Blog and Helpful Articles

What We’re Reading – Burnout is soaring. Here are 7 ways employers can help.

Is there a human being on the planet who hasn’t been affected in some way by COVID?  Highly doubtful.  We’ve seen (actual or reports of) people becoming infected and/or dying; regular and often quickly-changing recommendations for safety; disruptions to our routines, such as children out of school, workplaces closed, shortages of food and/or supplies, lack of social outlets; and overwhelming uncertainty, to name just a few.  People, of course, are resilient and may be able to handle these things for short periods of time.  But the point of this article is that 18 months later, we’re still grappling with the effects of COVID changes – with no end in sight – and we’re burning out.

Employers, in particular, are seeing it in the workplace as, this HR Executive article reports, burnout threatens to rule the… ummm… year.  Increased workloads, longer work hours, isolation and little time off are converging into a perfect storm of employees leaving for seemingly greener job pastures.  The author suggests seven great ideas for HR leaders and managers to alleviate the effects of burnout in themselves and their teams.

Be open.  Our society’s made strides in shining light on mental health issues, but this tip is about creating a culture of openness about these issues, and starting at the top.  When company leaders feel comfortable discussing their struggles, the rank and file can also be open to sharing with each other. This can remove some of the isolation that you’re the “only one.”

Offer help. Openness will lead to seeking help and HR has to deliver.  Explore company benefits and programs that will help your workers find the support they need.  Online yoga, meditation, even caregiver support and financial wellness programs, can be a welcome balm for the stress.

Time off.  Understandably, the last 18 months haven’t resulted in lots of vacation plans, and the author points out that even staycations have been on the decline.  The result is no time to disconnect, which makes the burnout wheel spin faster. Bosses should encourage time off and clear the way for it.  Another suggestion is collective time off.  That’s where the whole company closes down for – say – a week.  That way, everyone can recharge without worrying about what’s going on at the office and what’s piling up for their return.  As the ED for Robert Half told the author, “Working nonstop is counterproductive and unsustainable.”   

Zoom overload.  With employees off-site and more spread out, companies have relied heavily on meetings and Zoom calls to stay connected, which can result in some serious overload.  One company’s director is “encouraging thoughtful meetings.”  If only…. LOL  Some tips include limiting the number of on-camera meetings or designating a moratorium on meetings in general one day per week. 

Flex-time. If you’ve worked remotely during the last 18 months, you probably worked longer hours than you did pre- COVID and had a little difficulty (or a lot) turning off work.  Many burned out workers say blurred lines of home and work result in feeling overworked and uninspired. Consider allowing employees to flex schedules based on their energy levels.  One company implemented Summer Fridays and closed down at 1pm between Memorial Day and Labor Day, allowing staff to start the weekend early.  Fall Fridays or Winter Wednesdays might be something to consider.

Surveys.  Sounds simple, but many employers shy away from surveying employees, perhaps fearing the results.  However, a targeted survey on mental health issues, for example, might yield very valuable insight on how to help your workforce.  Consider questions with a COVID context:  How are you feeling? What are your biggest challenges? What tools or resources do you need?  Designate a group to analyze anonymous responses and get creative with some possible solutions.  Burnout is a real problem in our workplaces but it isn’t inevitable.  Managers and HR leaders who genuinely care about workers’ struggles can tackle this together, with creativity and empathy. 

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Billing No-Nos: Selective Billing Activities

Much in the same way no one instrument is the most important in an orchestral piece, so no one aspect of the billing process is the most important.  The stops along the billing route all contribute to the steady flow of revenue into the practice.  Consider the standard billing process, which includes:  timely locking of the visit note, which contains documentation to support all the services rendered; prompt processing of a clean insurance claim, preferably daily, but certainly on a frequent schedule; quick follow-up on denials of payment, which should be rare because your billing procedures are spot-on; and speedy payment posting so you can bill patients for their share.  Did you catch the many ways we said ‘fast?’  Billing must be efficient and prompt.  Let’s look at these individually:

Locking the note.  The widely accepted guideline is to have a note locked within 72 hours of the visit.  This often includes time to have a coder review the note for any glaring issues that must be corrected before processing the claim.  We periodically encounter practices with big backlogs of open notes for which claims cannot be submitted. We recommend a review of the practice’s open notes for each provider no less than weekly with action as warranted. 

