Thinking INSIDE the Box OR – I do things this way because this is the way I do things…

Some people like to learn new ways of accomplishing tasks and others think just because they have been doing a task a certain way THIS is the way you should be doing it. Examples:

Storing Records – “I file EOBs in the patient files.” Practice Management experts would agree this creates work and is completely unnecessary, yet there have been many practitioners who won’t quit this practice. I have been unable to convince these practitioners to file EOBs differently, they refuse to try something else yet at the same time they complain how huge their patient files are becoming. EOBs should be filed BY date, literally just set in chronological order as they are received. If you date stamp your mail and use that date in your billing software, it’s incredibly easy to quickly find any EOB. It’s even easier to receive your EOBs electronically and save in files on your desktop, OR scan and save on your desktop. Get a good back up system – you’re done.

Collecting from patients- “I am not going to collect from the patient because I don’t know how much to collect.” I’m going to wait until I get the insurance EOB and then collect from the patient. Whaaaaat? WHY would you wait 30 days to collect money when if you did a bit of prework you could know at the time of service? Oh – these are the same offices who complain about patients NOT paying…. Guess what – YOU gave them the idea!

Office Hours- “My office hours are by appointment.” NOW believe me this does not mean – I’ll come in when ever you want to see me.” This is more like I’ll come in when ever I want to come in and if I don’t want to, then I won’t and I don’t have to because I have no set office hours. NO successful office runs like this, successful practitioners aren’t worried about being in their office UN-necessarily. They know that patients need to know open office hours and when you’ll be there if they need you.

Try thinking outside the box; try something different (ESPECIALLY if someone who may know a bit more than you might recommend it.) There’s actually much more room outside the box, get out and see for yourself.

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What you don’t know WILL hurt you (Let me count the ways)

Patients – Are you positive they are who they say they are?  I am DEAD serious.  They give you their information, insurance card, address, but do you take a copy of their driver’s license or some other form of photo ID?  Oh – you don’t?  Then HOW DO YOU KNOW who they are?

Employees – Your neighbor’s daughter work 2 afternoons a week answering the phone and filing.  Did YOU do a background check and verify previous employment?  Again, I am NOT KIDDING.

As the owner of a billing company I am frequently asked to “take” an intern.  Last year a well known school in Los Angeles, repeated contacted me about taking one of their best and brightest – she was as they described- “hand picked” for me.  She presented a resume with NO contact information of previous employment, and only personal references. – I explained I must be able to contact her previous employer/s, so she provided additional information.  When I called her last employer, he answered the phone in a very hesitant manner-“What exactly do I want to know? He asked.   I jokingly said – “You know the usual type of questions, did she steal or was she fired, just things like that?”  He said, “Actually, I fired her for stealing.”  He went on to say she was stealing credit card information and buying things off eBay.  His company did not prosecute, however she was fired on the spot.

Obviously I didn’t have to do the background check, however I would have if the employer had not been so forthright.  Some employers will only confirm the time the employee was on payroll – nothing further. As someone who has hired her fair share of employees, (and reviewed hundreds of resumes), I can say with certainty– people will lie.   They exaggerate the number of years of employment.  They will give you the cell phone number of a friend as their previous employer.  I’ve seen it all.

Other Practitioners – I know of one acupuncturist who accepted an offer to share space in an existing practice.  She set up shop, had business cards, etc., filed her information with the carriers, only to find the other acupuncturist only had 2 months LEFT on his lease! (Of course he never told her.)  She had to start ALL over just because she believed him when he said he had a five year lease!

Am I bitter? – Absolutely not. Suspicious? Possibly.  But I have TOO MUCH TO LOSE and so do you.  I will always do my due diligence – and you should too.

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Forms Follow Functions

I went to a new dentist recently and was handed the obligatory forms to fill out. When I say handed it was more like nudged. As in the clipboard was nudged in my direction. No explanations – more like a nudge and perhaps a faint grunt. No smile, no words of welcome. That’s another story, this is about what I was handed.

