The patient presented with the typical signs of anemia. She would only let the doc perform a finger stick which showed a hemotocrit of 6!  I repeat 6. (Normal for women is 38-46). The doctor told me she sat with her patient for over ½ an hour (ignoring all her other patients) begging her to go to the hospital. The patient thought she could go home and eat red meat and feel better even though told that she needed to go to the hospital emergently.

The doctor was told that the patient had been driven to the appointment by an unknown man who was in the waiting room.  Eventually she had to let the patient leave and hope that she would go to the hospital.  She then told me that she called the patient two days later and the phone was answered by a man who said he was the patient’s fiancé and that the patient had died.

My Dr. friend said that had she known that he was her fiancé and not just a “ride” she would have marched into the waiting arena and “HIPAA be dammed” told him to take the patient to the hospital right away.

Now, what are your thoughts on this?   Should she have ignored HIPAA and done just that? We all know hindsight is 20/20.

Assuming that the patient was informed about how serious the situation was, is it the physicians responsibility to override the patients desire to return home because of lack of insurance and money? Should she have asked the patient who was with her?

This physician is an excellent doctor and very caring, she is a great diagnostician too, but is there anything she could have done and not violated HIPAA?

Your thoughts?

A good practice with good communication returns calls in a timely manner.  They return email requests and follow up on appointment requests, as well. Having the systems in place to make online appointments and email questions is all well and good but if the staff doesn’t follow though with their end, they have let down both the patient and the provider.

From personal experience, it should not take 2 days to get back to a patient who has a concern over a prescription mix up. And when I say mix up, I mean the patient has allergies to the medicine and needs a different medicine that day.

Sending an email with numerous post operative questions that were not answered when discharged for the hospital and never getting a response is unacceptable.  Written post op instructions should be given to the patient prior to surgery so there are no questions later.

Poor communication can lead to a bad review on Yelp or other sites and even if the practitioner is wonderful and fantastic and super skilled this can make him or her look bad and possibly drive away a patient.   Check your Yelp score; are there legitimate concerns with your office staff?

Asking for feedback will make a difference in your practice.  Utilize forms available for patient satisfaction review and make any necessary changes to staff so that you don’t look bad.  Poor communication  can make for a very unhappy patient and that not what you want. Believe me.

Before I had my own billing company I was in practice management. The article on CBS immediately took me back to office staff training and the daily pain of providers and timeliness. If you Google “billing doctors for running late” there are numerous posts and articles. Some doctors are paying even if they aren’t billed by the patient.

I believe the staff should keep the patient informed if the doctor or other provider is running late. The office should give the patient the option to either wait or reschedule the appointment. When a patient shows up and are told that their provider is running late, most will wait. However, wouldn’t it be nice if the office had the time to call patients before the appointment and let them know there is a delay and give them an option to reschedule? Only in a perfect world, right?

I know I’m opening a can of worms here because I can see this from both sides, the office side and also from the patient’s side. Yes, my time (as a patient) is valuable and why should it be less so than my doctors?

We know there are many reasons a provider can run late. Double booking is a major cause. Situations where “Mrs. Jones never shows up so lets put in Mr. Brown.” Well, then they both show up and need to be seen. There goes the schedule. I remember years ago hoping for no shows so the doctor could catch up.

Providers can also run late when patients are scheduled for their allotted time of 15 to 20 minutes and take much longer. When scheduling a visit, hopefully the patient gives all the reasons they want to be seen. For example, Mrs. Jones says she has a cough, but also while she’s there, “can the doctor just take a look at her leg that has been hurting and is swollen”? This just turned into a much longer visit. For something not urgent, the patient can be asked to schedule another visit, but, because of the nature of this problem, especially a possible DVT, she can’t be brought back the next day. This can happen daily in any office. Hopefully the staff has let the waiting patients know an “emergency” has come up and apologized for running late.

Surgeons can be called away to the ER. Specifically, for offices when the provider is on call, a patient should be given a note in the registration packet that informs them that there is a chance that since this provider takes ER call; occasionally the patient will need to be rescheduled or asked to wait. Information beforehand is the best policy.

If patients are kept informed it makes for a much less stressful environment for everyone. It would be a lot nicer for the patient who is sitting in a room, reading an old magazine, possibly in a gown, and wondering where the provider is, to know that they are going to be seen as soon as possible. It’s not good to have a patient stick their head out the door and ask, “Where is the doctor?” A staff member can just take a few minutes to let a patient know that they have not been forgotten, heaven forbid, and they are sorry that the provider is running late. An apology is always good. It can diffuse a bad situation. Apologies don’t hurt anyone and if accepted can make a world of difference.

Let the patient know that they’re cared about. If possible, call ahead of time to let them know the provider is running late. Give the arriving patient a chance to reschedule if the visit isn’t urgent. Keeping the patient informed shows them respect. Setting up an office policy should this scenario happen can go a long way to keep you from getting a bill from an angry patient.

And apologize.

Transparency, as used in the humanities and in a social context more generally, implies  openness, communication, and accountability. It is a metaphorical extension of the meaning a “transparent” object is one that can be seen through. Transparent procedures include open meetings, financial disclosure statements, freedom of information legislation, budgetary reviews, audits, etc.

The importance of transparency in medical billing cannot be stressed enough. We often see the sad fact of thievery in the workplace.  Embezzlement, unfortunately, is a fact and happens more often than you think.  Understandably, most providers don’t like to speak about this because of obvious reasons, one of which could be embarrassment of being “taken” by a trusted employee.

This brings me to the topic of transparency and why I love SaaS or Cloud Computing Practice Management Systems.  This type of Software not only gives the providers and practices the ability to look at their accounts anytime 24/7 but also gives them peace of mind that the billing company is doing their job and is accountable for their work.   If your billing company is not open about their billing policies,  if you are not able to review reports when you have time, be it 3 am on a Sunday or during regular working hours, possibly you need a company that practices transparency with a SaaS  Practice Management Program.

However, it made me think of the destruction I saw to the hospital in Joplin. I heard that X- Ray films were found miles away. The medical providers who have their offices there may  very well be trying find their patient records too.  I hope that scenario is not playing out in any of these towns.

One way to safeguard the physical loss of patient files and claims and records is to utilize a cloud based Practice Management software system.  The system keeps the information safe in a secure server; usually in another part of the country.  Think Amazon.com when you think cloud based software. The information is stored somewhere in the “cloud” and not in your office. It is secure. It is HIPPA  compliant. It is convenient. It is accessible from anywhere.

I hope that there are no medical offices who are trying to piece together their practice (literally) and get back on their feet with a loss of papers, patient’s protected information and billing information.    Let’s hope for the best and prepare for the worst.

While cleaning up, we found uncontested and unpaid claims stuffed in charts and denied claims in desk drawers. We found claims that were never billed to the insurance company. It was a mess.  No one was looking out for the doctor’s best interests. The doctor had no idea why she was loosing money. This practice administrator was also cashing checks made out to petty cash. Needless to say, the administrator lost not only her job but now has a police record.

To guarantee that fraud would not happen again; a series of checks and balances were set into place. Two people had to check off the daily deposit. The claims were no longer the sole responsibility of one person. Billing was done by a “biller” and that biller had to report to an administrator, who reported to the doctor. The physician was kept informed of problem claims in a monthly basis.

According to the amednews.com : “Nearly 83% of 688 practice managers were affiliated at some point with medical offices where employee theft occurred, according to a survey released Nov. 5, 2010, by the Medical Group Management Assn. Nearly 45% of practice managers reported cash stolen before or after it was recorded on the books. Experts say so much cash and minimal staff to check one another’s work make small practices particularly vulnerable.”

Regrettably, embezzlement is still a problem and if no checks and balances are put into place, the practice leaves itself open to fraud and lost revenue. One way to prevent lost revenue is to hire an outside billing service. A billing service has a vested interest in getting the practice paid. Most services are paid on a percentage of the net revenue the practice receives monthly. Another safeguard is to have all payments go directly to the practice office and not to the billing office. This protects both the practice and the billing company.

The billing company should have a system where the claims and payments coming from the medical office are accounted for daily. Thus a “day sheet” can be generated for each entity to verify that nothing is missing or miscounted.  Electronic Medical Records systems (EMR) have other safeguards in place, as well.

Another way to deter fraud is to screen potential employees with background checks.  All candidates should have some screening done.  Karen Zupko of Karen Zupko & Associates stated in her article to the America Journal of Orthopedics: “According to Donna Ploof of RHR Information Services, a company that provides background checks to a wide range of businesses, including medical practices, “one of every three applicants provides false, inaccurate, misleading, or incomplete information”.

Background checks aren’t fool proof and some of the employees who steal have been employees for years and a background check can not weed out the employee who has no “record”,  However, if all the tools are in place along with utilizing an outside billing agency or auditor, you have a better chance of steering clear of fraud and theft.

Dorothy Trottier, Owner

Medical Specialty Billing

www.medspecialtybilling.com

However, quite often the benefits of outsourcing to a billing company outweigh the warm fuzzy of having a staff member carry out the billing duties.  Time spent on the telephone with insurance companies, verifying that the claims actually arrived and are in process, calling on claims, appealing denials and other various calls eat up valuable time. A staff member can be on constant hold or “ignore” for minutes or hours at a time. That staff member could use the same amount of time to perform other important parts of your day to day practice mechanics, such as: calling patients back, or even greeting a patient; good old fashioned customer service.   Those lost hours on the telephone could be better utilized in face to face time with clients. There are a myriad of other important tasks that could be done instead of spending time on the telephone with an insurance company.

Additionally, outsourcing is cost effective. Typically a practitioner pays the employee’s taxes, workman’s compensation, payroll, and often health benefits are paid, not to mention, payment for sick days and holidays.  Training costs keep the biller or coder up to date on the latest changes in codes and regulations that change yearly. Training also comes into play with staff turnover. Office supplies and hardware can be expensive. And lastly what no one likes to think about is theft or embezzlement. Internal billing process may not provide for proper separation of revenue functions. According to the Medical Group Management Association in a survey released in November 2010, “nearly 83% of 688 practice managers were affiliated at some point with medical offices where employee theft occurred. Nearly 45% of practice managers reported cash stolen before or after it was recorded on the books.”

A billing company is generally paid per claim or at a percentage of the collected amount; usually from 4% to 8 % of net collections on a national average. Typically, there is little or no out of pocket expense for the practitioner. The difference between the expense of a full or even a part time billing employee and a good billing company should be a profit to the practice. In 2008 a report by National Healthcare Exchange Services states that physician practices are spending as much as 14% of their total revenue to ensure accurate reimbursement from health insurers.

Possibly you have staff members who have been with you for a long time. However, that person will eventually leave. Staff turnover and sick time means no claims going out and no money coming in. If you lose a staff member it can take weeks or even months for the new biller to catch up. Your income is affected. Family leave, prolonged illness and other reasons for staff members being out of the office are reasons to trust the billing company to keep the cash flow coming in at a steady pace. The practice expenses do not stop. Keeping the income flowing is important. Staff turnover is not an issue with a billing company. The billing company is there working to keep your money flowing. If the company is reimbursed on their collections, they will work hard to get you paid.

If you decide to utilize an outside billing company, do your research. Ask for references and make sure you are comfortable with them. There are online resources regarding what to look for in a billing company. Just make sure you have a contract in hand and a HIPAA compliant company.  Perform due diligence and all should go well in choosing an outside billing company.

Dorothy Trottier, Owner