under way. However, if not done carefully, a RAC team can end up pulling resources from other needed areas of the hos-pital in a disproportionate level to the threat posed by RAC recoupments. A carefully designed RAC team can minimize the effect on the hospital from both RAC recoupments and inefficient use of resources, including valuable staff and physi-cian time.

HCPro, Inc.’s RAC Preparedness Benchmarking Report surveyed providers on their preparations for the RAC program. There were more than 700 respondents from demonstration and non-demonstration states, as well as from each of the four RAC jurisdictions. This information will assist providers in their preparations by giving them benchmark information about how hospitals are preparing for RACs.

Strategy for building a RAC team When building a RAC team, consider whether you expect

the team to be a management group providing direction or a work group handling RAC responses. It is important to clarify the purpose of the group early on to ensure the cor-rect composition of the team. Some larger providers may need both. However, there is no hard-and-fast rule that cer-tain types or sizes of facilities need one or the other type of model. The culture and resources of the facility will dictate how to respond effectively to the RAC program.

A management group will consist of directors or managers who can provide direction to the staff in their departments as the team develops strategies, adopts policies, or establishes budgets. This type of group will generally have the ability to approve or move forward new positions as needed within the organization, as well as divide and assign work to current department staff members. Usually, it also has the ability to move forward budget allocation to RAC preparation efforts.

The RAC Preparedness Benchmarking Report indicates that a man-agement group is the most popular type of team providers are

forming. When asked which level of staff members were on their RAC team, more than 50% of providers indicated that they had a director-level individual from seven out of nine of the most common departments included in RAC teams. In fact, coding was the only department in which providers indicated using another level more than the director level, with 49% answering that they had an individual from the managerial level. Staff-level involvement ranged from 7% to 25%, with the highest percentage representing staff physi-cians, which could be considered quasi-managerial/directorial. Additionally, at least 68% of respondents indicated that their RAC coordinator was at a managerial level or above. RAC coordinator

Some providers have chosen to assign a RAC coordina-tor for purposes of assisting with RAC preparations and ongoing handling of RAC requests. In the RAC Preparedness Benchmarking Report, roughly half of facilities reported having a RAC coordinator in either a full- or part-time capacity, with 40% reporting they had a full-time RAC coordinator. However, the decision to designate a RAC coordinator will be influenced by individual provider budgetary constraints and should take into account the provider’s experience with RAC requests.

Health information management, including coding Another key department to be included in the RAC team is

the health information management (HIM) and coding depart-ment. The HIM department staff will have key tasks once the hospital starts receiving RAC requests. It will be tasked with timely submission of medical records for all requests received from the RAC and have the potential to be heavily affected in its day-to-day operations. Its input regarding available staff-ing resources and the need for additional internal or external resources will be invaluable. In the RAC Preparedness Benchmarking Report, providers with RAC teams identified HIM and coding as the most common backgrounds for coordinating their team because their participation is so important.

Even though coding often is a part of the HIM department, the coders’ role will be a bit different. Coders are important

continued on p. 8



8 Private Practice Success April2010 © 2010 HCPro, Inc.

determine specific roles for the physician involved with RAC preparations.

It will be important to have a physician who regularly attends and acts as a physician champion for initiatives and information coming from the RAC team. Such a physician can take real-time trends for inpatient denials back to medi-cal staff in specialties identified for RAC review. They also can assist on medical staff committees when medical staff policy changes are needed in conjunction with changes to hospital policy.

Most teams, however, also require physicians for more active tasks related to handling RAC requests. Case manag-ers or UR staff members may need a physician to assist in evaluating cases that are denied for inpatient medical necessity, especially if the cases do not fit standard screening criteria. Additionally, for cases singled out for appeal, physicians can assist in formulating the basis for appeal based on hospital medical staff policies and local standards of practice reflective of evidence-based studies applicable to their environment.