Now understand I pretty much KNOW what I was handed. (But that is not always the case with a new patient). The Patient Privacy Forms with accompanying acknowledgment. The arbitration agreement mandated by the office’s malpractice insurance and of course the actual 4 (count ‘em) four page intake form. It took a good 10 minutes to fill out this form, however I noticed that the front office person didn’t even look at it when I handed it back, and the dentist gave it no more than a 10 second glance through. The saddest part of this experience was watching the elderly couple next to me, the husband read each question to his wife then recorded her answers on the forms. They were still at it when I returned to the waiting room from my dental exam.

It was clear these forms were “off the rack”, the type you buy from a dentist supply place, also clear I wasted a good deal of my time filling out information that was not applicable and downright UN-necessary. Why did this happen? It happened because the office didn’t think about MY time, just their own. You see it’s easier just to buy generic forms then spend the time to create a form tailored to just the actual information needed to treat the patient.

Take a good look at what you hand a brand new patient. Are you using “off the rack” products? Frankly both your intake forms and your privacy practices should be tailored to your specific practice, and your consent to treat is tailored to state scope of practice laws, so even that isn’t a one size fits all product. If your intake forms contain a place for insurance information and you know the patient is a cash patient – or if your forms have information related to a work related accident, and your patient wasn’t in one, well,- cross out those boxes. Communicate with your patient, what is necessary and what isn’t, take the time to explain what you need, why you need it and why you appreciate his or her time in filling out these important pieces of paper. Stop the grunting and start talking.

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Quit Whining… Seriously – Stop it… Stop it NOW!

I am tired of hearing providers say that insurance companies are “out to get them” (yes- them personally), that carriers deliberately use stall tactics on their claims and their claims are “targeted” for non payment. In almost EVERY case the whiner has a tenuous grasp on how insurance claims are processed and paid. YES- you heard it, they aren’t even clear on the process, but they are crystal clear that THEY are the victims of the insurance industry who prey on them, the lowly acupuncturist.

Don’t get me wrong – I’m NO FAN of insurance carriers. I spend each and every day appealing incorrectly processed claims and having to educate carriers about how they should have handled patient claims. I just would never think to take it personally. There are reasons things happen and when you understand the system you have a better chance at a better outcome. Here are a few things I’ve come to realize over the years:

You can’t expect to get paid unless you verify the patient’s benefits yourself- End of Story.

Most patients have a minimal understanding of their own benefits. You are better off telling them what they have rather than have them telling you.

Insurance carriers make errors in at least 10% of all acupuncture claims submitted- and the vast majority of claims are NOT in your favor.

You MUST follow up on improperly processed claims, and probably more than one time.

Poor customer service (long wait times when calling; long hold times as they “investigate” the issue, really long times to process and pay claims) means this carrier will have MORE than the usual amount of claims not properly paid.

You’ll notice I’m not making excuses. I understand whom I’m dealing with and plan accordingly. I believe it was Sun Tsu who said: “If you only know yourself, but not your enemy, you may win or you may lose.”

I like to win- you should to.

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How Providers Built their Practices Back in the Day- And what YOU can learn from the Old School Guys.

There really are only two ways to get more patients.  The first is the absolute easiest: BE THE ONLY GAME IN TOWN.  Hey then you don’t even have to be that good!

But honestly that only works for a few, and I even hear about those guys hurting.  It’s because they don’t understand about patient expectations and the “old school” way of doing things.  Back in the day the insurance plan paid 80% and you paid the 20% and you could go to anyone you wanted, but you didn’t.  You went to the SAME office and you referred to your doctor as “my” doctor.  He knew you, your brothers and sisters and your parents.  You got a consistent experience, the nice old lady behind the counter just kept getting older (who knew she was his wife?) and just like her always being there, you had an expected experience- one of caring.

Acupuncturists today can duplicate that experience and get and keep patients for a lifetime but they don’t.  Instead of thinking about the patient, they think about themselves and wonder why they don’t have more patients.

A LOT of acupuncturists practice at TWO locations, AND still aren’t making much money. Why TWO locations?   Did you start part time in at one place (to save money-) then heard of another provider offering space who would said he would refer you patients so you took a couple days there.  Here, there, everywhere, seeing a few patients at each location, squeezing your patients into YOUR schedule rather than what works for them.

Why do you insist on putting your intake forms online?  I’ve seen providers sneer when their patients couldn’t or wouldn’t fill out their online forms.  Are you thinking about the patient?  NO you want the convenience of knowing your forms are automatically paperless.  Now if a patient wants to fill out the forms online give them the option but certainly don’t make it mandatory.

