March 2008

Employers face several recruitment challenges. This is due not only to a competitive market, but also to the changing workforce. There are several different types of workers, which brings an increased amount of diversity that must be addressed when contemplating staffing your office.

In recent years, more women have entered the work force, the work force is getting older, and there is an increase in the variety of religious and cultural affiliations of potential employees. And, of course, college graduates are entering the work force.

In order to be an attractive employer, you may be confronted with the need to be flexible to workers’ changing needs. This means learning new ways of communication, understanding the changing mindset of workers (older v. college grads), or providing on-the-job training, education and alternative working arrangements for employees.

Why Are Candidates Interviewing?

There are several reasons as to why a candidate might be interested in pursuing employment opportunities. Some of them are: relocation, growth, money and benefits. Naturally, the candidates will want to hear about their interests during the interview process. Studies by the American Management Association have shown that candidates consider the following during the interview process:

• Growth opportunities
• Courtesy during the entire process
• Desire for meaningful work
• Ethical working environment
• Flexible start date
• Vacation/personal time
• Flexible working arrangements
• Benefits
• Employee assistance programs

When faced with a staffing need, start by asking yourself this question: What do I want to see in a prospective candidate? Perhaps some of your answers include: stability, skills, relevant experience or a logical progression in career/positions.

Next, ask yourself: What don’t you want to see in a prospective candidate? Your answers might include: job hopping, no related experience, radical changes in career path or a lack of required skills.

The next logical step would be to make sure you don’t hire the people you don’t want. You can accomplish this goal by doing a little homework prior to beginning your recruiting and interviewing process.

Pre-Recruiting Preparation

In order to effectively and efficiently locate the candidates you need, you must be familiar with the position you wish to fill. Your familiarity should be such that you could easily explain all the essential details of the job, as well as your expectations of the person who performs it, to a potential employee. You can do this by asking yourself four key questions:

1. Am I thoroughly familiar with the qualities being sought in an applicant?
2. Are these qualities both job-related and realistic?
3. Can I clearly communicate the duties and responsibilities of this position to applicants?
4. Am I prepared to provide additional relevant information about the job and the firm to applicants?

By analyzing and answering these questions, you will be able to develop an iron-clad sense of the position you wish to staff, as well as the type of candidate you visualize in the position.

Recruiting Made Easy

The easiest way to recruit any candidate is to get the best people to seek you out. Market yourself as a great employer! You can do this by establishing yourself as the best employer in the industry. You can emphasize what sets you apart from other practices (like great benefits or a flexible schedule). Ask your current key employees to help you in recruiting

Of course, one of the easiest ways to make you an attractive employer is to find out what potential employees are seeking and offer it to them. Finally, recruit in the specific market most likely to get the results you want. Some considerations might include whether you want to market yourself locally or nationally. There are plenty of job boards on line that can meet every marketing need.

Once you place an ad, you will need to start screening the resumes you receive. Consider the answers to your four key questions when reviewing these resumes, to make sure you are finding candidates that match your needs and requirements. In addition, be wary of any “red flags” on a resume. These may serve as warnings to you, or perhaps help you develop questions you would like to ask during the interview process. Some common resume “red flags” are:

• Blanks or omissions
• Time gaps between jobs
• Overlaps in time
• Frequency of job changes
• Carefully review the applicant’s reasons for leaving previous jobs
• Ask! If the applicant’s duties are not clearly described on the application or resume, ask for a detailed description

Once you have screened your resumes, schedule your interviews in a timely manner. In a tight job market, candidates do not last forever!

If you find this process to be too time consuming, you might consider calling a staffing agency that specializes in medical staffing. Staffing agencies can offer recruiting expertise, taking away the stress of coordinating and conducting an employee search. For a small fee (usually payable upon successful staffing of a position), a staffing agency recruiter can assist with temporary or permanent staffing needs. The recruiter will already have a pool of candidates from which to choose to help immediately address your staffing concerns. In addition, the agency can place advertisements on your behalf, screen resumes, conduct interviews and background checks, and present only the best and the brightest candidates for your consideration.

This article was written by Paramount Staffing. For more information, contact www.paramountstaffing.net.

January/February 2008

Medical practices face an environment of declining Medicare and Medicaid reimbursements coupled with increased administrative costs to recover these shrinking revenues. Many medical practices are considering owning their own building as a way to increase their revenue and add an appreciating asset to their practice. Purchasing commercial real estate, however, is very different from purchasing your home and mistakes can result in the loss of hundreds of thousands of dollars. This article will discuss the three major aspects of the real estate transaction: the purchase contract, due diligence and securing the financing.

The purchase contract memorializes the essential terms of the real estate transaction between the buyer and seller. Unlike residential contracts, a commercial contract is typically not a standardized form agreement. Commercial form contracts do exist, however, these standardized forms never address the myriad of unique issues that come up in commercial real estate transactions. In a situation where a practice is looking to acquire a medical office building with existing tenants a vague form can have dramatically bad consequences. For example, these form contracts may only require a seller to make a good faith effort to obtain a letter from a tenant certifying that his lease is not in default. Most banks, however, will not fund a transaction unless they receive this documentation from every tenant. If this situation occurs once the buyer’s earnest money has become non refundable, the transaction will not close and the buyer will forfeit the earnest money.