Documentation review.  As we know, the adage, “If it isn’t documented, it didn’t happen” can have a big impact on the payment of claims.  Medical necessity for the services received must be clearly evident on the note.  In addition, a proper assessment must be charted, and there must be documented evidence that billed procedures like venipuncture, EKG performed & interpreted, injections, etc. were indeed performed. Outsourced billing services where the practice sends only a superbill can result in issues since the biller is not reviewing the documentation on the “front-end.”  This can mean recoupments and recoveries on the “back-end” if the note isn’t sufficiently descriptive.

Daily processing.  Two arguments can be made against daily transmission of claims and we reject them both:  we don’t have enough billing in order to process claims daily and we have too much billing to transmit daily. Hogwash! (a technical consulting term LOL)  Why would you not want to get the ball rolling on a payment as quickly as possible after rendering the service?  Delaying billing can lead to revenue disruptions.  Emergencies happen.  Your biller is in an accident or you experience a critical staffing shortage – or maybe, we’re hit with a pandemic – and the next thing you know, your claims are past the timely filing deadline.  Get in the habit of processing claims on a daily basis.  And if daily is truly impossible, shoot for two to three times per week, every single week.

Action on denials. Your billing processes may be pretty flawless, but denials of payment can happen through no fault of your biller. The important thing is to check for them as often as possible and/or on a regular schedule, such as weekly, depending on your volume of denials.   Next step is to commit a day or portion of the day – maybe it’s the last hour – to researching the issues surrounding a denial.  Some will be easy to fix while others may take calls to the insurance company and additional time-consuming tasks.  By devoting a set amount of time to denials on a daily basis, you will be more likely to turn them around quickly so you can receive your payment.  Managers should periodically spot-check that denials are being worked.  After all, your biller may be stuck on how to fix the error, set the denial aside to figure out later…. and never come back to it. If you’re not checking, how would you know about the lost revenue and the biller’s knowledge gap?

Payment posting.  The last two aspects of the billing process start with posting payments.  This tedious end of the line task is sometimes delayed in favor of processing new claims, which is a mistake.  The prompt posting of payments, firstly, stops the clock on the accounts receivable.  In another blog, we discussed the Billing No-No of neglecting the A/R.  Remember that the A/R aging calculates the time a claim is outstanding, so by posting payments quickly after receipt, you will more accurately reflect the time it took to complete the cycle on that claim.  The second reason to post quickly is to determine whether additional monies are owed by the patient… which brings us to the very last stop on the billing journey:  patient statements. 

Patient statements have to wait until payments are posted.  You want to bill your patients as quickly as you can after the visit, so as soon as your payment reveals any patient responsibility, a statement will be generated in your next batch of patient bills. Speaking of which, patient statements should be sent according to a set schedule, which for small practices is probably monthly.  If your volume of statements is high, consider sending 25% each week so as to spread out the work (which includes answering patient calls about the balances) and also maintain a steady revenue stream.

Remember how in the opening paragraph we stressed the speed with which these activities must take place?  Add to that the regularity.  Resist the urge to focus only on new claims and be sure to carve out portions of the day or days of the week where your billers concentrate on the other aspects of the billing process.    This will result in a billing cycle that resembles a most harmonious symphony.

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Kaiser Permanente: Most Recent to Fall Under DOJ Scrutiny

Kaiser Permanente is the latest Medicare Advantage (MA) plan to be embroiled in allegations of False Claims Act violations for risk adjusted coding activities.  As you might recall, Humana was flagged for reporting unsupported risk adjusted diagnoses, Anthem allegedly failed to remove knowingly erroneous codes and Cigna was accused of fraudulently reporting conditions during its Health Risk Appraisal process.  Kaiser is accused of pressuring providers to create invalid addenda to medical visits long after the encounter.  The DOJ specifically states these addenda were created “often months or over a year later, to add risk-adjusting diagnoses that patients did not actually have and/or were not actually considered or addressed during the encounter, in violation of Medicare requirements.”

In 2003-2004 – the early days of the CMS-HCC model – there was little guidance on the creation of addenda, and a 30-day time-frame from the date of the visit became the unofficial rule of thumb.  Since that time, more specific direction has understandably narrowed the deadline, bringing it more into line with general medical practice. 

