PRACTICE MANAGEMENT TOP 10 THINGS YOU NEED TO KNOW.

PRACTICE MANAGEMENT

TOP 10 THINGS YOU NEED TO KNOW

AGENDA

• CORE VALUES• CORPORATE OR PARTNERSHIP DOCUMENTS• GOVERNANCE• BEHAVIORAL ISSUES• DASHBOARD REPORTS• EMPLOYMENT ISSUES• RISK MANAGEMENT• MEDICAL RECORDS• ICD-10• SUPERVISION OF PHYSICIAN EXTENDERS

Core Values

Core Values

Built To Last

Core Values

The organization’s essential and enduring tenets

A small set of general guiding principles

Not to be confused with goals or policies

Not to be compromised for financial or short-term expediency

Collins & Porras - Built To Last

Core Values

• JFP has a strong religious foundation and believes in “Loving God’s People”

• Individuals are valued for the ‘Skills and Opinions’ they bring to the practice.

• The group works with a Team Approach to promote the concept of one practice.

• A Full Scope of Care will be provided.• Every individual is expected to work hard and help each

other.• There is a life outside the group, therefore, a Balanced Life

will be encouraged.• High Quality Patient Care is expected.• Everyone at JFP will strive for Excellence and Superior

Performance.• JFP will provide The Best Possible Medical Care.• JFP will treat all people with Respect and Dignity.

Core Values

• The physicians will maintain “High Ethics.”• The group will create an environment which will

promote a “Team Approach.” • Physicians are expected to “Work Hard” and help

each other.• The practice is committed to the orthopaedic

needs of the community.• Physicians will show humility.• There is a life outside the group, therefore a

“Balanced Life” and “Family Involvement” will be encouraged.

• The group will exercise fiscal responsibility.• Community involvement is supported by the

practice.• “High Quality Patient Care” is expected.

Core Values

• The group is more important than the individual, hence “One Practice”

• The group will create an environment which will promote a Team Approach

• A Full Scope of Care will be provided• Physicians are expected to work hard and help

each other• There is a life outside the group, therefore, a

Balanced Life will be encouraged• High Quality Patient Care is expected• The Group will strive for Excellence and

Superior Performance• The will provide The Best Possible Medical Care

Core Values

• Patients and achieving Excellent Surgical Outcomes.• We are Compassionate and always put the Patient First.• We expect everyone to Work Hard and we will Support Each Other to

ensure a Balanced Life. • Pride – We will strive to protect and foster those things we hold dear.

– We are proud to be General Surgeons– We are proud to be associated with the Physicians In This

Practice– We are proud our Employees– We are proud of our Legacy

• It is essential to Like Each Other and to work in a Collegial Spirit.• We will treat all people with Humility, Equality, Dignity and Respect.• We respect the Individual Strengths and Specialty Skills of each

physician.• We understand that Open and Continual Communication is crucial.• Our Employees are Part of the Memphis Surgery Associate Family.• We will do our part to Sustain General Surgery as a noble and

honorable profession.

Core Values

How To Use Them

• Dealing with a behavioral issues• Making policy and purchasing decisions• Recruitment• Dealing with people• Setting clinic standards• Setting priorities

CORORATE or PARTNERSHIPDOCUMENTS

CORPORATE or PARTNERSHIP DOCUMENTS

• Articles of Incorporation• Stock Certificates• By-Laws• Buy-Sell Agreements• Employment Agreement• Pension, Profit Sharing, & Retirement• Partnership Agreements• Operating Agreements• Minutes• Leases• Benefits Documents• Managed Care Contracts


WE TRUST EACH OTHER

THE ATTORNEY REPRESENTING YOUR EX-PARTNER OR YOUR SPOUSE IS NEVER YOUR FRIEND

WE DON’T HAVE TO PUT ANYTHING IN WRITING


• VALUE OF PRACTICE

• TIME TO PARTNERSHIP

• TERMINATION

• BY GROUP

• BY PARTNER

• DEATH

• DISABILITY

• RETIREMENT

• OWNERSHIP OF MEDICAL RECORDS

• BUY-IN

• NON-COMPETE

• PAY FORMULAS

• MALPRACTICE

• PREMIUMS

• TAIL COVERAGE

HOW IS THE PRACTICE GOVERNED?


