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
CORPORATE or PARTNERSHIP DOCUMENTS
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
CORPORATE or PARTNERSHIP DOCUMENTS
• 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?
CORPORATE or PARTNERSHIP DOCUMENTS
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
OPERATING FINANCIAL DATA
REVENUE• Gross Revenue• Net Revenue• Office• Ancillaries• Procedures• Hospital• Extenders
DASHBOARD REPORTS
OPERATING FINANCIAL DATA
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
FAIR LABORSTANDARDS ACT
TYPICAL EXEMPT
POSITIONS• Doctors• Administrators/Managers• Nurse Practitioners• Midwives• Physical/Occupational
Therapists• Registered Nurses
EMPLOYMENT ISSUES
FAIR LABORSTANDARDS ACT
TYPICAL
NONEXEMPT/COVERED POSITIONS
• Receptionists• Telephone Operators• Bookkeepers• Insurance Clerks• X-Ray/Ultrasound
Technologists• LPN• Medical Assistants• Registered Nurses
EMPLOYMENT ISSUES
FAIR LABORSTANDARDS ACT
COVEREDEMPLOYEES
• Must keep records• Must maintain
timecards• Must be paid overtime• Must be paid at least
minimum wage
EMPLOYMENT ISSUES
FAIR LABORSTANDARDS ACT
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
FAIR LABORSTANDARDS ACT
TIME CARDS• Hand written or time
clock acceptable• Workweek equals 7
consecutive 24 hour periods
• Keep 2 years
EMPLOYMENT ISSUES
FAIR LABORSTANDARDS ACT
MINIMUM WAGE$7.25 per hour- July 24,
2009
EMPLOYMENT ISSUES
FAIR LABORSTANDARDS ACT
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
FAIR LABORSTANDARDS ACT
COMP TIME
NO!
EMPLOYMENT ISSUES
FAIR LABORSTANDARDS ACT
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
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