This is my personal favorite – log on and make an appointment on line.  Why don’t you just tell them – WE DON’T WANT TO WASTE OUR TIME TALKING TO YOU!   We aren’t going out of our way for you.  We aren’t even going to try and “fit” you in or stay late for you, or come in on our day off.  You aren’t THAT important.

Who started the internet forms and log in capabilities?  Managed care – they need to cram MORE people in LESS time.  There is NO concern, make it as easy as possible to see as many people as possible, pay your co pay and take a number.  Do your really want to be like that?  Do you have to?

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You’ve Been Paid – What’s to Worry About? (More that you might think)

I’ve spoken with lots of providers whom I feel are not billing properly, either due to ignorance or sometimes deliberately attempting to get more money from an insurance carrier.  When I explain billing and coding and exactly what they are doing that is incorrect, the usual response is: “Well the insurance company is paying, why should I change?”  You know what – They’re right in that the insurance carrier usually is paying and quite well too, however what they do not realize is the information about those services they billing for can be requested AT ANY TIME by the insurance carrier.  The carrier has the right to request medical records to substantiate the need for the treatment long AFTER the claims have been processed and paid.

The following are three situations I see frequently that can come back to haunt a provider:

1.  Billing for an office visit EVERY single time they see the patient.  This is by far the biggest NO-NO, and carriers are catching on.  There must be a substantiating need for a separate office visit, and that can’t happen two to three times a week.

2.  Billing for a timed procedure that was only done for a short amount of time or not at all.  By far the biggest culprit is 97140, myofascial release.  The rule is you must provide the service for at minimum 8 minutes to bill 1 unit of a timed based code.  Giving the patient a 2 minute neck massage is not going to cover it.  Did the procedure but didn’t document the time on your notes?  Get audited and you’re giving the money back.

3.  Never changing a patient’s diagnosis.  I’ve literally seen patients that have been treated for years for the SAME condition.  Again the provider will say – well they keep paying. This creates two conditions.  Either: A.  You are treating the patient and he is NOT GETTING BETTER! Or B. You are treating the patient for one thing, but submitting a claim for something else.  The carrier requests the notes and/or sends a questionnaire to the patient, either way, and you’re going to be asked for the money back.

Audits, requests for records, are NOT GOING AWAY.  Mark my words – if you have been doing any of these three things, it’s only a matter of time before it comes back to haunt you, and I don’t want to say, I told you so.

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Don’t Bill Insurance IF You Don’t Know What You Are Doing

That’s right – don’t do it if you don’t know what you are doing.  Be a cash practice.  Collect cash, a check (does anybody even write a check anymore?) or swipe a card.  BUT – don’t send out a claim and expect to get sent a check if you aren’t 100% clear about the concept.  I’m sorry but I’m a bit tired hearing people say – Insurance companies are out to get me, OR they won’t pay me enough.  When it comes down to it – the practitioner DOES NOT know what they are doing.  They signed up to be in network – WITHOUT looking to see how much the network will pay – HEY you signed up with them- they didn’t sign up with you! OR – a practitioner bills insurance without verifying the patient’s coverage and is mad when it doesn’t pay.  IF you don’t verify the coverage why the heck do you assume they are going to cover your treatment?  Then since he promised the patient he would bill his insurance and when it doesn’t pay, he doesn’t want to go back to the patient and ask for payment.   NOW  he’s complaining because he isn’t making any money.   You know what?  Shame on you!

UNDERSTAND how it all works OR – BE A CASH PROVIDER!  NOW, in this economy you are not going to be able to treat some patients – believe it or not there are people out there that KNOW they have acupuncture benefits – and guess what?  They aren’t going to come to see an acupuncturist who doesn’t accept their insurance.  But that’s the price you pay when you don’t want to learn how it works.

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It’s Not All About You (Just Think About It)

Most providers think that patient’s satisfaction is based solely on the treatment they receive, and frankly that’s not necessarily true.  Take a moment to really think about your patient and his experience in your office.  What makes a patient satisfied with your service?  What makes a patient refer?

You must consider the “experience” from beginning to end if you really want to maximize the referral potential of a patient.