ARE THE DOCUMENTS SIGNED?

DOES ANYONE KNOW WHERE THE

DOCUMENTS ARE?

Governance

Organizational StructureBoard Administrator

Implements Strategic Plan

Committees

Appoints Committees

Approves MD Pay Plan

All Personnel Matters

Implements Policies

Accepts Committee Reports

Develops & Monitors Budget

All Contractual Obligations

Approves Budget

Develops & Approve Strategic Plan

Develops Core Values

Studies Issues Brought by Administrator

Finds Way to Improve Op

Safety of Pts & Employees

Operates Company Within Budget

Hires & Terminates Administrator

Sets Performance Standards

Evaluates AdministratorPerformance

Fiduciary Operation of Company

Approves Physician Partnership

Physician Behavioral Issues

Physician RecruitmentHires & Terminates Physicians

President

Resource for Administrator

Settles PhysicianBehavioral Issues

OperationsApproves Policies

Sets Agenda

Approves By-Lawsand

Operating Agreements

Facility

Finance

Technology

Building

Operations

Managed Care

Marketing

Governance

Things To Remember

• The group comes before the individual• All must follow the decisions of the board• There must be repercussions for those that do not

comply• The manager works for the Board, not any one

physician• The employee must have the right to say “no” and to

send things to the Board• All the employees work for the manager• The physicians must send the employees to the

manager

Governance

Scenarios

• One of the physicians tells the manager to do some and she does not think it is in the best interest of the practice

• One of the physician goes to the front desk and tells them send patients back even if a new chart is not, yet, been set-up in the system

• A physician is habitually late, doesn’t do his charts in a timely manner and sloughs off on call.

Behavioral Issues

Behavioral Issues

• Fails to comply with practice standards

• Shames others for negative outcomes• Uses foul, abusive language• Arbitrarily sidesteps policies• Acts in ways that are perceived of as

sexual harassment• Threatens staff or associates with

retribution, litigation or violence• Criticizes staff in front of others• Discourteous and disrespecting others

in the healthcare team• Casts slurs on someone’s ethnic

identification• Relies on intimidation to accomplish

goals• Fails to respond to direct questions

relating to patient care• Tells others they are stupid,

untrainable or uneducable• Disregards the personal/professional

comfort of colleagues

• Disparages others’ care or behavior in front of patients/family

• Reprimands others in front of patients/family or team members

• Uses bodily contact with team members which is not therapeutic or mutual

• Refuses to interpret or write orders legibly

• Refuses to apologize after harming someone

• Shuns those with whom there is a communication problem

• Refuses to respond to constructive feedback or criticism

• Shuns the use of appropriate grievance channels

• Threatening, assaultive and violates others’ professional space

• Repetitively cynical and aggressive

Examples of Disruptive Behavior Remember to look for a pattern.

Behavioral Issues

Positive Examples of Professionalism

• Compliance with practice standards• Using conflict resolution skills in negotiating

differences and disagreements• Addressing concerns about clinical differences directly

and privately• Approaching dissatisfaction with policies through

established grievance channels• Supporting policies that promote cooperation and

teamwork• Listening to and trying to understand constructive

feedback

Behavioral Issues

Approaches to Dealing With the Physician

• There must be a clear understanding that it this point the physician is to be treated as an employee and not an owner.

• The guiding logic should be – “How would the practice deal with any other employee that acted inappropriately?”– Counseling– Treatment– Corrective Action Plan For The Employee– Disability– Discipline– Termination

• The practice, it’s patients and employees must be protected.• Careful consideration must be given to the fact that if the physician

is determined be disabled that ADA regulations may apply.