Departments that may be optional Other departments to consider for inclusion on the RAC

team include the following: » Patient access or registration » Chargemaster coordinator » Information services » Finance » Other clinical departments

Whether they are included may depend on the nature of the team, the culture of the organization, and even the issues eventually identified for review by the permanent RAC program. H

Editor’s note: This article was adapted from The RAC Survival Guide: Successful Management of Recovery Audit Contractors by Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compli-ance at HCPro, Inc.

in risk assessment and ongoing evaluation of appeals viability because the second most-identified area for improper pay-ments in the demonstration project was coding. The coders are essential in evaluating new coding issues posted by the RAC to determine whether the facility has a vulnerability related to those issues. If the provider begins to receive denials based on coding, it will be important to have the expertise of the coders to determine appeal strategies. Coders may be aware of nuances in coding guidance that make appealing a category of claims more or less practical.

Case management/utilization review A major focus of improper payments during the demon-

stration project was inappropriate settings or lack of medi-cal necessity for inpatient admissions. Case management or utilization review (UR) nurses will be vital to the team, not only for risk assessment and minimizing that risk going for-ward, but also for appeals evaluation and preparation. Their clinical expertise, as well as familiarity with inpatient and outpatient admission criteria, will be an invaluable resource to the team.

Additionally, although many of the nonclinical depart-ments have been dealing with audits of claims, denials, and claims error detection for some time because of other CMS initiatives, this is the first initiative that has really targeted and denied inpatient admissions for medical necessity on a broad scale. Their presence on the team will assist in devel-oping meaningful education for the clinical departments on what to expect and how to minimize risk. The information they will take back to their department and other clinical departments will be an invaluable line of communication related to medical necessity issues.

Physicians Physician involvement will be important for reasons

very similar to those for case managers or UR nurses. Approximately two-thirds of respondents to the RAC Preparedness Benchmarking Report indicated they would have a physician involved in some capacity with their team. However, it was troubling that many facilities had yet to

RAC teamcontinued from p. 7







The secret to high-deductible health plans (HDHP) and consumer-driven health plans (CDHP) seems simple enough: Collect the amount due while the patient is in your facility.

But it’s not that easy. HDHPs and CDHPs (i.e., HDHPs with an account attached) are nothing new, but for many providers, challenges persist.

Some healthcare organizations, both as providers and as employers, have embraced them, but others continue to struggle. Among the complaints: increased bad debt, delayed reimbursements, and higher cost to collect.

An operational issueDealing with HDHPs is not a contractual problem; it’s an

operational one, says Maria K. Todd, MHA, PhD, CEO and managing partner of Global Health Sources, LLC, in Pompano Beach, FL. Many hospitals and practices lack the internal sys-tems needed to deal with them effectively. Although an organi-zation can address some of these issues in payer contracts, most challenges posed by HDHPs can be addressed by changes in process and policy.

The goal, of course, is to have the patient pay his or her share at time of service. But making that happen can be difficult.

Start by determining whether the HDHPs are creating problems, says Jeffrey B. Milburn, Colorado Springs–based independent consultant at MGMA Health Care Consulting Group.

Monitor your accounts receivable (AR), says Milburn. What’s being written off? Which accounts are aging? Why? Once you identify the scope of the problem, you can embark on the solutions.

The effect may not be as significant as you think, says Jay Savan, CEBS, ChFC, CFP, principal at Towers Perrin in St. Louis. Savan says the effect on AR is often exaggerated, especially where CDHPs are concerned.

Moreover, market penetration is low relative to other plan types. A survey released in November 2009 by the Employee Benefit Research Institute (EBRI) shows that 4% of the population was enrolled in a CDHP and 13% in an HDHP.

If your analysis reveals that these plans are impairing timely reimbursements, the following advice may help.

Promote prompt payment from CDHP, HDHP patientsEmbrace the plastic

Consider creating a form that authorizes billing an HSA or a credit card at the time of adjudication, up to a fixed amount, says Todd. The process is much like a hotel stay: The patient’s card is run at registration and charged at checkout.