The beginning…

Did the patient have to leave a message, OR did someone pick up the phone?  Did they get put on hold?  Did they get a call back right away OR 2 days later? Are your new patients greeted by name, such as “You must be Ms. X, we’ve been looking forward to seeing you.”  OR Do they just sign their name on the list and get handed a clip board?

My personal favorite – Do you give the patient pages to fill out that contains duplicate questions OR information that is NOT PERTINENT to their condition.  Think about HOW LONG it takes to fill out this information.

The middle …

You do a superb job, an excellent examination; give the patient a through understanding of how you practice and what they can expect, a treatment that leaves them feeling better.

The end…

Does the office know how much to collect from the patient? Was the patient informed of the costs in advance?  Is he offered handout materials?  If your patient has questions about his insurance, does he get satisfactory answers?  If he has a limited number of visits under his insurance, is he told how many visits are remaining?

Each office is different, in size and staff. Consider this:  In business the rule is:  It is 6-7 times more costly to acquire new customers than maintain existing ones.  The same is true for patients.  You want lifetime patients. You want patients that refer new patients. You want those patients to be lifetime patients that refer new patients…

There is NO doubt that your treatment is why the patient is in your office, but if you want to keep him coming back, if you want him to refer, remember the beginning and ending of the experience, because you can be sure he will.

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I really hate when people say, “Well I guess I’m going to have to play the insurance game.”  It really isn’t a game in my mind, because while it does have a distinct set of rules and a distinct set of players (the patient, you and the insurance company), nobody knows the outcome of a game; whereas when you deal with insurance it can’t be by chance, and you always have to know if you are going to be paid.  So, how do you set yourself up to always win so that you know the check is coming?    The bare minimum is to level the playing field (o.k., I couldn’t resist).  You make sure you know the rules just as well as the other side (the insurance carrier) and you keep that patient aware every step of the way.  You see he’s in the game too, and you always want him to know that.  Sure, the carrier made the rules, but it’s “even steven” when both sides know how it all works.  MD’s have known this for years.  It isn’t that the insurance industry is against them, it’s just that the carrier helps write the benefits packages and distributes the reimbursements, so it’s up to the provider to understand exactly how it all works and their place in the system.  Acupuncturists are the only ones I know who say “Insurance is out to get us”; but it’s just like in gambling: anybody who wants to maximize the returns that are allowable given the circumstances has a responsibility to learn how to play the game.  With healthcare reform there are new rules, and they are shifting more and more responsibility to the patient and to the provider.  Now more than ever it’s important to understand what you have to do to expect reimbursement from insurance.  Know what to do, and do it; it really is as simple as that.

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Some of the best practitioners I know aren’t practicing anymore and they were some of the best: great skills, great clinicians, and really, really good at what they did; and well-liked by their patients. So why aren’t they still practicing? Because they weren’t good to themselves. They simply “burned out.” This business, the healing business, can take A LOT out of a provider. It isn’t simply, “Just take this pill for two weeks.” It involves caring and commitment and visits together alone in a room with a person that needs your help. You have to be a good listener and provide what is necessary and that can change each and every time with each and every patient.

So how does it happen to some people? Is it that they don’t have people around them that care about them? Or is it that they don’t have interests or activities in addition to their practice? Well, possibly, but what I see in most cases is they are too busy being nurturing to be nurtured. They have lost the ability to “turn it off,” to realize they need to be cared for too. When you are taking care of people you can easily forget that you need the same things they do. So how do you do that?

First, you need to get away. The farther away it is from your office, the better. Otherwise, you shape your environment until your environment begins to shape you; and what happens is you start to do the same things in the same place thinking the same thoughts. You have to schedule time away no matter what; it’s vital to your life and the life of your practice.

Second, it can’t all be about the practice. You must have hobbies entirely different than your medicine. It can be absolutely anything you want it to be but nothing that deals with herbs or needles! But seriously, the happiest people are well-rounded.

Finally, and probably the hardest, at some point you will have to relinquish some control. Get help in your office, and let some things be done by others. Those really great healers who used to practice were often control freaks; they were so confident in their abilities but weren’t sure that anyone else could do what they could. The insurance couldn’t go out until they checked it, they had to know about every phone call, they’d hire an assistant, a really good person, but never fully let them do their job.

So, get away, think outside the office and let people help you. Take care of yourself so that you can take care of your patients.

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