Behavioral Issues

Confronting The Individual

• Agreement within the leadership or governing body with the action to be taken

• A clear understanding about who (Spokesperson) is responsible for confronting the disruptive physician

• Be resolute in explaining the problem (do not debate)

• Have an action plan prepared to present

Behavioral Issues

Support & Assistance

Arkansas Foundation for Physicians Health

Behavioral Issues

Assessing The Problem

What If Physician Denies The Problem?Or

The Practice Wants to Have The Physician Assessed Before Suggesting A Plan.

VANDERBILT COMPREHENSIVE ASSESSMENT PROGRAM FOR PROFESSIONALS (V-CAP)

Behavioral IssuesVanderbilt Comprehensive Assessment Program

for Professionals (V-CAP)

• Psychological Testing and Reports• Psychiatric Evaluation• Psychosocial History (may include interviews

with family members)• History and Physical, where indicated• Blood Work and Drug Testing, when indicated• Collateral Information – with client permission

other interested parties maybe interviewed• Follow-up Sessions• Comprehensive Report for Client & Practice

Behavioral Issues

Action Plan

• Identify the inappropriate behavior (no debate)• Insure that the physician understands the spokesperson speaks

for the whole group• List actions that the group is going to require of the individual,

– Such as:• Be evaluated by Vanderbilt• Come under the care of a psychologist• Get charts caught up by a specific date• Stop doing surgery• Attend anger management course• Apologize to surgical team• Follow the prescribed action plan• Physicians Health Program

• Create a monitoring plan• Give regular feedback• Define repercussions for failure to adhere to the plan

Behavioral Issues

Financial Considerations

• A Key Question - The physician’s professional competency has been brought into question, does adding a financial burden on top that aid in bringing about a positive outcome?

• Is the practice willing to support the physician by:– Protecting his/her income?– Paying for all evaluations & treatment?

• If compassion does not prevail, ask the question– Will the practice be better off financially if this

physician can be helped?

Behavioral IssuesManager’s Role

• Group Practice– Insure that proper governance & responsibilities are in place– Support the Board and the Spokesperson– Be supportive of the physician, but not an enabler– Aid in the monitoring process– Keep the plan on schedule

• Solo Practice– If the rapport is there – the manager may need to deal with the

physician– Request advice and assistance from the state’s physician health

program– The hospital may be of assistance – same problems are likely to be

present there as well – Consider bringing a third party into the situation– If patients, employees and the manager’s wellbeing are at risk and

the manager cannot bring about change they should leave the practice

– If patients are at risk and the manager is unable to bring about change the licensing board should be informed

DASHBOARD REPORTS

DASHBOARD REPORTS

DO YOU GET PILES OF REPORTS?

BUT

NO INFORMATION?

DASHBOARD REPORTS

• OPERATING FINANCIAL DATA

• ACCOUNTS RECEIVABLE• CASH• BENCHMARKS

DASHBOARD REPORTS

OPERATING FINANCIAL DATA

PRODUCTIVITY• Relative Value Units

(RVU)• Charges• Collections• Office Visits• Procedures• Admissions• Days Worked

DASHBOARD REPORTS


REVENUE• Gross Revenue• Net Revenue• Office• Ancillaries• Procedures• Hospital• Extenders

DASHBOARD REPORTS


EXPENSESEmployeeBuilding OtherPhysician

DASHBOARD REPORTS

ACCOUNTS RECEIVABLE• Total A/R• Days in A/R• A/R Aging• Credit Balance Report

DASHBOARD REPORTS

CASH• Cash vs. Net Income

DASHBOARD REPORTS

CASH• Cash vs. Net Income• Bank Balances

DASHBOARD REPORTS

BENCHMARKS• Internal

– Prior Years– Doctor to Doctor– Budget

• External– Medical Group

Management Association (MGMA)

– Specialty Societies– Hospital– Health Plans

2012 2012 2013 2013 % Monthly % YTD MGMA MGMAMay YTD May YTD Change Change Monthly YTD

ProductivityCharges 57,332.11$ 259,667.14$ 65,877.56$ 315,889.74$ 14.9% 21.7% 62,381.92$ 311,909.60$

Office Visits 266 1,399 320 1,511 20.3% 8.0% 292 1,460 Procedures 8 47 15 55 87.5% 17.0% 11 55

RVUs 300 1,415 333 1,684 11.0% 19.0% 322 1,610

RevenueNet Receipts 41,221.22$ 187,687.33$ 46,779.56$ 230,489.66$ 13.5% 22.8% 44,046.83$ 220,234.15$

Refunds 1,755.66$ 7,598.30$ 1,301.09$ 5,578.87$ -25.9% -26.6% Other Income 3,000.00$ 15,000.00$ 3,000.00$ 15,000.00$ 0.0% 0.0%

Total Revenue 42,465.56$ 195,089.03$ 48,478.47$ 239,910.79$ 14.2% 23.0% 44,046.83$ 220,234.15$

ExpensesEmployee Costs 15,889.56$ 75,877.32$ 14,877.23$ 65,887.44$ -6.4% -13.2% 13,669.67$ 68,348.35$

Building Costs 3,855.00$ 19,275.00$ 5,000.00$ 25,000.00$ 29.7% 29.7% 3,748.25$ 18,741.25$ Other Expenses 11,100.80$ 66,405.34$ 8,588.63$ 54,984.72$ -22.6% -17.2% 8,700.41$ 43,502.05$

Total Expenses 30,845.36$ 161,557.66$ 28,465.86$ 145,872.16$ -7.7% -9.7% 26,118.33$ 130,591.65$

Net Revenue 11,620.20$ 33,531.37$ 20,012.61$ 94,038.63$ 72.2% 180.4% 17,928.50$ 89,642.50$

Physician Costs 10,000.00$ 50,000.00$ 12,000.00$ 60,000.00$ 20.0% 20.0% 17,735.17$ 88,675.85$

Net Income 1,620.20$ (16,468.63)$ 8,012.61$ 34,038.63$ 52.2% 306.7% 193.33$ 966.65$

2012 2013 MGMAA/R

Total A/R 89,667.32$ 78,661.88$ 74,402.00$ Days in A/R 47.57 36.32 35.62

Credit Balances (12,878.55)$ (368.89)$

2012 2013 2012 2013 MGMA

Cash Transcription 5,678.16$ 3,124.99$ 3,817.92$

Checking Account 256.77$ 15,063.22$ Investment Account 3,353.88$ 35,115.22$

EMPLOYMENT ISSUES

EMPLOYMENT ISSUES

• ADEA• ADA• COBRA• ERISA• FUTA• OSHA• THA

• CRA• INA• FMLA• FLSA• DBRA• EPA• CCPA

EMPLOYMENT LAWS

EMPLOYMENT ISSUES

EMPLOYMENT APPLICATIONS AND

INTERVIEW LEGALITIES• Race• Religion• National Origin• Sex• Marital Status• Pregnancy• Disability• Height/Weight/Age

EMPLOYMENT ISSUES

Fair LaborStandards Act

• 1938• 1 or More

Employees• Salaried/Hourly• Record Keeping• Minimum Wage• Overtime Pay• Child Labor

EMPLOYMENT ISSUES

FAIR LABOR STANDARDS ACT EXEMPTIONS

• Executive• Administrative• Professional• Highly Compensated

EMPLOYMENT ISSUES

FAIR LABORSTANDARDS ACT

EXEMPT EMPLOYEES

• No overtime required • No time card required• Regular, predetermined

salary• No reduction in pay because

of the quantity or quality of work

• No deductions for absences of less than one day

EMPLOYMENT ISSUES


TYPICAL EXEMPT

POSITIONS• Doctors• Administrators/Managers• Nurse Practitioners• Midwives• Physical/Occupational

Therapists• Registered Nurses

EMPLOYMENT ISSUES


TYPICAL

NONEXEMPT/COVERED POSITIONS

• Receptionists• Telephone Operators• Bookkeepers• Insurance Clerks• X-Ray/Ultrasound

Technologists• LPN• Medical Assistants• Registered Nurses

EMPLOYMENT ISSUES


COVEREDEMPLOYEES

• Must keep records• Must maintain

timecards• Must be paid overtime• Must be paid at least

minimum wage

EMPLOYMENT ISSUES


RECORDKEEPING• Personal Information –

Name, Address, Title, Sex • Earnings History – Amounts

Paid, Hours Worked, Regular Pay Rate, Overtime Pay Rate, Wage Deductions, Taxes and Other Amounts Withheld, Dates of Payment and Pay Period Covered

• Keep records for 3 years

EMPLOYMENT ISSUES


TIME CARDS• Hand written or time

clock acceptable• Workweek equals 7

consecutive 24 hour periods

• Keep 2 years

EMPLOYMENT ISSUES


MINIMUM WAGE$7.25 per hour- July 24,

2009

EMPLOYMENT ISSUES


OVERTIME PAY

• Must be paid for any hour or portion of an hour over 40 hours per week physically worked

• Work week equals 7 consecutive 24 hour periods

• One and one half times regular rate

• Must be paid in the regular pay period during which the overtime is earned

EMPLOYMENT ISSUES

Arkansas state law does not guarantee

employees the right to a break period of any

length during the work day.

The federal Fair Labor Standards Act does not guarantee the right to

breaks either.

EMPLOYMENT ISSUES


COMP TIME

NO!

EMPLOYMENT ISSUES


ENFORCEMENT• Department of Labor – Wage

and Hour Division• Payment of overtime for 3

years• Liquidated damages equal to

back wages• Attorneys’ fees and court

costs• Fine and/or imprisonment for

willful and repeated violations

EMPLOYMENT ISSUES

SEXUAL HARASSMENT

HARASSERDoctor

ManagerSupervisorCo-Worker

PatientDrug Rep

Delivery Person

EMPLOYMENT ISSUES

SEXUAL HARASSMENT

VICTIMAny Employee

EMPLOYMENT ISSUES

POLICY MANUALS

• Set of Written Rules• Maintains

Fairness/Equality• Easy To Understand –

Keep It Simple• Give Each Employee

One• Have Employee Sign

For It

RISK MANAGEMENT

RISK MANAGEMENT

IT’S MORE THAN MALPRACTICE!

RISK MANAGEMENT

• Employees• Patients• Business• Facilities• Money• Others• Laws & Regulations

RISK MANAGEMENT

COMPLIANCE PLAN• Monitoring and Auditing• Practice Standards and

Procedures• Designation of Compliance

Officer• Conducting Training and

Education• Responding to Detected Offenses• Open Lines of Communication• Enforcement Standards

RISK MANAGEMENTCOMPLIANCE ISSUES

• Medicare Rules• Stark Referral Rules• CLIA• OSHA• Fire & Safety• Wage & Hour• Workers Compensation• FMLA• COBRA• Unemployment Compensation• Migrant Workers Laws• Employment Discrimination Laws• ADA• HIPAA

RISK MANAGEMENT2013 OIG WORK PLAN

Physicians/Medical Practice and Other Services• Non-Hospital-Owned Physician Practices Billing Medicare as

Provider- Based Physician Practices • Physicians Encountering Beneficiaries Face-to-Face When

Certifying Them for Medicare Home Health Services • Physicians’ Improper Use of Commercial Mailboxes• Physicians Failing to Refund Overpayments Will Have Recent

Medicare Payments Reviewed• Questionable Billing By Ophthalmologists • Interest in Recent Increase of Medicare Payments for

Polysomnography • Review of High Utilization of Sleep Testing Procedures • Questionable Billing for Electrodiagnostic Testing • Review of High Utilization of Sleep Testing Procedures • Orthopedic Implant Devices Used in Spinal Fusion Procedures • Safety and Quality of Surgery and Procedures in Ambulatory

Surgical Centers and Hospital Outpatient Departments • Medicare Payments for Practice Expenses Related to Part B

