Author: Chandresh Shah

By Chandresh Shah

Everyone talks about patient no-shows. Some practices take charge and control, and some, do not so much. I’m dividing the nemesis of no-shows into parts. One, how to avoid them in the first place and also, how to manage them because inevitably you cannot ever eliminate them.

Good scheduling practices are financially more rewarding.

We have to start by analyzing, understanding, and empathizing with the reasons why there are no-shows to begin with. They can range from forgetfulness, and financial issues, to a lack of transportation.

Avoiding No-Shows

1. Chronic Culprits: Patients miss appointments from time to time which is understandable but you need to identify chronic appointment ‘Missers’. Restrict them to the same day or one day in advance.
2. Same-day openings: Try to keep a few appointments for the same day if your patient backlog permits.
3. Double book: Double book chronic culprits so that you don’t end up with empty slots.
4. Appointment reminders: Phone reminders and SMS are good but manual reminders for some patients – chronic, high value, etc. One size does not fit all.
5. Keep waiting time to a minimum.
6. Thank patients who keep appointments and arrive on time.
7. Provide printed copies for the next appointments – even if you send emails and automated messages.
8. Ask about transportation if you know some patients have issues.
9. Staff education and prioritization. Create a policy to address scheduling needs and all staff must be on the same page.

Manage

1. Keep wait list
2. Follow-up no-show immediately – don’t wait.
3. Manage ‘latecomers’. Counsel, and warn them as necessary. Enforce a small penalty after repeated warnings.
4. Have a written policy that is clear, and implementable.
5. Have a clear no-show fee. You can try the approach of taking it off on the next on-time appointment.

Let me know your thoughts and if you have something to share.

By Chandresh Shah

Wrong question. It is like putting a cart before the horse.

In the past few weeks, I have talked a lot about practice revenue and revenue cycle management. Let me focus on that as I try to explain what I mean.

Examine some possible problems or ‘current state of affairs’.

Example 1

Overall collections are not bad, but there are two issues that can be improved:

o Patient collections down

A few Denials are too many!

The billing department (in-house or outsourced) is doing a good job. The over-90-day accounts receivables are within industry norms, they work very diligently to pursue all claims and every last dollar. They are doing everything they can, within their power.

The problem is, that there are things that can be done better upfront – before the patient comes in before the claims go through. How?

• Getting pre-cert done for procedures beforehand.
• Getting eligibility for special types of visits before patients walk in so that you are not caught with pants down.
• Full knowledge of Patient co-pays, out-of-pockets and balance remaining on deductibles, before the patient comes in for a visit.

Solution(s)

Examine your practice workflow with respect to these specific problems.

• How/Who can check eligibility and other insurance details before patient visits?
• How/Who can check insurance details, outstanding patient balances, pre-certs, and authorizations?
• Once checked, what should be done to take care of and/or avoid downstream problems?

Example 2

Your practice receives a paper EOB and checks for 10 claims. You receive this check on the 1st of the month. Someone enters payment into your billing software and deposits the check into the bank. The person in charge of payment posting is not able to post the payment until after 2 weeks, say the 15th of the month, for whatever reason.

Problem:

The Billing Manager runs the ‘payment’ report where there is a discrepancy.

She wants the report to reflect the Payment Posted date to match the date when the check was received.

Read the above sentence again. Do you see anything wrong with this?

First of all, every activity in any system should reflect the date when that activity is performed. If the software reflects the date of payment posting on a claim as May 1 instead of May 15, that is exactly what it is.

So, why does the billing manager want the payment posted date as the date on the check? If the reason is to be able to accurately reconcile the claims payment date, then the payment posting process needs re-examination, not the technology or software!

Therefore, the answer is to link workflow and processes to Problems and Solutions rather than technology.

Conclusion:

Practices are too close to the problem to realize that the process is broken, or can be improved because it is based on assumptions and conditions that were established a while ago. Environments – business, and technology – change, which requires adaptability to change processes.