Let’s backtrack for a few minutes.  Risk adjusted conditions reported by providers form the bulk of payments from CMS to MA plans for their members. (Feel free to read the many blogs on our website for more background.)  The specific conditions in the CMS-HCC model, which are assessed and managed by certain clinicians and reported to MA plans, result in higher payments because of predictive cost factors. 

Conditions may only be reported when they’re assessed/addressed by the provider during a visit.  We’ve said it before and we’ll say it again:  risk adjustment is not about payment because the patient has a condition, but because the provider is managing it. And as we all know, the healthcare adage, “If it isn’t documented, it didn’t happen” is always true.  Some providers try to get around this by creating an addendum to the note and reporting MRA conditions because they were not on the original note. 

An addendum is a valid practice when information is appended to the original note because an assessment was begun during the visit, but additional information was still pending at its conclusion.  Here’s an example:  a member with signs and symptoms of a possible clot in his leg sees the PCP, who suspects a clot but needs imaging evidence to confirm it.  On the date of the visit, the PCP codes what she knows for sure:  just the symptoms (e.g., pain, swelling, etc.).  She orders a stat test and receives a positive result on the following day.  In this situation, the PCP can make an addendum to yesterday’s visit, date it with the day she received the result, explain the test result, new diagnosis, treatment and plan provided to the patient, and ask the biller to re-process the claim with the new information. The first key point is that the assessment of the condition (or symptoms) was begun during the visit and a critical piece of information was left pending.  This information arrived quickly after the visit (second key point) – not months later – and the provider took action on it.

Most providers would argue that it’s best to see the patient again to deliver the test result and establish the treatment plan, or refer the patient elsewhere for treatment.  While this is certainly at the clinician’s discretion, it’s also acceptable to discuss the information with the patient by phone and append the info to the note, thereby saving time.

Addenda may not be used to report risk adjusted conditions that were “forgotten” during the visit.  We’ve seen this habit in operation and it ages us each time LOL  Usually, a coder or biller realizes that a chronic condition has not been reported in the current period and asks the provider to add it to the note. Or, an administrator, acting on an MA plan’s reports of conditions “dropping off,” asks the provider to create an addendum.  If this is occurring in your practice, you need to stop this immediately and conduct a widespread coding review.  Audit every risk adjusted condition reported to make sure it has been properly assessed during the visit and promptly submit a removal report to the plan for any improperly reported codes.

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What We’re Reading – Major trend coming as COVID-19 vaccines show up in job listings

Recent reports mentioned in an HRExecutive article show a huge – 5,000% since January! – increase in the number of high-level job postings requiring candidates to be vaccinated against COVID-19.  It’s also interesting to note that this requirement is not only evident for healthcare jobs, but is seen in a variety of industries, from small to large businesses.  In addition, a survey from Indeed found a 34% increase since last month alone in the job posts requiring vaccination. 

Job postings historically have been limited to experience and education prerequisites, main job functions, salary range, etc. with employment issues relegated to the employee handbook.  Seeing this requirement to such a large degree in job postings is a “massive” trend that experts predict will continue through the fall and winter.

We’d love to know your thoughts.  Please leave a comment below.

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What We’re Reading – Your Employees Are Vaccinated. Now What?

One of our home health clients recently asked how to handle a patient’s request for a vaccinated caregiver.  While confusion and misunderstanding still seem to rule the day when it comes to employers and their workforce’s vaccination status, Fisher & Phillips published a comprehensive FAQ document with common queries like this one. 

Essentially, an employee’s individual vaccination status is “confidential medical information that must be protected and not disclosed.” It may be acceptable to publish a company-wide statement that X% of your workforce is vaccinated.  Company employees should be prepared to deflect questions from customers about any worker’s vaccination status.  A general statement, such as, “We can’t disclose anyone’s vaccination status but 80% of our company’s workforce is vaccinated” can be bolstered with the measures the company is taking to keep everyone safe.

However, F&P reminds us to be careful because employees may feel pressured by this type of disclosure, especially if they’re unable to receive vaccination.  In addition, fear of unequal treatment by the employer or fear their medical status or religious affiliation may be exposed may also heap on employee stress.