Imaging Services • Noncompliance with Assignment Rules • Incident-To Services• Errors in Coding Based on Place-of-Service • Appropriateness of Use of Claim Modifiers

OIG

RISK MANAGEMENT

INSURANCE TO CONSIDER

• Workers Compensation• General Liability• Automobile• Directors & Officers• Keyman

– Life– Disability

• Overhead Expense• Employee Bond• Umbrella

RISK MANAGEMENT

BILLING WITHOUT CREDENTIALS

RISK MANAGEMENT

WHAT SHOULD YOU DO IF THE GOVERNMENT SHOWS UP AT YOUR FRONT

DESK?

RISK MANAGEMENT• Ask agents for identification• Direct them to Administrator or

Compliance Officer• Must have search warrant • Review warrant carefully• Contact your corporate attorney• Employees do not have to speak

with agents and may wait until they have an attorney present

• No one is required to answer questions or assist agents

• Avoid obstruction of justice• Monitor the search and take

notes do not volunteer any information

• Insist on an inventory

MEDICAL RECORDS

MEDICAL RECORDS

PURPOSE• Document history of:

– What the patient has reported– The diagnosis– The treatment– The progress

• Legal document for the defense of the physician’s actions

MEDICAL RECORDS

SVMIC’s RECOMMENDATIONSRETENTION OF MEDICAL RECORDS

• Retained 10 years from last contact with patient

• Immunization records – indefinitely• Incompetent patients’ records –

indefinitely• Mammography records – 20 years• X-rays – 4 years (if there is a separate

interpretive record)• Minors – 1 year after majority OR 10

years from last contact – whichever is longer

• Under dispute – after meeting above rules, at the resolution of dispute

MEDICAL RECORDSDESTRUCTION OF MEDICAL

RECORDS• May be destroyed in the normal

course of business with a policy that does not violate any provisions of these rules

• No record may be singled out• Methods

– Burning– Shredding– Other effective means of keeping

information confidential• Record of time, date and

circumstances of destruction must be maintained

• Destruction record does not have to list each individual record, but identity of group of records is sufficient

MEDICAL RECORDS

COPIES OF MEDICAL RECORDS

• Physicians “own” their medical records

• Patients are entitled to copies or summaries of their medical records

• HIPAA

Medical Records

Copy ChargesArkansas

• Photocopy charges are limited to $0.50 a page for the first twenty-five pages, and $0.25 for each additional page.

• A physician’s office may charge a labor charge not exceeding $15.00 or an additional retrieval fee for stored records for each medical records request.

• Physician may charge an additional fee for providing a narrative medical report, but the patient should be notified in advance of the charge

• The actual cost of any postage may, also, be charged.

PHYSICIAN EXTENDERS

SUPERVISION OF PHYSICIAN EXTENDERS

EXTENDERS IS THE OPERATIVE WORD

• Physician is responsible for care

• The patients “belong” to the physician

• The medical record “belongs” to the physician

• EVEN IF THE EXTENDER IS NOT EMPLOYED BY THE PHYSICIAN

ICD-10

ICD-10

• Significant expansion of the diagnostic coding system

• Increased specificity - for instance – ICD-9 – 733.82 – other disorders of bone and

cartilage, non-union of fracture– ICD-10 – there 2530 different codes for this one

diagnosis– Will require very detailed and specific notations

in the medical record in order to code• All are 7 characters• Goes into affect October 1, 2014

ICD-10

Preparation

• Educate your board• Inform your staff• Assign responsibilities for implementation

– Research impact on practice management and EHR systems– Train coders– Review all affected clinic operations and develop plan

• Train physicians and staff• Schedule implementation

– Software– Coding– Test

• Go live• Monitor

TOP 10 THINGS YOU NEED TO KNOW

Thomas H. Stearns, FACMPEVP Medical Practice Services

State Volunteer Mutual Insurance Company

[email protected]

mailto:[email protected]

PRACTICE MANAGEMENT TOP 10 THINGS YOU NEED TO KNOW.

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