It can be simple, but it needs to be drawn up, or at least reviewed, by an attorney, Todd says. She’s seen several cli-ents create the form, and she’s signed them as a patient, as well. But they aren’t in widespread use yet.

Having a patient’s credit card number on file can be help-ful, but be mindful of the security risks, says Milburn.

Make patients check outSometimes the solution is as simple as office layout, Milburn

says: You want to close the loop.Even if you can collect money at registration, you don’t

necessarily know what’s going to happen in the exam room. An examination could turn into a procedure.

You want a way to collect any additional payment before the patient leaves, says Milburn. That means not only cre-ating a checkout procedure, but laying out the office so patients can’t leave unnoticed. Find a way to catch them on the way out.

Of course, without real-time adjudication, it’s not precise. But you can have a more realistic estimate after the patient leaves the exam room.

The approach not only aids collections, but you may dodge potential contractual and regulatory missteps by collecting after services are rendered, says Robin J. Fisk, Esq., principal at Fisk Law Office in Ashland, NH.

EducatePatients may not always be aware of how their plan works.

When the appointment is made, let your patient know what payment is expected in addition to explaining your cancel-lation policy, copays, etc. You don’t have to know the exact cost of the procedure, but you can give them an estimate and the percentage they will be expected to pay. “Be politely aggressive,” Milburn says.

continued on p. 10




address those issues themselves, they should be able to refer the patient to someone in the office who can help them fig-ure it out, Milburn says.

“A physician isn’t generally equipped to discuss the financial, tax, and related issues that surround ... coverage,” Savan says. Physicians will do better to refer the patient to someone who can.

However, the clinician does have another role, Savan adds: helping patients understand that treatment recommendations don’t change based on the level of coverage.

Check your contractsBefore altering your processes and procedures too dramati-

cally, review your contracts and your state law, Fisk advises.Most contracts Todd has seen allow for collection of the

estimated liability at time of service. But not all do.Fisk recently reviewed one that barred billing until after

the EOB had been sent.Review state regulations, too. For example, in New

Hampshire, the Department of Insurance cannot let providers collect up front, says Fisk. But they still can collect after the visit and before the patient walks out the door. (If the patient is out of network, you can collect the full amount up front, she says.)

Dealing with payersPractices and hospitals must examine their internal systems

and policies, but they also need to review the arrangements they have with insurers. Examine your cost to collect and your collection rate.

Make your staff and clinicians aware of the issues posed by CDHPs and other HDHPs. Milburn suggests creating scripts to help respond to patient questions or issues. For example:

Patient: “I left my checkbook at home.”Receptionist: “That’s okay. Here’s a stamped addressed enve-

lope. You can send your payment when you get home. If we don’t receive it in two weeks, we will add a rebilling charge.”

Patient: “But we don’t know what the insurance will cover.”Receptionist: “Let’s get a partial payment now. If insurance

pays more, we’ll send you a refund.”

Clinicians and cost conversationsIn the exam room, cost discussions become more difficult,

especially when patients start asking questions about treat-ment costs.

EBRI found that individuals in CDHPs in 2009 were slightly more likely than those with traditional plans to ask the doctor about other treatment options and costs and rec-ommendations for a less costly prescription drug.

The informed patient is interested in costs, but the clini-cian doesn’t have that information. A paper in the October 2008 American Journal of Managed Care (AJMC) found that phy-sicians are not prepared to advise patients on financial mat-ters such as the costs for treatment.

Although clinicians don’t necessarily need to be able to

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you waive the deductible.Keep in mind that CMS requires providers to use the same

hardship standard for all patients, Fisk says.