Some other interesting points from this article are that, per OSHA, employees should not be treated differently in terms of workplace safety precautions based on vax status.  That means that mask mandates in the workplace and physical distancing should be observed by everyone regardless of vaccination status. Lastly, while private employers can certainly mandate vaccination, the F&P attorneys advise us to make sure we can articulate how the vax is job-related and consistent with business necessity. 

To be sure, all things COVID are fluid and new variants may void past decisions.  Our biggest recommendation is to get legal advice from labor attorneys before you make sweeping reforms and implement COVID-related mandates in your business.

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Knowledge is Power: AHCA Financial Projections

We continue our short series on Knowledge is Power geared to new entrepreneurs by discussing financial projections.  You can catch up with earlier posts by reading the first installment and moving through all our stops on the new business journey.

In Florida, applications for home health agency and nurse registry licensure require financial schedules, which take into consideration your business’s known and projected overhead and operating expenses, based on the volume of patients you expect to see.  The purpose of the exercise of producing financial projections is to consider all of the realistic expenses in operating the business for the first one (nurse registry) or two (home health agency) years and showing the capital required to sustain the business until its profitability.  In essence, this is AHCA’s way of making sure you’re going into a potential business opportunity with solid financial footing and real-world expectations, not unrealistic, “big money” hopes.

While the financial schedules for home health agency license applicants must be created and certified by a CPA, those for a nurse registry do not.  This means that someone with experience with budgets, etc. may be able to successfully create the AHCA financial projections that must accompany the licensure application.

Here are some common pitfalls we’ve seen over the years:

  • Unrealistic expenses.  Every entrepreneur wants to launch a business with the least amount of capital possible, and we understand that.  So does AHCA, and they also know how much it roughly takes to get a new health care business off the ground.  If, for example, you project that you and your leader colleagues will forego a salary, AHCA won’t take your word for it.  You will need to produce evidence that meets AHCA’s scrutiny that these individuals have alternate means of support. 
  • Working backward from your finances.  There is a tendency to try to finagle the financials to match how much money an applicant has.  This is a serious mistake because we’ve seen applicants leave out or low-ball important expenses so the schedules don’t exceed their bank balance.  Keep in mind that when you submit application documents to AHCA and there are errors, this will not be an endless exercise of tweaking, sending back and re-revising.  You get one re-do to fix whatever they point out to you. If you do not fix the schedule to their satisfaction, AHCA withdraws your application from consideration and you forfeit the $2,000 application fee paid.
  • Not following directions.  The schedules are complex and interconnected, and there are instructions for completing them.  Lest you think, “How hard can this be?”, keep in mind that the schedules must conform to generally accepted accounting principles (GAAP) and will be reviewed by accountants.  Enlisting a professional with experience with these AHCA documents is a wise investment and one that will save you headaches, and more money than a forfeiture.

We understand that when you have a dream of opening a new business, you have every expectation you’ll be successful, and some have bristled at needing to demonstrate this to the State.  But remember that AHCA wants the same thing:  a solid healthcare business that meets accepted financial standards, and will be around a long time, successfully providing care to Floridians.

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MRA Issues from the Trenches

We have blogged quite extensively on all things MRA and especially the need for solid documentation. Historically, a provider’s charting improves when the spotlight is shined on it, but old habits are hard to break; we find that, sadly, documentation deteriorates over time, which can result in risk adjusted codes being removed for lack of proper assessment.  Below are some timely reminders of common errors we find in the most seasoned of clinicians, working in the risk adjustment world.