The contract must also address how the seller will resolve any title problems that arise during the due diligence period. In certain contracts, the seller may choose not to remedy these problems, in such case the buyer should be able to terminate the contract and be refunded the earnest money. Alternatively, the buyer may choose to close the transaction and deduct the payoff of any of seller’s mortgages from the amount due to the seller. The goal here is to provide the buyer flexibility in determining how it wants to resolve title problems.

The due diligence process is really what separates the commercial transaction from the more familiar residential one. In a commercial transaction, the buyer should typically perform the following due diligence: (1) obtain a title report on the property; (2) perform a Phase I environmental survey; and (3) review a current survey of the property.

A commercial title report will describe all the issues that affect title to the property. Many issues can arise from a title report that will impact the ability to timely close a transaction. These issues might include, unsatisfied security deeds, defective chain of title, unpaid taxes, improper zoning or failure of the property to have all the proper easements for parking or utilities. The Phase I environmental survey is typically required to confirm there are no environmental issues related to the property. It is important to discuss the environmental survey with the bank as many banks will require that this environmental survey be conducted in order to finance the purchase of the property. If the report discloses any environmental issues, that will lead to a more detailed Phase II report. A Phase II report can significantly increase the cost of the transaction and delay the closing depending on what such report reveals about the property condition. Lastly, the survey is a critical component in the due diligence process as it reveals any encroachments on the property that come from adjacent properties. It also plots the location of all the easements that affect the property to confirm the property can be used for its intended use. A survey might also reveal the parking lot servicing the property is actually located on the adjacent property. It may also indicate that the water from the property runs off into a detention pond on an adjacent property and there is no easement permitting such water runoff.

The third important aspect in a real estate transaction is financing. Prior to obtaining a loan commitment from a bank, the bank will require that the medical practice submit financial statements, tax returns and the personal returns of the practice owners. In the current tightened credit environment, the lending institution will closely scrutinize this information. If the practice is aware of any financial issues it is best to work with the lending institution at the outset to resolve them. The medical practice does not want to forfeit earnest money because the bank will not fund the loan because the practice failed to timely inform them about a financial issue. Most traditional bank financing will require that the practice owners sign a personal guaranty to personally guarantee the loan by the bank. This can become a very sensitive issue if a practice owner wishes to retire but the bank will not terminate his personal guaranty. In such situations, the bank might be persuaded to terminate the guaranty if the practice pledges additional collateral or pays down the principal amount of the debt. The bank’s willingness to terminate the guaranty is directly related to the financial health of the practice and whether or not it needs the added protection of the continued personal guaranty.

Medical real estate continues to grow at a rapid rate in response to the continued trend of medical practices owning real estate. The purchase contract, due diligence and financing are key pillars to successfully concluding a commercial real estate transaction in a timely fashion. Medical practices who pay attention to the details of the real estate transaction will be rewarded with a timely closing while those who do not will find the lessons learned painfully expensive.

Justin S. Daniels is a health care partner at the law firm Wagner Johnston & Rosenthal, P.C. in Sandy Springs, and can be reached at (404) 261-0500.

The information in this article is for informa¬tional purposes only and is not legal advice. Use of this article does not create an attorney-client relationship between you and Wagner Johnston & Rosenthal, P.C. You should not act upon the information in this article without seeking ad¬vice from a lawyer licensed in your own state or country. Please note that you should not send any confidential information pertaining to potential legal services to Wagner Johnston & Rosenthal, P.C., until you have received written agreement from Wagner Johnston & Rosenthal, P.C. to per-form the legal services you requested. Unless you have received such written confirmation, the firm will not consider any correspondence you send it as confidential.

Employee Retention Through Personality Profiles

January/February 2008

By Charity Q. Boulton, CMPE

Medical practices are notorious for their high rate of employee turnover. With the many hats practice managers wear, it is easy to neglect the financial and emotional value of employee retention. Most of us have some form of employee programs aimed at retention whether it is through group recognition for achievements or appreciation luncheons. We are comfortable with this form of acknowledgement. However, there are other ways to show appreciation and respect through deeper understanding.

Does the idea of touchy-feely management make your stomach do a flip-flop? You are not alone in the medical practice management arena. Many of us can barely keep our heads above water; much less invest time and energy into the feelings of our staff. However, understanding the “why” behind employee behavior can be a worthwhile investment.

It is not an uncommon experience to ask the same request of two staff members in exactly the same way and get opposite responses. One may respond positively while the other may react defensively. It could be related to their personality preferences, which affects how they perceive and react to others.

So much of what we do as a manager, at any level, depends on our understanding of others. How do we effectively discuss, motivate and instruct our staff if we don’t take the time to analyze what forces are at play with the decisions, choices, and responses that they make? Our personality, along with each staff member’s personality, combines to create a unique office culture that affects every aspect of our practice.

Throughout our careers, most of us have completed personality profiles using methods that vary as much in sophistication as they do in results. How many of our front line staff members have had this opportunity? And after doing our own profiles, how many of us are adept enough to extrapolate that data to meaningfully define someone else? The answer to both is very few.

From a management perspective, personality tests can help you understand a person’s motivating factors. This information is helpful during the hiring process as well as during orientation, training and succession. Hiring the right person for each position is the first step. Effectively communicating with the new employee to make he or she and the practice get the most from the employment relationship is crucial.

The assessments help not only managers; but also, co-workers to find an effective approach to communicating with one another. I chose to have each member of our practice complete the DISC profile this past fall. This is an assessment similar to the Myer’s Briggs profile that is widely used in the mental health profession. It breaks personality types into four pure styles (Dominance, Influence, Steadiness and Conscientiousness) with over 380 blended styles that include 2 or more of the pure styles. It also takes into account a person’s natural tendencies compared to their work or stressed tendencies. It is more detailed than some of the personality profiles that compare styles to lions, koala bears, monkeys and owls; but is still easy to teach and understand.

Each person had a couple of weeks to sufficiently review and absorb their profile. During this time I welcomed all questions, which meant I had to understand the metric fairly well. Fortunately, most of the vendors I spoke with offered good resources and support for my new topic of interest.

At the following month’s staff meeting I compiled my resources and the staff’s frequently asked questions. I spent an hour discussing and teaching the DISC profile with a singular purpose and four goals. The stated purpose was to help everyone better understand their own motivations and how to communicate more effectively based on the “typical” motivations of other styles. The four goals to be accomplished were: to provide a broad overview of DISC; assist each employee in understanding their profile; teach each employee to recognize the main styles without the DISC assessment; and identify the different communication tendencies and needs of each style.

The most difficult goal to attain was to arm them with the tools to recognize and adapt to the general personality types without the benefit of a DISC profile to read. Again, I relied on the vendor’s resources for games and exercises to illustrate and emphasize the points. Surprisingly, while my goal wasn’t team building or morale boosting, the general understanding, acceptance and the trust that came from sharing with each other did, in fact, have that secondary effect.

Additionally, without betraying confidences, I graphed each employee’s work personality in the four quadrants of the DISC square using generic indicators. We discussed which types of personalities would best fit each job type in our office to demonstrate that our diverse job responsibilities require different cognitive and personality styles that naturally put medical practice employees at odds. This further underscored that the saying “it takes all kinds to make the world go around” parallels the world of a medical practice as well

Here’s how the four different personality styles might fit into a typical medical practice.

• Dominance – doctors, administrators, managers
• Influence – customer service, receptionist, drug representative
• Steadiness – medical assistants, nurses, medical records, data entry
• Conscientiousness – coders, bookkeepers, and compliance officers

With the advent of the Internet, the administration of these tools has never been quicker, easier, or less expensive. For about $30.00 and 10 minutes per test you can gain more in-depth knowledge than you could ever glean from pure work exposure. And for a couple hours of your time to educate yourself and your staff you can gain countless hours and dollars in employee satisfaction, increased morale and, of course, employee retention.

If you are interested in learning more about how to use personality profiles in the management of your staff, look for an upcoming Atlanta MGMA educational meeting focusing on this topic in 2008.

Charity Q. Boulton, CMPE is the Practice Administrator for the North Fulton Internal Medicine Group and the incoming president of the Atlanta Medical Group Management Association (AMGMA).

November/December 2007

For the past six years, Cheris Craig has been Practice Administrator for Atlanta Women’s Obstetrics & Gynecology, PC, where she is responsible for almost everything aside from treating the patient medically, including financial management, marketing, collections and patient satisfaction. Craig, who recently took on the role of President of the National Medical Group Management Association (MGMA) Obstetrics & Gynecology Assembly (OBGA), spoke with M.D. News about increased expenses and decreasing reimbursement and how being a part of the MGMA helps her tackle daily challenges.

What challenges does your practice face in the upcoming year?
Practice management on a daily basis is like fire fighting. Dealing with staffing, cash flow, accounts receivable and operations every day is time consuming. However, there are definitely some hot issues on the horizon for not only OB GYN practices, but also medical practices in general. Continually decreasing reimbursements, increasing expenses, diverse workforces and increasing administrative burden are just a few of the hot topics headed our way for 2008.

Can you address one area of decreasing reimbursement?
Medicare is currently phasing in a 75% reduction in the reimbursement for bone densitometry scans, a screening test for osteoporosis. Reimbursement is slated to decrease from approximately $140 per scan in 2006 to around $35 per scan by the year 2010. Other insurance carriers will follow Medicare’s lead and so many practices like ours will be forced to make tough decisions about preserving osteoporosis screening as a service to their patients. Many practices, especially smaller ones, will be forced to liquidate or scrap their equipment and its associated staff because it won’t be financially feasible to maintain it.

Can you address one area of increasing expenses?
It seems there are cost increases around every corner. It shouldn’t be too hard to find one. Insurance premiums are a great example. Whether professional liability or health insurance, our premiums increase about 5% to 10% per year. Premium increases always have a direct impact on compensation. In the case of professional liability, the additional premiums are subtracted from the physician’s salary. In the case of health insurance, the additional premiums can be absorbed by the practice, which would further reduce the physician’s salary; absorbed by the staff, which would reduce their take home pay; or shared between the two. No matter how you divide them, premium increases are generally outside the manager’s control and negatively impact salary, employee retention and morale.

Can you address one challenge of a diverse workforce?
Today, we have many generations in the workforce. Managers cannot approach staffing in a cookie cutter fashion because employees want and need different things from their employers. The diversity forces managers to offer a myriad of schedules, benefits and training programs. Generation X employees are generally more computer savvy and often want to see instantaneous results from their work. Baby Boomer employees may need additional training on technology-driven components of their job. Women in the workforce are looking for flexible schedules to help them balance their professional and personal lives.

Can you address one way that your practice’s administrative burden is increasing?
The never-ending cycle of lab exclusivity agreements is a great example of increasing administrative burden. It seems now somewhat fashionable for insurance companies to restrict physicians to one preferred laboratory. Unfortunately, these restrictions add to a practice’s challenges rather than help increase its efficiencies. Practices are forced to deal with multiple labs and decipher which laboratory to use based upon the patient’s insurance coverage. Managing different forms, test codes, interfaces, tracking systems and result systems increase costs, decrease efficiencies and cause patient access and patient care issues. Patients have very limited knowledge of these restrictions, and the practice is left to absorb all the additional work and expense, which can include monetary penalties assessed by the insurance carrier for choosing the wrong laboratory. The system would run a lot smoother for everyone if the physicians were allowed to choose a laboratory based upon service, turn-around time and other clinical factors.

How does being part of MGMA and OBGA help you address the challenges you described?
MGMA is a great resource. The organization listens to its members and takes action. On a national level, MGMA influences many facets of the medical practice industry. Its influence and most importantly its understanding of our industry is imperative to the success of medical practice management. MGMA offers its members research tools, benchmarking tools, educational programs and most importantly networking. Networking by specialty such as OB GYN is offered through specialty societies such as the Obstetrics & Gynecology Assembly. Specialized list-servs, educational sessions and benchmarking tools are readily available online, which is essential to managing a successful medical practice in today’s healthcare environment and maintaining your sanity.

For more information on the Georgia chapter of MGMA, visit www.gmgma.com.

October 2007

Charity Boulton is a “technology-lover.” As the Practice Administrator for the North Fulton Internal Medicine Group for over 13 years, Boulton relies on all that today’s modern electronics have to offer. Whether it is e-mail or certain computer programs, Boulton relies on these tools to make her office run smoothly and as the incoming president of the Atlanta Medical Group Management Association (AMGMA). M.D. News spoke with Boulton about her role as a Practice Administrator and the incoming president of the Medical Group.

What are some of the challenges you face as a practice manager?

As the practice manager of a 5-provider internal medicine practice, I face the same challenges as many of my colleagues both in small and large practices alike. While some are specific to primary care many span all specialties and range from physician compensation and contracting to human resources and emerging legislation. You know the saying “Jack of all trades, master of…” Well, I wouldn’t say master of none. I would say master of some and for everything else there’s a resource. That’s where being involved in my local, state and national associations comes into play. Having the ability to network with managers in my locale and/or in my specialty gives me the resources to effectively wear the many hats that are required of a practice manager.

How does being a part of Atlanta MGMA help you address these challenges?

Atlanta MGMA brings numerous opportunities to its members. Whether you call yourself an office manager, a practice manager, a practice administrator, or a CEO Atlanta MGMA has something to offer. At the 5 educational sessions held each year, the association offers cutting edge topics presented by well-informed, professional speakers, many of whom are national MGMA speakers. In addition to the dissemination of useful information, I am able to network with my colleagues which many times means being able to pool our resources to affect a needed change either in my specific practice or across the industry.

What is your practice doing about Pay for Performance (P4P) and Physician Quality Reporting Initiative (PQRI)?

We have participated in several pay for performance programs, some more successfully than others. I have found that the P4P programs that are interactive and that do not benchmark solely from claims data to be the most beneficial for reaching the practice’s and the insurance company’s mutual goals. There are many reasons why claims data is not the best way to benchmark actual procedures performed. Chiefly, it is difficult for any plan to properly capture everything due to claims errors or when a patient utilizes a facility outside of the plan. It further complicates things to reward or penalize based on a previous year’s data that has known flaws.

An interactive P4P program allows you to look at the patient panel ahead of time to see if you meet the guidelines and have the data for the exceptions. After all, isn’t the goal to ensure the proper testing and treatment is provided for the patients? Blue Cross Blue Shield rolled out their first interactive program this spring. The exchange of real time information between BCBS and our office, which can only be credited to improved technological resources, made for a very successful program. While having an EMR (electronic medical record) system made tracking the data and auditing the results much easier, participation is still a very time consuming process.