Embrace technologySeveral software vendors are developing—or have devel-

oped—technologies to address the point-of-sale benefit calcu-lation issue, says Savan. “To do so requires intelligence around the individual’s plan design and where the individual is in the course of satisfying their deductible and other out-of-pocket exposure,” he says.

It can be done, Savan says. He points to the CIGNA Cost of Care Estimator as one example. TransUnion recently launched one for hospitals.

But Fisk is not seeing real-time adjudication in her contracts.Even when such technology is available, it isn’t widely

used by providers, especially medical practices, Todd says. There is real-time adjudication on the plan side, she says, but practices aren’t connected.

Getting there from hereMany hospitals and practices are not up to speed on what

CDHPs entail. The AJMC paper found that many primary care physicians have low knowledge and limited practice readiness vis-à-vis CDHPs.

Savan agrees, but notes that “providers aren’t monolithic on the issue.” He expects to see understanding grow as more provider organizations use CDHPs for their own employees. “Those who have adopted and sought to really embrace/understand CDH have become almost cultic about it,” he says, citing Alegent Health and Baylor Health System as two notable examples.

“So yes, we’re on a learning and adoption curve, but as with most technological advances, there are those who embrace them and learn to leverage them, and those who dig their heels in and refuse to change,” Savan says. H

SourceAdapted from ManagedCareContracting&ReimbursementAdvisor, February 2010.

Prepare your argument to get rates that reflect true cost, says Fisk. The argument is simple: “You are hobbling me, and I’m losing money. Until you make it more user friendly, you don’t get my best rate.”

It’s not just about CDHPs and HDHPs; labels are irrelevant, Fisk says. This should be your approach to any provisions that cost your practice money. Your reimbursement should reflect true costs, including collections, she says. If the HDHP is cost-ing you more money, you need to make it up in your rates.

Reward payers who give you the tools you need by giving them—and only them—your best rates. Theoretically, you can request different rate schedules for different plan designs, Fisk says. Or you can have one schedule but use a multiplier of, for example, 1.07 for the HDHP and other more difficult plans.

If the insurer says that its systems can’t accommodate it, ask for a higher rate for everyone, Fisk says. In return for conces-sions, you can agree to keep your rate confidential. Your chances of success depend on how much leverage you have and how well you make your case.

Milburn isn’t convinced such a strategy will work. Providers can ask for higher rates for more difficult plan designs, but they aren’t likely to win them unless the provider has considerable leverage.

Savan offers an intriguing vision of the future that will obvi-ate such concerns. If CDHPs catch on with more employ-ers, that will drive greater cost and price transparency. When patients have that transparency, different rates for different networks may become passé. “Transparency is the death knell for provider networks,” he says.

Some surveys indicate that patients increasingly want to know what they are paying for. A national survey of recent hospital patients commissioned by TransUnion found that two-thirds of adults nationwide would like to see greater transparency in their hospital bill.

Consider hardship provisionsKeep in mind that many patients’ HDHPs don’t have

HSAs or health reimbursement accounts. They are underin-sured, Fisk says. If a patient cannot pay the deductible, you can decide to treat him or her as a hardship case. But be sure you do this in a structured fashion. You want language to that effect in the payer contract. If you make a good-faith determination that the patient is a hardship case, you want to be able to collect the insurance company’s portion even if




Make sure editorial board is updated



by Elyas Bakhtiari

It seems to be difficult—perhaps more difficult than it should be—to get an accurate estimate of the physician offices that are actually using electronic health record sys-tems (EHR). The go-to survey during the last year or so, when the Health Information Technology for Economic and Clinical Health (HITECH) Act and healthcare reform were being drafted, has been a Harvard Medical School study from 2008, which reported that only 17% of office-based physicians were using EHRs.

But a recent National Ambulatory Care Survey, con-ducted by the National Center for Health Statistics (NACS), suggests that number was much higher in 2008—above 38%. Preliminary data for 2009 put the overall adoption rate at 44%.