  • Improper assessment.  We’ve linked some blogs on this subject but in a nutshell:  refilling meds, ordering lab tests or pasting copious, templated, un-customized, counseling suggestions does not constitute an assessment. Remember the M-E-A-T acronym; document how you’re Monitoring, Evaluating, Assessing/Addressing and Treating each condition.
  • Errors with lab-based conditions.  Almost every lab-based diagnosis requires two consecutive values, spaced a few months apart, to confirm.  Assessing a lab-based condition similarly requires lab data.  Charting that a patient’s “GFR is low” is not a real assessment; better to document that the GFR on MMDDYY was 23 as this conveys a status.  If your EMR embeds lab reports into the progress note, this can go a long way toward bolstering your assessment.  No need to rewrite the values, but do reference them by describing if they’re better, worse, uncontrolled, etc.
  • Inactive cancers.  Many years ago, a clinician told us that she considers a patient to have cancer forever because it’s lurking somewhere in that patient’s body.  Regardless of your personal feelings about cancers, there are very specific coding guidelines. They are:  1) A cancer that is active.  By active, we mean that you have a recent test result or confirmation, and the patient is either not a treatment candidate or chooses to forego treatment, you both elect to “watch & wait” before initiating treatment, or the patient is in the process of beginning treatment.  2) Treatment is directed to the active cancer.  This means that the patient is undergoing some treatment directed to the actual malignancy. Common treatments are chemotherapy and radiation therapy. 3) There is evidence of a recurrence.  This one is clear-cut:  you have a biopsy report or other objective evidence that the malignancy has returned. When a patient has had a malignancy removed, and the treatment is to prevent a recurrence, this is not an active cancer; it is coded as a personal history.
  • Combo codes.  ICD-10-CM has saved us a few coding steps by creating combos of conditions that often occur together.  Some common examples are ASHD with angina and diabetes with a manifestation.  It’s important to keep in mind that although you report only one ICD-10-CM code, there are actually two conditions involved. This means that you need to assess both of them and document accordingly. When a patient is diagnosed with diabetic polyneuropathy, for example, and the note discusses only the diabetes, your coder should query you (if the note is still open) or change the code to match what you assessed – in this case, only diabetes. 

Consider running a report from your EMR or claims system of patients with a cancer diagnosis, for example, and spot-check a few cases to determine whether they have been correctly coded.  Remember to process removals for any erroneous codes you find in your review.

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Billing No-Nos: Ignoring Your A/R – Part 2

Welcome to Part 2 of Billing No-Nos:  Ignoring Your A/R.  In Part 1, we discussed the need for every practice owner and manager to know their accounts receivable, and we hope you’ve taken steps to review those reports.  The next most logical question is, “Now that I know, what do I do about the issues?”  That’s what we’re going to discuss today.

In addition to your fee schedule, which affects your revenue and A/R, we can’t underestimate the impact of your internal billing processes, which can support or harm your payment efforts. 

Denial of Insurance claims.  When a claim is denied by a payor, the practice suffers in two ways:  revenue is delayed (or lost) and your practice incurs the costs of appealing the denial. The most common reasons for denials are: 1) missing or inaccurate insurance information 2) lack of pre-authorization for procedures (if required) 3) missing filing deadlines.  You can attack all three by verifying patient insurance coverage at every visit (a quick, “Is your insurance still ______?”) and assuring your billers review claims carefully before submission. 

The office or billing manager should know the top reasons for claims denials in your practice, which can reveal processes requiring correction or staff members who need additional training.   Finally, the manager must make sure denials are being worked and corrected so you receive the payment you earned for services provided.  The industry standard for denials is not more than 5%.  What’s your denial rate?

Write-offs.  One of our pet peeves is the unregulated nature of write-offs in many practices.  What is your policy, and who has the authority to write off balances?  It helps the discussion to distinguish between a write off and an adjustment.

Adjustments occur for many reasons, most of which have to do with the insurer paying a contracted amount which is less than your fee schedule.  In that case, the “balance” after posting the payment is adjusted to bring the patient account to a zero balance.  A write-off is the elimination of a patient balance that was the patient’s financial responsibility.  Only someone in a position of authority (practice owner, administrator) should be able to make a patient balance disappear.  We suggest an office policy for the reasons and dollar amounts that can be written off as a norm.  It’s also important monitor the write-off pattern over a time period to see if there are hidden issues with your payments or billing procedures. 

High bad debts & patient responsibility.  Since your practice is verifying insurance at every visit as explained above, you will have actionable info for billing purposes.  Next, it’s crucial to make sure the upfront costs (deductibles, copayments) are collected at the time of the visit, certainly before the patient leaves the office. If your staff knows the patient’s out of pocket expenses before the visit, they could remind the patient or caregiver of the required payment prior to the visit.  Take the time to properly train your billers so, for example, if the patient is having a procedure, they can provide clear and detailed billing information to the patient that hopefully reduces the likelihood he or she will renege on any financial responsibilities.

