Even though adjusting to new staff member can be stressful for you as well as for existing employees, there are times when it is unavoidable. Finding the perfect staff and then keeping them for many years seems to be a difficult task these days. In fact, even if all of your staff members are planning on staying, you may find that additional people are needed in order to deliver the best level of care. Typically, there are three signs that can reveal to you the need to begin looking for new people to join your staff as quickly as possible.

Inter-Office Disputes and Tension

When employees cannot complete the number of tasks expected of them in a given time frame, they are likely to feel stressed. This, in turn, may lead to co-worker disputes if they have to take time to adjust to the work habits of other staff members. Your employees have enough work to keep them busy all day, make sure that the work load is not creating excessive disharmony. Under these circumstances, you may want to ask staff members where they feel an extra person might be useful. In some cases, this will help you define the job description for the new person, as well as gain an understanding of how this person will help the office function more efficiently.

Tasks That do not Get Done

For example, if you notice that some claims are not being billed on time, or that collection efforts are not being taken at sufficient stages, hiring a new employee for the billing department may be of immense benefit. While you may be tempted to look for computer software solutions when it comes to the billing department, invariably you will find that it requires human effort to collect on insurance claims, as well as on debts that are the owed by the patient. You may need to look at outsourcing your billing and have someone else take on this area depending upon your practice needs.

Working through the process of finding the areas that need help and creating a solution to the problem takes careful insight and planning, but you need to take the time to listen to your employees and help find this solution using a team approach. If this means hiring a new employee or replacing an old technology, you may find that the problem resolves itself completely.

Patient Complaints

Invariably, when you do not have enough employees to attend various patient needs, you may find that a variety of problems occur. For example, patients may complain that prescriptions were not called in, paperwork was not filled out, or questions during a visit remained unanswered. In the worst cases, you might hear that your staff members were rude, or did not appear take adequate care while performing specific duties. While you may want to inform your staff of these issues, you should also make it a point to study employee actively in order to determine if the work load is simply too heavy.

Considering the modern economy, constant cuts in reimbursements and the difficulty to stay ahead in this industry, you may be inclined to keep staffing costs as low as possible. On the other hand, if the quality and reputation of your practice is suffering from a lack of necessary staff then it is important to have an office process evaluation to reveal specific practice issues that can more effectively be resolved by having additional staff. As a result, once you notice the three main symptoms of excessive work load, then hiring a new staff member may be worth more than you realized and enable your office to be more productive and increase revenues.

Read more articles at MedBillingnCoding.com.

The physicians in your practice put patients first. They’re eager to serve and dedicated to the task of providing quality care, but that doesn’t mean they’re willing to work for free. Each time your insurance carriers deny claims for reimbursement, however, they do just that. Says Cheris Craig, chief administrative officer at Urology of Greater Atlanta, it’s a loss of revenue that her practice can ill afford. “We have a very small [profit] margin,” she says. “Some of the injectable medications we use cost $2,000 to $3,000 a dose. If you’re making 2 percent on each and you’re forced to eat one out of 100 [due to a denied claim], then you’re losing money each time you give an injection.”

Thus the importance of developing a denial management plan. “Too many denials create a cash flow problem,” says Mary Jean Sage, president of The Sage Associates, a practice management consulting firm in Pismo Beach, Calif. “From a policy and procedures standpoint, you need to establish some benchmark policies regarding what percentage of claims you’re willing to write off as denied.” Depending on the size of your practice, she notes, that amount should be no more than 4 percent.

Be proactive

The best way to minimize delays and denials is to monitor your claims submission reports regularly, or designate someone on staff to do it for you, says Sage. These days, most practices either submit claims electronically, or use a clearinghouse to do it for them. In either case, practices should track which claims were accepted and which were not. “This is something that practices don’t always do well,” says Sage. “You should get a report when you send the claim from your practice management system to the clearinghouse, but there’s a second report that gets generated when it goes to the health plan and you have to make sure you review both immediately.” The reports provide an explanation of benefits, or EOB, which identifies the reason for any denial, including incorrect demographic information, or lack of eligibility. “There you’ll find out if you have an incorrect patient ID number, for instance, so you can resubmit the same day,” says Sage, noting your turnaround on resubmission should be no longer than 48 hours.

Craig says she also reviews the expected payment report each quarter. “That’s important even if you are getting paid because it tells you whether they’re paying you correctly,” she says. “Sometimes they under or overpay.” For that reason, she suggests all practice managers keep a fee schedule for each carrier in their computer.

According to the Medical Group Management Association, some 5 percent of claims submitted for reimbursement ultimately get denied. The most common reasons for denials include errors committed by the front desk during registration (such as incorrect patient demographic information or identification numbers), lack of medical necessity, and lack of preauthorization. Incorrect or invalid ICD-9 and CPT codes ― especially where bundled services are concerned ― and inadequate documentation from your providers will also cause your claim to boomerang. Getting it right, and maximizing the reimbursement to which you’re entitled, means getting everyone on staff educated on proper registration procedure and the importance of accuracy, says Dannelle McDermott, office manager at Wilkes Family Medicine in Newbury Park, Calif. “It’s a collective task that the whole office is involved in,” she says. “It starts from the minute your patient walks in the door and making sure your clerks enter insurance information correctly, to making sure your doctors are using proper diagnostic codes. It goes through several steps before it even gets to the billing department.” McDermott says she uses mistakes as a learning opportunity to reduce the incidence of denials going forward ― flagging manual errors as they occur and discussing them with the staff.

Denials in McDermott’s office, she says, are down significantly since they implemented an electronic health record several years ago, which verifies eligibility in real time. Eligibility is confirmed well before the patient’s appointment, giving her office a chance to get coverage questions cleared up. McDermott notes practices should not be afraid to involve the patients. “If a claim gets denied, I look at the reason and decide whether it needs to be appealed or call the insurance company to reprocess it,” she says. “But I’ll also call the patient at times to find out if their insurance has been terminated and get them to take responsibility for themselves. We already did our part and filed the claim.”

Start a claims denial log

According to Sage, all administrators should maintain a claims denial log, enabling them to spot trends early and react in a timely manner. Such logs, which can be kept either on paper or electronically as part of a practice management system, should include written documentation from the insurance company, dates of service, dollar amounts, individual claim numbers, the specific code denied, and how it was handled by your team ― resubmitted, charge adjusted, or appealed. “Usually, denials come back in the form of correspondence from the insurance plan,” says Sage. “You need to work your correspondence. If I get a denial in the mail today, for example, it needs to be resolved and back out the door again within 48 hours.”

That may require a little digging. “You need to understand why a claim was rejected and that’s where I sometimes see practices not doing such a good job,” says Sage. “You need to know why so you can either correct the mistake and resubmit or file an appeal ― and if you’re going to appeal you need to be sure it’s being appealed for the right reason.”

Likewise, each practice should establish a policy for how it intends to handle appeals, says Sage. Some practices appeal based on a monetary threshold, while others focus on the specific service provided. For example, Craig says her practice typically doesn’t appeal a denial if the dollar amount is small, since she estimates it costs roughly $50 in human resources to process, but it does make exceptions if it’s a procedure or test that’s done routinely. “We perform a urinalysis on almost every patient who comes into the practice so we have to get reimbursed for that,” says Craig.

Make them experts

If you’ve got the manpower, it helps, too, to assign your billers to one or two individual health plans, since reimbursement contracts differ greatly by company. Each has their own restrictions for what constitutes medical necessity, what is considered a bundled service, and the process for filing an appeal. All, of course, require that appeals be handled in a timely manner ― but some allow you to appeal by phone, while others may want it in writing. If a written appeal is required, you’ll improve your chance for reimbursement by submitting supporting documentation, including labor and test results, progress notes, and operative reports. Craig says her practice, with eight physicians and 65 staff members, has enough billing staff to train and assign each biller to a single carrier, which gives them an added layer of expertise. “My Blue Cross biller does Blue Cross claims all day long so she would know, for example, that there’s no need to appeal that denial because they bundle it,” she says, noting larger carriers are particularly complex since their rules differ for members of their HMOs and PPOs.

Given the complexity of insurance contracts, and the trend toward shrinking reimbursement, claims denials are a harsh reality for most practices. But you don’t have to take it lying down. By tracking your denials and educating your staff on best practices for filing a clean claim, you can help your physicians collect their fair share for services rendered. In a market where every penny counts, says Sage, it’s time well spent.

Shelly K. Schwartz, a freelance writer in Maplewood, N.J., has covered personal finance, technology, and healthcare for more than 17 years. Her work has appeared on CNBC.com, CNNMoney.com, and Bankrate.com. She can be reached via editor@physicianspractice.com.

Read more articles at PhysiciansPractice.com.

Medical practices are going through seismic changes, and physicians are looking for ways to increase revenue or lower costs. There are many tactics that address the myriad ways to do both of those: by changing practice strategy; adding services; solving patient-flow and workflow problems that have been ignored; and focusing more on getting money that is owed to you.

Throughout the year, Medscape has offered expert advice on ways to build a more successful practice. Here are some of the tips that physician readers found most helpful.

1. Offer Your Patients One-Stop Shopping

For your patients’ convenience, do everything possible in-house: Draw blood, conduct urinalyses and stool guaiac tests, and so forth on your own. You should be able to bill for these items, and your patients won’t have to wait at an outside lab to get the services that they need.

When your patients need outpatient procedures that you cannot offer in-house, help them schedule appointments while they are in your office so that they won’t have to hassle with the bureaucracy. Make their lives easier and they will reward you for it.

2. Get New Patients by Creating a Niche

You’ll go broke if you wait for sick patients to walk through the door. There aren’t enough of them to go around. Consider doing wellness medicine, which widens the scope of potential patients to include everyone.

Develop a subspecialty such as in dermatology, thyroid disorders, diabetes, or geriatrics. Get into occupational health — pre-employment physicals, drivers’ physicals, flight physicals, workers’ compensation for minor injuries, drug screening, etc — and advertise that you offer these services. A river of money may run by lawyers, but it doesn’t run by physicians. We have only rivulets, but add them up and you will have a mighty stream.

3. Avoid Gaps in the Schedule Due to No-Shows

Start with the basics: Have a no-show policy that charges patients either for the first or the second no-show appointment. It may be difficult to collect, but if patients wish to return to the practice, collect it via credit card when booking an appointment. Communicate the no-show policy to patients.

Confirm all new patient visits 36 hours prior to the visit. If a patient cancels, that gives the practice time to fill the slot. Develop a cancellation list of patients who want to be seen sooner, and call them for cancellations. Track no-show patient characteristics. Are they emergency department referrals? Follow-ups? Is the no-show rate so high that the group needs to book extra patients to keep gaps from the schedule?

Monitor the number of no-shows at baseline, implement changes, and set a goal that reduces the number. Graph your progress, and involve all staff members in meeting this goal.

4. Try to Get Paid on the Basis of RVUs Rather Than Collections, if You’re in a Hospital or Large Group

Many hospital billing services are really bad. Relative-value units (RVUs) are directly tied to the coding. It’s a better measure of patient acuity than collections, and it eliminates contractual discounts.

One problem for doctors starting a new job is that they may not get a productivity bonus in the first year if their incentive is based on collections that are measured annually. Because there’s typically a 3-month lag before their charges are collected, the extra revenue that they generated through hard work won’t show up in the first year.

In contrast, they can get a productivity bonus in the first year if they’re rewarded for hitting RVU targets, notes Tommy Bohannon, Senior Director of Recruiting and Development Training for Merritt Hawkins & Associates in Dallas, Texas.

If a hospital or group includes quality metrics in its payment calculation, that will usually constitute about 10% of compensation. Sometimes a contract will specify that various percentages of the potential productivity bonus be paid to doctors, depending on how well they score on the quality measures.

Intangible factors may account for another 10%. Among those factors are patient satisfaction, participating in committees, doing community service or community education, and public speaking, he says. In some cases, physicians who work harder and see more patients can earn more than those who spend a lot of time being good citizens.

5. Make Sure That All Physicians Are Pulling Their Own Weight, and Deal With Those Who Aren’t

Though a daunting prospect, you must have a frank discussion with the physicians who are dodging a share of the duties, regardless of seniority. “The senior doctor shouldn’t carry more weight than the other partners. We should all be even stakeholders who are looking out for the common good of the practice,” says Practice Management Expert Judy Capko, of Capko & Company, in Thousand Oaks, California.

Advance preparation is essential. “There’s a certain baseline cost for carrying a doctor, whether 10 or 20 patients are being seen. You need to gather a lot of data to see what the financial impact of this physician’s routine is on the practice,” Capko says. Determine what you need an underperforming physician to do; discuss the best way to lay out your position; and present it as a united group.

The group spokesman should be someone who this physician greatly respects. Although some practices engage a management consultant as a facilitator, “you have a much better chance of succeeding if a physician expresses the group’s viewpoint than if the consultant is given the role of dealing with this. Otherwise, the doctor who feels challenged is just going to attack the consultant. He or she is not going to see that the doctors agree with that consultant unless that’s voiced,” Capko says.

Steer the discussion away from the physician’s behavior and focus on the long-term health of the practice. Capko recommends: “You have been the foundation of this practice. We owe you a lot, but this practice — your practice — is struggling with some issues, and we need to address these for the future.” Then you can delineate your concerns.

6. Get Payment Even if Your Patient’s Check Bounces

Your practice’s financial policy needs to include your policy on bounced checks and what steps the practice will take to recover that payment. If there are bank charges, stipulate that the patient will be charged for those fees. If you’re in a state that allows you to collect a processing fee above the bank charges, that needs to be stipulated in the financial policy that a patient signs.

For example, in Illinois the value of what can be collected is 3 times the face value of the check plus court costs if litigated. In North Carolina it is the cash amount of the check, bank fees, plus $35 for the handling fees. In Florida, you’re only allowed to charge $20 above the check value and bank fees. The National Check Fraud Center lists the bad-check laws for each state. It is helpful to publish or reference the consumer credit laws in your financial policy. These simple steps will keep everyone on the same page and establish the financial component of the medical care relationship.

Successful practices will make every method available for patients to pay bills. Cash, checks, postdated checks, credit cards, debit cards, and online services such as PayPal are all viable means for patients to settle their debts. Postdated checks are a good collection tool unless they bounce. Postdated checks are considered “promissory notes” rather than checks unless they are truly held until the date written on the check by the debtor before deposit.

Consider using a check-scanning system from a company that guarantees the check if it clears. This will protect the practice as well. The monies are immediately deposited into your practice’s bank account without the added burden of a trip to the bank.

Almost all of these payment methods have some amount of service fee attached to them. However, the fees paid are a small price to pay for the general practice’s cash flow. The smart practice will shop around for the bank with the best small-business service package available or will look to build a hybrid system with a couple of different vendors for the various services needed. No matter how you build your financial recovery process, you’re wise to make as many methods available as possible as long as those methods protect the practice.

7. Be Money Smart When You Move to an EHR

Take a closer look at application service provider (ASP) technology. ASP technology means that the electronic health record (EHR) program and data are housed securely at a vendor’s or an institution’s location; you don’t need to have expensive servers and tech support in your office if you have high-speed Internet access.

The ASP EHR model will range from about $350 to $650 per month, plus training. Billing software will be an additional cost. The other option is buying an EHR that requires an in-house server and software. Systems like this that I reviewed averaged between $40,000 and $60,000 depending on the amount of bells and whistles added.

With ASP models, benefit changes and software improvements are continually updated on your site so that your practice is always using the most recent data and advanced software. You don’t need proprietary hardware or additional servers. You do not need to house your own server, and many systems have a minimal cost up front. You also will be able to log in from home to view patient data and reports.

The downside to ASP technology is that when the Internet is down, so are you. Make sure that you have good, stable Internet service before considering this option.

8. Think About a Professional Services Agreement if You’re Considering Employment

Professional services agreements (PSAs) have been around for many years but are now growing in popularity. Physicians may view a PSA as a way to get the advantages of employment without selling their practices, and hospitals see it as a mechanism for controlling doctors without employing them directly.

“In a PSA, the physicians maintain their own professional corporation,” explains Alice Gosfield, a Philadelphia, Pennsylvania, healthcare attorney. “The physicians assign the right to payment to the hospital; the hospital bills for them; and the physicians receive a base salary, usually with productivity bonuses. In more and more PSAs, the physicians also get bonuses that are based on quality metrics.”

Despite doctors’ retention of practice ownership, Gray Tuttle, a practice management consultant in Lansing, Michigan, says that a PSA “is very similar to an employment relationship. The end results financially are close to identical. The difference is that the physicians are employed by a practice that they own. Typically the hospital will employ everybody else including the receptionists, nurses, and technicians. The providers — physicians and even midlevels — retain their relationship with the professional corporation.”

The physicians still own the practice assets including ancillary services, which, notes Tuttle, they lease to the hospital. The hospital must factor revenues from those ancillaries into the amount that it agrees to pay the physicians or the doctors won’t sign up, he adds.

“Typically the hospitals provide reasonably long guarantees with no pay cuts and, in many cases, enhanced reimbursement,” says Tuttle, adding that the guarantees may last up to 5 years for specialists and 3 years for primary care doctors.

One reason why PSA reimbursement may be higher than what the doctors previously earned is that the hospital can often negotiate higher rates than most practices could on their own. In addition, some hospitals will pay doctors extra for quality and efficiency.

9. Be Aware of Which Aspects of Prevention Care Are Now Reimbursed

The Patient Protection and Affordable Care Act has given physicians new tools to offer patients easier access to preventive care. Starting in January 2012, Medicare will eliminate its Part B deductible and copayments for a host of proven preventive services including bone mass measurement; some cancer screenings; diabetes and cholesterol tests; and flu, pneumonia, and hepatitis B vaccinations — among other services.

Medicare now covers annual wellness visits. It covers smoking cessation counseling. It began paying a 50% rebate for the brand-name medications that seniors need to manage chronic conditions when they reach the coverage gap known as the “doughnut hole.”

Your patients in new private insurance plans also won’t pay out of pocket for many preventive services including screening blood pressure, diabetes, cholesterol, and for certain cancer screenings; counseling to quit smoking or cut alcohol consumption; routine vaccinations; and regular well-baby and well-child visits from birth to 21 years of age.

The Centers for Medicare & Medicaid Services is working to make sure that you and your patients have the support that you need to achieve better health. Our investment in prevention takes a big step in that direction. If you or your patients are looking for more detailed information, go to healthcare.gov and click on “Learn About Prevention” at the top.

10. Prepare for IDC-10 So That You Won’t Have Billing Lags and Mistakes When It Is Live

In 2012, talk to vendors. Confirm again that you are on the most up-to-date version of your office coding software and that your vendor will be ready. Confirm that the system can handle both code sets at once and can flip the switch overnight. Confirm that the vendor can move from diagnosis codes that were 3-5 digits in length to codes that will be 3-7 digits in length.

Nonclinical coders in your office should take medical terminology and anatomy and physiology courses. This is the year to lay a solid clinical foundation. There are online courses and community college courses. Maybe your local hospital would sponsor courses for physician staff members.

Practice using the International Classification of Diseases, Tenth Revision (ICD-10). Every month, print out a list of 15 more diagnosis codes for each clinician and try to code them. Keep a list of those that are causing questions and problems. Re-educate clinicians about the detail that is required in their documentation for specific conditions and symptoms that they treat. Expand the focus of practicing. Look up codes that clinicians use less frequently.

Train the trainer. At what point in the year you train the trainer (or trainers) in 2012 will depend on the size of your group. In a small group, it might be prudent to wait until the end of the year. If you are a large, multispecialty group, begin earlier. Some large, multispecialty groups may be planning this step for 2011.

Review encounter forms or electronic charging documents. With the increase in codes, it is less likely that a paper encounter form will work for most practices. There will be too many codes. The favorites list in an electronic charging system will need to be updated for each clinician.