As far as CMS’ version, PQRI, we are not quite ready to jump on board in its inaugural year. As the Legislative Liaison for the national Primary Care Assembly, I try to stay abreast of emerging legislation. Currently, there is pending legislation regarding the funding of the program for 2008 that may make participation voluntary without financial incentive. The pending bill, HR 3162, rededicates the 2008 PQRI budget to thwart the looming 9.9% physician fee schedule reduction (a.k.a. Sustainable Growth Rate reduction) in 2008 and the 5% 2009 SGR reduction in 2009. While I think PQRI could be beneficial once all of the kinks are worked out; I think the reallocation of funds would be better spent in direct reimbursement to physicians for their work instead of a convoluted program that could cost physicians as much to facilitate, as they would ever gain in increased reimbursements.

How is your practice coping with the new generation of technology driven patients?

As patients are getting used to the security of online banking and other online transactions they are warming up to and asking for online access to their doctors. Prior to implementing an EMR this past fall, we didn’t have a lot of innovations to offer to our “techie” patients. In fact, other than one-way email communication from our patients to a group email box we didn’t have much in place at all. However, our EMR system offers a patient portal in which patients can view their appointments, review approved lab tests, pay their bills online, and communicate with their provider. While we have purchased and installed the necessary enhancements and begun the set-up process for this feature, we haven’t fully implemented it. It is my goal to roll this functionality out to our patients this fall.

What is your practice doing about the new legislation requiring Medicaid prescriptions to be written on tamper resistant prescriptions?

This has been a hot topic recently on the national MGMA email forums as well as the Georgia MGMA email forum. Many questions have been raised regarding the definition of “tamper-resistant.” We looked for guidance from the Washington MGMA Office, which forwarded CMS’s clarification on the provision. They stated that tamper-resistant prescription pads must meet one of the following characteristics for Oct.1, 2007:

• Contain one or more industry-recognized features designed to prevent unauthorized copying of a completed or blank prescription form;
• Use one or more industry-recognized features designed to prevent the erasure or modification of information written on the prescription by the prescriber; or
• Include one or more industry-recognized features designed to prevent the use of counterfeit prescription forms.

By Oct. 1, 2008, prescription pads must meet all of the above characteristics to be considered tamper-resistant. Under the guidance, CMS has given flexibility to state Medicaid directors to determine exactly how each state will meet the new requirement. Note that states that currently have laws and regulations governing tamper-resistant prescription pads will be considered in compliance with the CMS guidance (MGMA Washington Connexion, August 2007).

Our office faxes and sends the majority of our prescriptions electronically. For the prescriptions that have to be written out we fall back to our standard prescription pad, which already incorporates an industry recognized standard. Much like your checks would, the word void appears when the prescription is copied. I think many offices are already in compliance just by using what they have always used.

To learn more about the AMGMA, visit www. atlantamgma.com.

September 2007

By Robert Nebel

Glenna Masters, president of the Atlanta Medical Group Management Association and a healthcare professional for over 20 years, recently spoke with M.D. News-Metro Atlanta Edition about the organization’s mission and status in the medical community.

M.D. News: How long have you been President of AMGMA?
Glenna Masters: I have been serving since January 1st. It is a one-year term. The President progresses through the board. They start out on the committee, then hold an office and then are president. I joined Atlanta AMGMA five years ago.

MDN: Who is involved in AMGMA?
GM: It’s mostly practice managers, practice administrators. Depending on the subject manager, they have some of the billing staff come along.

MDN: What do meetings cover?
GM: We speak about legislative, personnel and billing issues. We talk about everything related to the medical practice.

Lately we have been discussing the changes with Medicare and Medicaid and how they pertain to all of our specialties.

MDN: Any specific changes?
GM: The only thing that has been changing is a new program where the doctors are reimbursed miniscule amounts for doing a lot of paperwork.

MDN: How does your organization keep abreast of changes?
GM: We have a program committee and a board that keeps everyone aware of these changes.

MDN: What billing issues do you discuss at your meetings?
GM: We have someone come occasionally and show us the proper way to code procedures and diagnoses and things like that. Sometimes we have the payers like Medicare, Medicaid, United Health Care and Aetna demonstrate they way they operate and make attendees aware of their changes.

MDN: How has Atlanta AMGMA addressed the transition from paper to electronic billing?
GM: One of our programs was on electronic medical records. Several vendors came to display their products.

MDN: What challenges do you face as President?
GM: The biggest challenge is finding programs that are of interest to managers so that they will attend. It’s difficult because you hear the same things over and over. I try to get differing viewpoints.

Sometimes just the title of the program pulls the managers in-most of the time if it has something to do with the financial end of the practice or a personnel issue. Those are big draws.

MDN: With so many differing opinions in the medical field, are there meetings where there are a lot of sparks flying?
GM: Sometimes there is a little controversy, but nothing major has happened. We have at least one program that has a roundtable discussion with administrators and managers who bring up one topic to discuss. It works really well. We had a big crowd this year.

MDN: What are the benefits of being the group?
GM: It is the knowledge that you pick up and the networking. Whatever specialty you are in, there is always someone who is in it. It is great because you can always compare notes.

MDN: Where are the educational seminars held?
GM: Ours are at the Ashford Club at the Glenridge Connector. With Georgia 400, 285 and 85 nearby, it is accessible for many of our members.

MDN: How long have you been a practice administrator?
GM: For over 20 years. Before that I worked part-time in a medical office doing transcription and posting charges. I also stayed at home with the kids.

The AMGMA works to foster and increase knowledge of and proficiency in medical practice administration. Member benefits include educational sessions and networking meetings, access to supporting member companies, continuing education credits and discounts. Educational seminars cover a range of topics. As an example, one recent meeting titled Ways to Reduce Costs in Medical Practices featured tips and anecdotes from on how to reduce annual spending.

July/August 2007

By Jill Medzelewski

In a time when reimbursement seems to decrease while expenses increase, some medical practices are struggling to bring in revenue. Many are taking big steps, such as putting together joint ventures, merging with other practices, or investing in ancillary equipment. However, not every practice has the time and the means to take such complex and expensive measures. The good news is that there are other, simpler ways to quickly and efficiently bring revenue into your practice. Following are the three steps that I most often recommend when I visit practices experiencing cash flow issues:

1. Review your practice management system to verify all patients are receiving statements. Recently, I was in a practice that had a “programming glitch” in its practice management system that only allowed patients to be sent four statements–for life! If patients had been visiting the practice for several years and had already received a total of four statements, the system would not allow them to receive any more. There were countless co-pay and deductible balances for which patients were not getting billed.

Review your own system; check to ensure all your patients are receiving statements. If you are generating manual statements, stop! Most practice management systems will allow you to batch statements electronically, and will even mail them to the patients for you. This is almost always cheaper than doing it yourself.

2. Verify insurance. Merely glancing at a patient’s insurance card does not always verify their current insurance status. For example, a patient could present a card for an insurance carrier that they no longer have, and not even realize that they are giving you the wrong card.

Not too long ago, I was in a hospital-owned physician practice system completing an operational assessment. When asking the managers of the different clinics if they had instructed the front desk staff to verify patients’ insurance, one manager said, “No, I think that’s a waste of time.” However, the total dollar amount of charges denied for “no coverage in effect at the time of service” was well over $1 million–hardly a waste of time! That is not to say that the practice did not eventually receive payment, but those denied charges constituted $1 million in claims that had to be re-worked by someone in the billing office, costing the practice time and money. When the front desk staff verifies the insurance coverage (which can be done online for most payers), most denials are avoided. You may be skeptical that verifying insurance is really worth the time and effort, but in my experience, every practice that has implemented this simple task has seen denials reduced and cash flow increased. It really works!

3. Send electronic claims every day. With the ease of batching and sending electronic claims, there is no reason not to send them every day. Many practices, as a matter of policy, send them only once per week or several times per week. The sooner the practice delivers the claim to the payer, the sooner the practice receives payment. This allows the practice to send the balance to the secondary payer (if one exists) or send a statement to the patient, ultimately relieving the burden from the Accounts Receivable staff. Implementing this new insurance-checking system will reduce the bill’s days in A/R, putting your practice closer to the benchmark for your specialty, allowing you to focus on other issues.

Consider the processes in your practice and don’t be afraid to “think outside the box” to improve revenue collection. Too often we visit practices that follow established patterns because “that’s the way we’ve always done it.” Instead, look for opportunities to improve your processes to yield better results!

Jill Medzelewski works in The Coker Group’s practice management division as a consultant to medical practices in both operations and system management and solutions. She holds undergraduate and masters degrees in business administration from Georgia College and State University in Milledgeville, GA, where she majored in management. She was certified as a Professional Coder by the American Academy of Professional Coders in 2005.

For more information on increasing revenue and improving processes in your practice, contact jmedzelewski@cokergroup.com, or call 800.345.5829.

June 2007

Consumer-driven health care (CDHC) has evolved to encompass more than just a patient’s health care finances. Patients are demanding more involvement with and power over every level of their care, from scheduling appointments to handling insurance. In many ways, CDHC has given birth to The Modern Patient.

The Modern Patient demands more transparency in almost every step of the health care process, and looks to technology as a way to gain such access. The Modern Patient is Web-savvy, and is not content to be a passive player in his or her own care. And as he or she demands more interactivity and power in their Web experience, some health care organizations are using the Web 2.0 as a vehicle for involving The Modern Patient in their own health care.

Consider the following statistics from a September 2006 study conducted by Harris Interactive for the Wall Street Journal Online [2]:

• A large majority of adults (77%) would like reminders via email from their doctors when they are due for a visit or some type of medical care (4% currently use this technology, and another 3% have it available to them, but do not use).
• Three-quarters of adults (75%) say they would like to have the ability to schedule a doctor’s visit via the Internet (3% currently use and 4% have it available to them, but do not use).
• Many adults (74%) would like to use email to communicate directly with their doctor (4% currently use and 4% have it available to them, but do not use).
• Approximately two-thirds of adults (67%) would like to receive the results of diagnostic tests via email (2% currently use and 3% have it available to them, but do not use).
• Sixty-four percent of adults would like to have access to an electronic medical record to capture medical information (2% currently use, and 3% have it available to them, but do not use).

Given these new trends and the technology available, health care providers now have a tremendous opportunity to reach and help patients – especially The Modern Patient – in ways they never could have before. Thanks to various breakthroughs and developments in web functions and technology, practices can now offer websites and portals with easy applications that patients can use.

Here are a few such simple functions to consider adding to your website. Many of them can be achieved through working with a capable web developer, particularly one with experience in health care web development.

Online appointment scheduling. One of the more popular additions to providers’ websites in recent years, online appointment scheduling, when done right, allows patients to log on and immediately schedule an appointment in an automated system, often drastically cutting the number of incoming phone calls to the practice.

Secure messaging/e-mailing. An enormously efficient and simple resource for providers and patients alike, a HIPAA compliant email exchange system with patients and other health care organizations is easily developed through working with a health care web development specialist. Secure emailing is a particularly convenient way of sending appointment reminders and sending patients their lab test results.

Electronic bill pay. This handy function cuts out the hassle and delay of mailing out bills and having patients send in checks. Electronic bills can be instantly delivered, and instantly paid. In some cases, it also allows patients to respond to discrepancies or make inquiries over the same portal as the bill/payment transfer – an infinitely better system than mailing a patient a bill, and, if the patient has a dispute, receiving an irate phone call. With electronic bill pay, there’s no need to mix mediums as such – just a clear, inbound/outbound flow of information.

Online Patient Registration. Online registration is another popular application with patients, many of whom tend to resent having to fill out seemingly endless amounts of forms on their first visit. When synchronized with a practice’s PM/EHR system, online registration is enormously efficient way of ensuring that the practice’s staff spend considerably less time manually entering patients’ medical histories and other information.

Installing one or more of these applications in a practice’s website can make a tremendous improvement, both in office efficiency and in patient satisfaction. For the office, the simplified, automated functions decrease time spent per patient, resulting in greater office productivity. And the ease of performing these simple functions online will help quench some of The Modern Patient’s desires for simpler, more transparent, and more involved care.

Andrew Stewart, Staff Consultant with the Coker Group. For more information on The Coker Group call 678.832.2000 or visit www.cokergroup.com.

May 2007

I recently presented a lecture entitled “Doctors Orders: Know your Shareholder Agreement” to a group at Piedmont hospital. This article summarizes some of the questions after the presentation ended and my answers. I hope the questions and answers give you some insight into the legal issues that arise now that physician’s move from practice to practice with much greater frequency.

Q: Is there any difference in the enforceability of a non compete in an employment agreement versus a shareholder agreement?

A. Yes. A court reviewing a non-compete in an employment agreement will apply a higher level of scrutiny which makes it tougher for the practice to enforce the agreement against a physician employee. A non-compete in a shareholder agreement, on the other hand, has a lower level of scrutiny applied to it as Georgia Court’s view physician shareholders as having much more bargaining power than physician employees. When I represent practices whose shareholder physicians’ also have employment agreements, I recommend having a non-compete in both the employment and shareholder agreement. The basis for this is the difference in the scrutiny levels applied by Georgia courts.

Q: What is the typical time period for the enforcement of a restrictive covenant in a shareholder agreement?

A: Non-competes should never go past two years, although the shorter the time period the more enforceable the non-compete. Each situation is different as time period is only one component of the three part test a Georgia Court will apply when assessing the enforceability of a non-compete. The three element test consists of the: (1) non-compete time period; (2) geographic limitation of the non-compete; and (3) scope of the activities limited by the non-compete.

Q: What methods are typically used to calculate the buyout price when a shareholder physician retires or otherwise leaves the practice?

A: The methods I see used to calculate the purchase price vary but there are three common themes. One method is the board of directors setting a share price that will be used for the year until the board meets again to set the price for the following year. Another method is agreement on a purchase price formula based upon the Doctor’s collections during a period of time or book value of assets (although many practices have few assets other than accounts receivable) or other agreed upon measure. The third method is to hire an appraiser who will calculate the value of the practice at the time of the buyout. Each of these methods has benefits and drawbacks. Many boards do not meet regularly to discuss the buyout price so it can get stale over time. Purchase price formula’s often work well but I have seen disagreements that such formula’s do not accurately reflect non-monetary services that bring value to the practice such as community involvement or practice management. Appraisals are typically very accurate but are usually the most expensive method and if not drafted properly can lead to disputes over who pays the appraiser.

Q: My partners and I have been together 17 years without a shareholder agreement why is it that important now?

A: The medical landscape has changed dramatically as most physicians may change jobs many times over the course of their careers. Business divorces, unfortunately, remain a common feature of today’s medical landscape. I know an anesthesia practice that had no agreement in place for buying out a departing physician because no one had thought about it. One day a physician decided to leave and demanded to be bought out. With no agreement in place, the parties, as you probably guessed, got into a dispute over the value of the buyout of the shares. They spent many months arguing over the buyout before resolving their dispute. The dispute also led to many stressful contentious hours away from treating patients. It is still fairly common for me to see multi-physician practices that have no shareholder agreement. They typically only see the folly of this omission after being dragged through an expensive litigation that is time consuming and exhausting.

Q: When I become a shareholder at a practice what do I really care about in the Shareholder Agreement?

A: You should understand all aspects of your shareholder agreement but the following are three areas of particular concern: (1) the buy in and the buyout; (2) how management decisions are made; and (3) restrictive covenants. When you review the buy in and buyout you want to know how the price is calculated, but you also want to know if you will pay or receive the purchase price at once or over time. When it comes to management decisions, do certain fundamental decisions such as buying an office building, selling the practice or hiring a new shareholder physician require a mere majority or a supermajority. I have seen other shareholder agreements vest most management decisions with the board and curtail involvement by shareholders. Finally, it’s important that you understand the impact of restrictive covenants when you are a shareholder physician as Georgia Courts look upon their enforcement more favorably than they do with respect to physician’s who are merely employees.

I hope the answers to these frequently asked questions assist you when considering the legal issues that arise as physician’s frequently change practices in Atlanta.

Justin S. Daniels is a health care partner at the law firm Wagner Johnston & Rosenthal, P.C. in Sandy Springs, and can be reached at (404) 261-0500.

The information in this article is for informa¬tional purposes only and is not legal advice. Use of this article does not create an attorney-client relationship between you and Wagner Johnston & Rosenthal, P.C. You should not act upon the information in this article without seeking ad¬vice from a lawyer licensed in your own state or country. Please note that you should not send any confidential information pertaining to potential legal services to Wagner Johnston & Rosenthal, P.C., until you have received written agreement from Wagner Johnston & Rosenthal, P.C. to per¬form the legal services you requested. Unless you have received such written confirmation, the firm will not consider any correspondence you send it as confidential.

May 2007

By Christine Ingram, Senior Consultant

Errors at the front desk can cause denied claims in your practice, but with a few simple exercises, many of these discrepancies can be avoided. Most of these errors are caused by putting incorrect information into the patient’s account, and many can be avoided, including incorrect demographic information and insurance information on the patient. For most office managers this is not earth-shattering news, as looking for ways to reduce front desk errors has been an ongoing challenge for many practices.

There are several steps you can take to avoid the front office errors and pitfalls that cause denials and other inefficiencies in the office.

Review of Processes
One of the first steps to reducing front desk errors is to review and understand your processes. Are they consistent, easy to manage, and not too labor intensive? This is important because the same process will be used for times of low patient volume and times of high patient volume. Talk to your employees about the current processes and work together to try and streamline the steps. Look for areas of redundancies in your processes and eliminate them. In your attempts to ensure that you have recorded everything, you are duplicating efforts and causing more work for front office staff.

Staff Training and Education
Next, make sure your front office staff is trained on your practice management system. When hiring new staff comes at a time when a practice is short staffed, and because we are short staffed when they are hired on, the tendency is to skimp the training the new hire, or to skip it altogether. This fragmented education can lead to increased errors when entering information into the data system. Make sure staff understand the importance of entering patient demographic and insurance information correctly. Many times, front office staff members are not aware of the billing process and how the claims are generated. Diagram the steps that the claim goes through from beginning to end. Understanding the revenue cycle and how claims can be denied when incorrect information is entered will help raise awareness of the importance of entering information correctly the first time.

Raising Patient Awareness
Educate your patients on their financial obligations up front. Having a strong financial policy in place that your patients understand can save your staff from having to collect over-the-counter payments at the front desk. Create tools for collecting over-the-counter payments, and offer several payment options. This will increase your overall revenue with less time and effort for your front desk.

Working with Insurance
Make sure staff is verifying insurance prior to the office visit. This will save time once the patient arrives and it will increase collections.

Use claim scrubbing software to help catch “unclean” claims and track the reasons claims were not able to be billed. Track these errors and review them weekly with staff. Set benchmarks for improvement and monitor and give frequent feedback on improvements.

Tracking Errors and Workflow
Assign tasks to staff and create personalized “task sheets” to be filled out daily. Front desk staff work in roles that require multi-tasking, but because these positions can be very multifaceted, it is easy for staff to forget to complete all daily tasks. A task-tracking system can be used as a tool for staff to ensure that all tasks are completed daily, and it will help hold individuals accountable for their work.

Once you have looked at your processes and identified changes for improvement, include your staff in the change process. Implement these changes as soon as possible and communicate them to everyone. Monitor the new processes and determine if they are making a difference.

Christine Ingram holds a Masters of Science in Healthcare Management from Troy State University, and has amassed over 10 years of expertise and experience in all areas of managing medical practices. As a Senior Consultant with The Coker Group’s Practice Management division, she assists medical practices across the country with solving operational and financial issues. You can email Christine at cingram@cokergroup.com.

For more information on The Coker Group call 678.832.2000 or visit www.cokergroup.com.