Successfully solving problems requires partnership and information sharing. It is a result of two or more people sharing the workload and committing to the same outcome.

If you see your vendor as a vendor that is simply making and peddling software, you’re on your own. If you see your vendor as a partner allow them to help you, they have a lot of experience and you don’t have to pay ‘consulting’ fees to more expensive health IT consultants.

A vendor that says yes to everything you want should be approached with caution. Is the vendor challenging you to think of your current state and encouraging you to visualize a better future state? If yes, proceed.

By Chandresh Shah

We have heard stories or have firsthand knowledge of how patients come to see physicians armed with printouts and information gleaned from the Internet about conditions that they are experiencing.

It almost seems like patients visit Dr. Google first before they come to see their physician. You probably have experienced times that when they come to your office, some already have a diagnosis in mind.

According to a study in 1999, it was found that health-related concerns dominated much of what people were looking for on the Internet. People are finding it easier to search online for answers to their health-related questions. They seem to be bypassing traditional medical sources.

This creates a dilemma when patients walk in armed with information from “Google”. People fail to understand that Google is just a search engine and not a database of health-related information. There are instances where even if these patients are unable to determine the trustworthiness of the sources of information, they would still take the information hook, line, and “clicker”

Dealing with Dr. Google

When dealing with a patient equipped with a “diagnosis” from Google, the obvious question is, how do you win a patient’s trust and resolve conflicts if a patient wants tests and treatments that you believe are unnecessary?

There can be many creative ways in which physicians can tackle this issue [I’m not calling it a problem].

The 1st goal is to Acknowledge that people go to the Internet because they have a problem, and the Internet is available and accessible easily.

2nd is to Understand and Acknowledge that patients are sometimes confused by the abundance of medical information available online.

You know very well and believe that the Internet can never come close to the physician. It is not about competing with the Internet. We must accept the Internet as a tool, not as a replacement.

Acknowledging can go a long way as it can help promote more open communication. As with any patient exam, you must always start by acknowledging the patient’s concerns. This is what we call as active listening even when you think you know exactly what the patient is going to say.

A large percentage of patients see their physicians with ideas they may have acquired from the Internet, which may or may not prove valid. However such research can bring out emotions and concerns related to their health symptoms, such as fear, uncertainty, sadness, and worry. Being attentive to these underlying emotions, recognizing the patient’s perspective, and allowing the patient to feel respected and heard go a long way in developing mutual trust.

It is this trust that has the best chance of converting the challenges presented by Dr. Google into opportunities. This is the new evolution of physician-patient partnership that overcomes the threat posed by patients conducting their own research online. Instead of resisting and resenting the fact that patients conduct their own research online, it is better for physicians to be patient and understand the reasons why patients do this.

Dr. Google-From Threat to Opportunity

Knowledge empowers patients in shared decision-making. When providers realize that patients have received misinformation, or biased medical suggestions and come into the office with preconceived ideas about their diagnosis or treatment, it is precisely the trust that allows providers to overcome those fears.

It must also be realized that many patients come to see the doctor based on their online research which convinces them that they need medical attention and need to see a medical professional. It should be seen as a positive patient engagement rather than a negative one. Patients who have done online research seem to be more attuned to his or her symptoms and they can articulate them more easily.

In summary, changing the mindset of the Internet being a threat to an opportunity not only develops trust but can also lead to better patient outcomes as it can encourage better patient compliance with treatment plans because patients are now part of the solution.

By Chandresh Shah
I have written about leadership and delegation in the past, but I just realized that sometimes, over-delegating can become a problem.

As a physician, you focus on patients and managing your practice. You work on projects and initiatives that need your attention. Working on tasks that do not add a lot of value, will quickly make you overwhelmed and stressed.

Most of you realize that delegation in some form is extremely important. Too much of anything is not good though. You need to make sure that you do not delegate too much as that can lead to delegating the wrong things.