The discrepancy between the two estimates is pretty startling. The NACS reports that most of the decade’s growth happened in 2007 to 2008, when usage of EHRs jumped 19%. Perhaps the data in the Harvard study lagged a bit and just missed a major shift in adoption.

As the industry is learning from the process of developing meaningful use standards for the HITECH Act, so much depends on how you measure and define an EHR system. Adoption rates will vary significantly depending on whether we’re talking about a full-fledged system or a bare-bones EHR. Even in the NACS survey, only 4.4% of doctors reported having a fully functional system.

TheDoctor’sOffice (ISSN: 0733-2262 [print]; 1937-7460 [online]) is published monthly by HealthLeaders Media, 200 Hoods Lane, Marblehead, MA 01945. Subscription rate: $199/year. • TheDoctor’sOffice, P.O. Box 1168, Marblehead, MA 01945. • Copyright © 2010 HCPro, Inc. All rights reserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HealthLeaders Media, or the Copyright Clearance Center at 978/750-8400. Please notify us immediately if you have received an unauthorized copy. • For editorial comments or questions, call 781/639-1872 or fax 781/639-2982. For renewal or subscription information, call customer service at 800/650-6787, fax 800/639-8511, or e-mail:[email protected]. • Visit our Web sites at www.hcpro.com or www.healthleadersmedia.com. • Occasionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be included on this mailing list, please write to the marketing department at the address above. • Opinions expressed are not necessarily those of TDO. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions.

Group Publisher: Matt Cann

Executive Editor: Rick Johnson

Senior Managing Editor: Debra Beaulieu [email protected]

Editorial Board JOELV.BRILL,MD,AGAF,FASGE,FACG,CHCQMChiefMedicalOfficerPredictive Health, LLC Phoenix, AZ

CHARLENEBURGETT,MS-HCM,CMA(AAMA),CPC,CCP,CMSCS,CPMAdministratorNorth Scottsdale Family MedicineScottsdale, AZ

JENNIEL.CAMPBELL,CMPECOOSummit Medical GroupKnoxville, TN

JUDYCAPKOPresidentCapko & CompanyThousand Oaks, CA

JEFFERYDAIGREPONTSeniorVicePresidentofBusinessDevelopmentThe Coker GroupRoswell, GA

KENNETHT.HERTZ,CMPEPrincipalConsultantMedical Group Management AssociationAlexandria, LA

JILLLEWISCEOUrology Austin, PLLCAustin, TX

MAGGIEM.MAC,CMM,CPC,CPC-E/M,ICCEConsultingManagerPershing Yoakley & Associates, PCClearwater, FL

Physicians making progress on EHR adoptionSo the overall adoption rate is somewhere between 4.4%

and 44%, depending on how optimistic you want to be and which survey you use.

But the real takeaway from the latest survey isn’t just the absolute adoption rate. It’s the progress that has been made. In the past decade, using the NACS estimates, physi-cian adoption has climbed from 19% to 44%. That’s pretty impressive and contradicts much of the conventional wisdom about physicians’ struggles.

There have been challenges. EHR systems are expensive. Reimbursement has been stagnant or falling. Installing the systems can be disruptive, and some physicians still aren’t convinced that they are worth it.

But despite all of that, physician practices are find-ing ways to move forward and prepare for the future of healthcare, and they are now in a position to receive $44,000 for their efforts.

Suddenly the HITECH Act’s ambitious goal of near-widespread adoption by 2014 seems more achievable, even if the industry is still likely to fall short. There is certainly less ground to cover.

Many challenges remain, particularly for small and rural physician practices. But I’m convinced, particularly after these latest numbers, that physicians can overcome them. Roughly 44% of physicians have already started paving the way.

Even for those pessimistic about EHR adoption, the glass is nearly half full.

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A HealthLeaders Media publication - HCPro · According to Terri Levine, president of Comprehensive Coaching U in North Wales, PA, there are six basic rules for managing conflict: