Solo doctors take aim at non-billable tasks
From the May ACP Observer, copyright © 2007 by the American College of Physicians.
By Yasmine Iqbal
Like many internists who started their own practices, Alex Foxman, ACP Member, quickly discovered that nothing he learned in medical school had prepared him to take on the management of a small business. Instead, to get through a typical day, the Beverly Hills, Calif., solo practitioner often finds himself drawing upon lessons learned when he and his brother opened a comic book and collectables store as college students.
"Medical school and residency don't prepare us for the realities of private practice," said Dr. Foxman. "Most physicians know nothing about budgeting, marketing, billing and all the tasks involved in running a business." Dr. Foxman estimated that he spends 25% of his time dealing with administrative issues.
Physicians who consider such tasks an unpleasant necessity are even more dismayed to find out that many are either non-billable administrative chores or unreimbursed services to patients, including coordinating patient services, filling out paperwork and providing consultations for hospitalized patients.
Anne S. Wilson, FACP, a Maryland-based internist, said that she might spend up to an hour a day just calling patients about lab results. Even with the help of an electronic health record (EHR) system, Arvind R. Cavale, ACP Member, a solo-practice endocrinologist based in Southampton, Pa., often spends up to 90 minutes a day reviewing and analyzing patient data and usually doesn't leave the office before 8:00 p.m.
To cope, solo practitioners "can't just work as hard as possible, we also have to work smart," said Dr. Cavale. Here's a closer look at some of the most pressing and time-consuming of these non-billable tasks, and some tips on coping with them from four solo practitioners.
Invest in EHRs
When he was setting up his practice three-and-a-half years ago, Dr. Foxman invested in the GE Centricity EHR system. "It was $70,000 that I didn't have at the time, but I thought it was absolutely necessary," he said.
Every exam room in Dr. Foxman's office is equipped with a laptop that is hooked into the EHR, allowing him to update patient records and order labwork during the patient visit. The EHR also allows his staff to scan in forms, electronically fax prescriptions and streamline billing. "It shaves at least 60 minutes off of my day, reimbursements are returned earlier and my staff is happier," he said. "I just completed paying for the system, but I believe it's already paid for itself in improved patient care, efficiency and staff satisfaction."
He can access patient information remotely via the Internet to manage complicated patients or begin treatment when he is away from the office. And, he's expanding his EHR's capability to save time when he's called to consult on patients who are hospitalized at Cedars-Sinai, where he has privileges. Hospital staff will soon be able to access his patient records—minus financial and billing information—through a Web portal, freeing up time that he might have to spend answering questions on the phone.
Dr. Cavale, who provides intensive, continuous management of diabetes and other endocrine system-related issues, also relies heavily on his EHR system, Intelligent Medical Software.
"If I start patients on insulin or another medication, I ask them to call, fax or e-mail me their glucose levels, dietary patterns and other key information every week," he said. "That means that every day, I get at least 15 to 20 bits of data that I or my staff need to enter into the medical record. Just looking over that information can take 60 to 90 minutes, but without the EHR it would be impossible to provide this level of care. Documentation of continuous care via an EHR is superb and can be utilized for reimbursement, if necessary."
Both Drs. Foxman and Cavale emphasized the importance of researching potential choices before investing in an EHR. Dr. Foxman chose GE Centricity because Cedars-Sinai used the same system and because he felt comfortable going with an established brand. Dr. Cavale started out with a small, local vendor's EHR but switched to a new system in 2004 after two years in search of better ongoing support."
"Even though it wasn't easy to make the switch, I needed a vendor that understood my process flows and could provide one-on-one support," he said. "With this company (Meditab, Inc.), unlike larger ones, I can even the company founder and ask for help."
EHR systems can often be prohibitively expensive. However, an August 2006 change in federal anti-kickback laws might make it easier for small practices to procure EHR technology at a nominal cost from hospitals or other healthcare entities. The law now provides a safe harbor for EHR software, subject to certain restrictions. For example, the system must contain an electronic prescribing capability that meets Medicare Part D standards, and the physician must pay 15% of the cost of the software. A white paper regarding the safe harbor can be found here.
Streamline patient communications
To cut down on the time she spends answering patients' questions over the phone, Barbara Magera, ACP Member, a solo-practice allergist in Charleston, S.C., prints out instruction sheets on how to take prescriptions, how to prepare for lab tests and anything else patients might need to know.
"We try to anticipate any questions patients might have before they leave the office," she said. She also makes use of instructional videos; one such video teaches parents how to help their young children use a nebulizer.
"Younger patients, in particular, tend to understand and retain more information from a video rather than a doctor's explanation," she said. "By just giving them these reference materials, I can save a lot of time and prevent a lot of confusion."
Limit time with drug reps
Dr. Magera, who used to be a pharmacist, feels that although time spent with pharmaceutical representatives is non-billable, it does provide value. "In addition to providing drug samples, the reps help me keep a finger on the pulse of what's happening in the pharmaceutical industry," she said.
Although she welcomes pharmaceutical reps in her office, she lets them know up front that her time is limited. Other physicians put more explicit limits on their time; Dr. Wilson, for example, bars pharmaceutical reps from visiting the office on Mondays and Fridays. Dr. Foxman usually refuses to see them at all. "I ask my front desk people to fight them off for me," he said.
Charge for uncovered services
Asking patients to cover the cost of non-reimbursed medications or tests, pay for non-billable services such as writing letters or filling out forms, or even sign advanced beneficiary notices to pay for services that Medicare may not cover is often fraught with tension.
"You can ask for payment, but this might poison the water—some patients don't think they should be paying anything," said Dr. Wilson, who pointed out that she regularly runs across this attitude even though she lives in a relatively wealthy community. "Moreover, my patients think that I'm getting a huge percentage of their premiums."
Dr. Magera noted that Medicare patients, who are of a generation when insurance used to cover everything, and college students, who are usually covered by their parents' policies, often balk at paying what they perceive to be extra costs. Patients with high deductible insurance plans or health savings accounts tend to be reluctant, as well.
"Patients need to understand that any non-covered service that takes my time or my staff's time either needs to be kept to a minimum or somehow reimbursed, preferably by the patient or entity asking for this information."
—Barbara Magera, ACP Member
Nevertheless, Dr. Magera, who has instituted an insurance verification process before every patient appointment (see sidebar) is adamant about being up front about costs and collecting for non-covered services at the time of the appointment. "Patients need to understand that any non-covered service that takes my time or my staff's time either needs to be kept to a minimum or somehow reimbursed, preferably by the patient or entity asking for this information," she said.
Drop difficult insurers
Some solo practitioners have elected to drop insurance companies that pose too much of a hassle. Dr. Cavale, for example, no longer deals with the three Medicaid HMOs in his area. "They're disorganized and dysfunctional, unwilling to negotiate, their denials have no basis and we can't cover the cost of care," he said.
Dr. Magera does not accept any HMO insurances, particularly HMO Medicaid. "I made this decision years ago and not accepting any HMO's has helped rather than hurt my practice," she said. "Additionally, my staff does not waste time with additional precerts or precertification processes that are nearly impossible to obtain with an HMO policy."
But Dr. Wilson, who has converted from a mixed HMO/PPO practice into primarily a PPO one, noted that leaving an insurer is often a hassle in itself. She's still negotiating disputes with an insurer with whom she'd discontinued a capitated contract in 2004, while another HMO that she'd left still has her on their provider lists. Despite all this, she noted that "Not having to write referrals frees up staff time, and is one less thing to contend with."
In the future, Dr. Wilson hopes to leave insurance hassles behind completely by converting to a fee-for-service practice. "It would be great to cut the insurance companies out. I see this as the next step as my practice evolves," she said. "But first, I need enough loyal patients who value my professional services enough to go out of network."
Dealing with denied insurance claims is one of the most frustrating and time-consuming non-billable tasks, and some solo practitioners simply elect to let someone else manage it. Anne Wilson, FACP, a Maryland-based internist, outsources her billing.
"The billing company is probably not as aggressive as they should be in handling denials, but dealing with billing would probably drive me insane, so I elect to stay out of the loop," she said.
Others take a proactive approach. Barbara Magera, ACP Member, an allergist in Charleston, S.C., has instituted an insurance verification process that her staff goes through before every patient appointment. After the front-desk person gets a general idea of what the patient will need, her in-house billing specialist contacts the patient's insurance company to get a better idea of what the company will pay for.
"This is especially important if I think I'm going to need a specialized test that may not be covered," she said. The billing specialist then calls patients to give them a range of what they might have to pay.
"Most patients are very appreciative that we're up front with them and aren't just hitting them with a big bill at the end of the visit," said Dr. Magera. Although verifying insurance consumes time, it pays off.
"Before we started doing this two years ago, we had $150,000 in outstanding accounts receivable—now it's less than $10,000," she said. "It's allowed me to improve my patient collection rate by at least 40%."
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