In this article, I’m not going to talk about why some people do not delegate. (It could be either they don’t trust others, they don’t trust that others will be able to handle certain tasks according to their standards and they would have to redo those tasks. I have also discussed this in my previous article). I will, on this article focus on

Over

Delegation

What is over-delegation? Over-delegation means:

· Delegating everything.

· Delegating way too much

· Delegating to the wrong people

· Delegating the wrong tasks

Here are some examples of what I have observed while working with clients:

Example:

A solo provider in his private practice has a very respected position in his area. He loved talking to patients and taking care of them. Beyond that, he pushed everything else to others. He said he had a very capable office manager. A couple of months ago, he called me in a panic saying that some good staff members were leaving and his billing collections were falling behind. He was at a loss to explain the reasons. He also commented that perhaps he had the wrong person in charge of office management all along.

His office manager was actually a very capable person.

Looking at what happened, here is what I found out the most important issue was lack of clear and frequent communication, not only with his office manager but also the administrative and clinical staff. The provider, who thought that he should “delegate” simply told them what he wanted, and assumed they understood and would get it done. He did not consider the implication of the kind of delegation he is doing where he is resigning responsibility and authority to his staff. In effect, when things go wrong, the physician gets upset. This is what happens when you delegate too much.

Delegation is not an art; it is a skill that must be learned.

It is important to know what to delegate, who to delegate, and how much to delegate. But behind all this, is the importance of proper guidelines and communication tied to tasks you carefully chose to delegate. You also need to clearly communicate expectations and methods of reporting.

It is amazing how many physician owners do not know the details of their revenue cycle management. Providers should know and proper communication on this delegated task will get the provider information relevant to him.

In summary, Delegation does not mean simply giving orders and handing off tasks and projects with the assumption that you will get the results you desire.

Ultimately, you are still responsible to ensure and close the communication loop. You must establish key performance indicators or metrics for the measurement of success. Communication is one thing that you cannot delegate. Otherwise, you will set yourself and others up for a lot of frustration and problems.

By Chandresh Shah

As you know, I have been focusing on a high-level financial analysis of your practice.

Part of this analysis involves looking into your collections and related gross collection percentages. However, collections do not always meet expectations and there are a few possible reasons you should look for:

1. Shift in your payer mix (click here for last week’s article)

2. Decline in reimbursement rates

3. Poor follow-up on unpaid insurance receivables (Insurance A/R)

4. Poor front desk collections

5. Poor claim filings

6. Not sending out patient statements

7. Poor patient receivables management (Patient A/R)

8. Possible embezzlement

This week I will be focusing on the fourth reason: Poor front desk collections.

For certain medical practices, a payment at-the-time-of-service policy should be in place. If patients do not make payments at the time of their office visit, insurance has to be filed for these services and consequently, the office must wait for its payment.

As a result, collections will fluctuate and the related gross collection percentages will not be as good as they could have been if these payments were secured at the time of the visit.

An explanation of benefits (EOB) review is very important. Staff members must be educated on this as local collection percentages can be a direct result of not filing clean claims.

Patient-Centered Front Desk Collections

Customer service, or Patient service in Medical Practices is gathering more prominence however this focus can create a sense of confusion among practice owners and providers.

Consider this all too common scenario:

You fail to collect copay and/or outstanding balances at the front desk.

Patient receives a bill which is generally delayed because you wait for the insurance to pay their part first. By this time, the patient had forgotten about the visit.

When they get the bill after a month or two, they are surprised for two reasons. One, they did not think they owed anything, and second, the staff did not mention that they would get a bill after some time – or better, provide some kind of estimate.

This means the patient did not ‘budget’ for this and spent money elsewhere.

This leads to frustration – they may call their health plan which generally does not help. This leads to frustration. They take it out on – you guessed it, your practice – the front desk person, the biller, and sometimes, even the provider.

This scenario is a result of what I believe is a wrong idea of Patient Centered Service. This confusion can arise if the following questions are not addressed within the practice:

• Does Patient-Centered service mean not focusing on patient collections?
• Will patients be unhappy with you?
• Will you lose patients if you ask for an outstanding balance?

As a response to that, data gathered has shown the exact opposite – Engaging patients in meaningful financial conversation actually creates a positive image of your practice and its patient service.

I know you work very hard to take care of your patients and in fact, coach your staff to do the same. Somehow, conversation related to money is left out and avoided at all costs. Everyone feels it inappropriate to talk about money when a patient is in pain. Ironically, if you don’t engage in a comprehensive conversation with a patient that includes financial terms, this can portray the wrong image of your practice. Practices that engage in a holistic approach of 360 degrees conversation including money show that you actually care about the overall well-being of a patient.

We all hate dealing with uncertainty. Spending a little time talking to patients about money goes a long way in patient satisfaction and in the process, keeping your patient aging or patient account receivables low.

Summary

In summary, you should train and make sure the front desk is proactive in engaging and alerting patients about statements, and their financial responsibility and even educate them a bit about how their insurance plan works if possible. This is one of the best services you can do for them to maintain a healthy relationship.

By Chandresh Shah

As you know, I have been focusing on a high-level financial analysis of your practice.

Part of this analysis involves looking into your collections and related gross collection percentages. However, collections do not always meet expectations and there are a few possible reasons you should look for:

1. Shift in your payer mix (click here for last week’s article)

2. Decline in reimbursement rates

3. Poor follow-up on unpaid insurance receivables (Insurance A/R)

4. Poor front desk collections

5. Poor claim filings

6. Not sending out patient statements

7. Poor patient receivables management (Patient A/R)

8. Possible embezzlement

This week I will be focusing on the third reason: Poor follow-up on unpaid insurance receivables.

The most common problem practices face when filing claims to insurance companies are payers who may try to delay payment or an error made by the office resulting in a rejected or delayed payment. Though practices have little control over payers, rejected or delayed payments can be resolved by follow-ups.

However, follow-ups do not just mean “following up, for the sake of it” as follow-ups should be timely. Timely follow-up is something that everyone knows should be done. Providers, Office Managers, and billers all know this. Yet, a breakdown in practice workflow is extremely common and is overlooked. It is easier to blame systems and technology than internal personnel and processes. The end result of course is that it negatively affects cash flow.

It will be helpful to keep in mind that the average time for receiving payments must be 45 days from the date of service; not the date of filing. Submitting claims to insurance companies is the easiest part of billing. The bigger problem is securing payment. Knowing what the holdup is maybe half your battle. Yet, many practices, for various reasons don’t file claims in a timely manner. Claims must be filed on the same day as the date of service.

Delay in managing this process and delay in payments from insurance companies affects monthly collections. The resulting fluctuations affect cash management and therefore owners and providers may have to dip into their personal reserves.

The overall objective is always to have a consistent cash flow from month to month. The biggest enemy of any business is unpredictability.

How to work out your outstanding claims and denials?

Knowing why claims are not paid is the first step. Here are some of the most common reasons why claims may be unpaid/rejected/denied.

1. Wrong information: Get the correct information from the insured patient. People sometimes forget that Billing really starts at the Front desk. Diligence in recording the correct patient demographics and verifying the insurance for every patient at every visit is the most critical task that a practice should do.
2. Insurance Eligibility and Insurance Coordination of Benefits: Know which insurance is primary and how much the secondary insurance will pay, as per coordination of benefits. The front desk must ask patients and verify the details. Billers must know this before filing a claim.
3. Depending on your location, insurance participation, and specialty, you may be required to get a referral. Failure to do so will result in non-payment. Here too, the front desk staff plays a critical role.
4. Missing authorization number for procedures – in-office as well as services performed at a hospital. There are ways to follow up if a claim is rejected. If there is no authorization number on file and the insurance company requires it to pay the claim, you can submit an appeal letter with medical notes. If the insurance company denies the claim for no authorization, you cannot bill the patient; you have no choice but to write off the claim as a loss, even if you followed up on time. That is why all work upfront is important.
5. The claim was submitted to the wrong insurance company: Expedient follow-up can correct this error.
6. Incorrect ICD-10 or CPT® code: Incorrect coding usually happens because diagnosis and procedure codes change every year in October, after ICD-10, HCPCS Level II, and CPT® code books are released for the following year. Make sure your billing system is updated with the latest codes.
7. Other: There are lots of other reasons for denials, including invalid patient name, invalid subscriber number, wrong date of birth, wrong date of service, wrong place of service code, etc.

Following up Process-Back to Basics

If a practice has an in-house biller, make sure that person is dedicated and the task of follow-up is the most important – which takes precedence over any other task.

It can be difficult to follow up on claims on a regular basis, if that person is dealing with many other roles. Practices make the mistake of dumping too much work on critical employees and asking them to multi-task. This can and will take a toll on payment follow-up.

Thorough and regular follow-up on unpaid claims will result in fewer losses and more revenue.

By Chandresh Shah

In the next few newsletters, I will be focusing on a high-level financial analysis of your practice.

Part of this analysis involves looking into your collections and related gross collection percentages. However, collections do not always meet expectations and there are a few possible reasons you should look for:

1. Shift in your payer mix

2. Decline in reimbursement rates

3. Poor follow-up on unpaid insurance receivables (Insurance A/R)

4. Poor front desk collections

5. Poor claim filings

6. Not sending out patient statements

7. Poor patient receivables management (Patient A/R)

8. Possible embezzlement

This week I will be focusing on the first of the possible reasons.

Shift in your payer mix

Health plan penetration can change suddenly, depending on your geographical location and service area. The current state of healthcare in our country along with many unknown variables means health plans can change from commercial insurance to managed care. Within a short period of time of less than a year, your mix of 20% managed care penetration can change to 70% as an example.

Managed care plans usually pay less because the contracted fee tends to be lower than your office’s normal fee schedule. Therefore, if the managed care percentage of your payer mix arises your gross collection percentage should decline accordingly.

What can happen if you fail to analyze the shift?

Many offices do not analyze their financials and therefore fail to identify such a shift in the payer mix until it is too late to do anything about it. Not only that, people in your geographical location can change health plans more frequently than ever before which can have a direct financial impact on your practice.

Take action- analyze

If you suspect a shift in the payer mix, the first thing you should do is to get a detailed breakdown of the current payer mix. Compare that with last year. Determine what percentage of the revenue is being derived from managed care, commercial insurance, self-paying patients, Medicare, Medicaid, and other insurance programs.

Once you have all this information, find out and determine how you can shift your mix of patients to the type of patients for whom reimbursement is the highest.

How do you do this? You can come up with marketing strategies to target specific payer classes. Of course, if your entire geographical area has moved towards managed care you probably don’t have much leeway. In this case, you may be stuck with a reduced managed care reimbursement because there may not be other alternatives.

In any case, an analysis of the payer mix will certainly let you know if that is the reason for your lower collections, and if there is anything you can possibly do about it.

By Chandresh Shah

As you know, I have been focusing on a high-level financial analysis of your practice.

Part of this analysis involves looking into your collections and related gross collection percentages. However, collections do not always meet expectations and there are a few possible reasons you should look for:

1. Shift in your payer mix (click here for last week’s article)
2. Decline in reimbursement rates
3. Poor follow-up on unpaid insurance receivables (Insurance A/R)
4. Poor front desk collections
5. Poor claim filings
6. Not sending out patient statements
7. Poor patient receivables management (Patient A/R)
8. Possible embezzlement

This week I will be focusing on the second reason : Decline in Reimbursement Rates.

Many insurance companies are changing the way they pay physicians. This is a very disturbing trend.

Physicians are receiving less for their services than they were before. Many commercial insurance carriers and managed care plans are adopting Medicare’s resource-based relative value scale system as a way to pay their position providers.

Then they select conversion factors that will place the new reimbursement rate structure as a percentage of the current Medicare fee schedule.

In many cases, this switch can cause up to 40% decline in surgical reimbursement rates in that service area. Some payers in some areas of the country are even paying contracted rates less than the Medicare’s rates.

As payers reduce what they pay physicians, you can expect decline in both the practices overall collections and related gross collection percentages over time. According to some reports 65% of physicians see declining reimbursement rates as the top issue negatively affecting practice profitability.

Unfortunately, many doctors who maintain independent practices are forced to change their business model. For example, reimbursement and other cost pressures have forced 26% of physicians to stop accepting Medicaid while 22% have reduced office support staff.

But it does not have to be this way.

What can / should you do about it?

There are many ways to effectively counter these reductions. While there isn’t much you can do to stop reimbursements cuts, a proactive approach will help you offset the negative effects of declining reimbursement rates.

Increase Your Patient Base

When margins decrease, increase volume. Decreased reimbursement means per claim revenue drops. To make up for this, you need to see more patients.

Finding patients to treat shouldn’t be a problem. Number of patients joining the healthcare system has been increasing.

Making use of good tools (healthcare IT systems) coupled with optimized workflow will help you take on the upcoming patient influx without having to add more staff. Find systems and tools that focus on workflow efficiency rather than fancy features.

Consider Outsourcing Medical Billing

Outsourcing billing can make up for declining reimbursement rates by bringing in higher net collections after cost. According to a report from Software Advice, outsourced billing can bring in $1,496,000 after cost for a typical three-physician practice, compared to only $1,241,800 for in-house billing.

The savings of outsourced billing come primarily from a decrease in staff costs plus the ability to bypass purchasing billing and collections software/hardware.

Reduce Claims Denials

You must battle declining reimbursement rates by reducing claims denials as much as possible. On average, denials cost practices $25 to $30 each. There are a couple routes you can choose for reducing claims denials.

Reduce rejections and denials through patient eligibility checks and code reviews. This is the speedier and more effective route to correct claims.

The other is to be meticulous when submitting manual claims. There are plenty of opportunities for your billers to make costly mistakes. It can be something simple like misspelling a patient’s name or something more complex like misusing CPT modifiers.

Maximize Your Tax Deductions

This sounds fundamental and basic. But my CPA says many Physicians don’t pay much attention to Tax-deductible expenses which are identified as almost any purchase that helps with operating a business.

Maximizing deductions can be a balancing act. For example, offering disproportionate benefits to your employees may reduce taxes, but may also be outweighed by the extra costs of benefits. Striking the right balance can mean an increase in revenue for your practice.

In summary

Being proactive about overcoming declining reimbursements is essential for the success of your practice. Remember, inflation didn’t suddenly go down along with reimbursement rates. The problem will only get worse if not confronted right away.

By Chandresh Shah

DOJ fines Greenway $57 million

I was planning to do part 2 of the financial analysis articles series that I started last week. I’m going to interrupt that because of a very serious news that I saw today, and you may have seen it too.

This concerns the EHR giant Greenway Health. Click here to see the article.

There are 2 major reasons for which Department of Justice has fined Greenway $57 million.

1. False EHR certification claims. Neglecting to fix the problems.

2. Paying customers kickbacks for recommending its products to others.

It is not the first time that this is happened. The first culprit was eClinicalWorks.  In 2017, eClinicalWorks agreed to pay hundred and $155 million to settle allegations.

The obvious implication of this is that providers and physicians no longer know who to trust and who not. Physicians are not experts in technology. Common reasoning would lead you to believe that it would be safer to go with the product of a larger company. On the flipside, some smaller companies were acquired by larger companies and have deactivated products of these companies.

My suggestion is to stick with relatively smaller companies, not startups, that have been around for at least 10 years. Companies must have sound management and financial strength. That really is the best you can do and hope that it all works out in the end.

I’m glad to be associated with an organization that I have known for 10 years.  10 years is enough time to figure out if this is a genuine company or not, especially if your intimately involved with the decision-making process and day-to-day operations with the staff.

Although these news are scary, I am still optimistic of the future of healthcare information technology.