Collecting Unpaid Balances. When you have provided services to the patient, you’re entitled to be paid.  Part of A/R management is establishing and monitoring the collection process, and holding your staff to the established guidelines in following up on outstanding payments.  For example, at what point is there any follow up?  How many calls are made to collect unpaid balances?  Where are notes of any communications kept?  How many patient statements do you send, and what happens after the last unpaid statement? Some practices are reluctant to use collection agencies, and that is certainly your preference.  But consider that if you don’t value your services by requiring fair payment, how will your patients value them?  

We hope this two-part series is helpful to your practice in putting in place the processes that will bring your continued financial success. 

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Billing No-Nos: Ignoring Your A/R – Part 1

Quick… off the top of your head, what’s the approximate dollar value of your practice’s accounts receivable (A/R)?  Many providers (and administrators!) will say they don’t know.  Our question to you is: why not?  In Part 1 of this two-part series on your A/R, let’s look at some common reasons the A/R is often ignored.

You don’t receive reports.  Some providers – whether their billing is in-house or outsourced – don’t receive reports.  And they don’t request them either.  In our many decades of practice management (don’t ask how many LOL), we’ve seen countless providers continue their work patterns with a false sense of security because checks are still coming in.  They don’t stop to question if the checks are correct, how many are not being received and the state of their practice’s finances.

You don’t know what to look for.  We’re so glad you asked!  You can do as deep a dive as you’d like but the basics to look at are: 

  • Fee schedule. Before looking at the dollars you’re owed, you need to know the mark-up of your fee schedule because this forms the basis of your A/R.  A good guide is the Medicare Physician Fee Schedule (MPFS), which tells you the Medicare allowable (MCA) for any service.  Your biller should be able to tell you the percentage increase in your fees over the MPFS, and once you know this, you’ll be able to look at your A/R more realistically. You can also spot-check to make sure it’s a consistent mark-up by looking up the MCA for a few services and checking your fee schedule accordingly.  The last thing you want is an over-inflated fee schedule – like 250% – because the A/R figures will be staggering and wholly unrealistic unless the majority of your payors pay your billed charge.
  • Total accounts receivable.  Have a sense of the dollar amount of your total A/R.  Remember, as we explained above, if your fees are – say – double the MPFS, you need to understand that you will not generally collect the total dollar amount you’ve billed.  At a minimum, based on MCA, you can discount the A/R total by 100% to give you a truer number.  In addition to knowing the real A/R, look at the percentages of monies owed across different time-frames: 30-, 60-, 90- and 120+ days.  Medicare pays within 14 days of claim receipt and commercial payors vary, but usually, you will see payment within 45 days.  How much is lingering in longer categories?  A good rule of thumb is 70% to 75% of the total A/R within the 30-day and 60-day categories with no more than 15% to 20% at 90 days and 10% or less of the total A/R at 120 days or longer.   

One challenge many practices have – when they discover large balances outstanding for a long period of time – is how do you fix the issue?  The remedy has to do with identifying the issues that contributed to the high balances and then implementing necessary standards to keep your practice’s financial health at its peak.  Fortunately, that’s the subject of Part 2 of this blog on Ignoring Your A/R.

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HR Issues and the Employed Practitioner – Part 3

In this three-part series, we’ve explored administrative issues with employed practitioners that may interfere with the smooth running of your practice.  We discussed untimely processing of a clinician’s work in part 1 and in part 2, we looked at attendance and punctuality challenges.  In this last installment, let’s examine scheduling concerns. 

As much as some would like to debate it, medical practices are businesses and as such, they need to be profitable.  Now, many factors go into achieving profitability, but let’s at least agree that your service schedule is the starting point.  Most primary care practitioners see between three and four established patients per hour, and virtually all of our clients have some formula for scheduling appointments.  Among the most important scheduling considerations is the time allocation for new patient appointments, routine follow-up appointments, annual wellness or preventive visits, pre-procedural visits and hospital follow-ups.  Of course, your practice may have a few other visit types, but the most common choices are 15- and 30-minute slots.

We advise highly capitated practices to safeguard a few open slots for same-day/urgent or walk-in visits; these can vary from 10- to 15-minutes in length for which criteria exist to fill them.  Some practices also build in some “breathing room” for providers, who might run late or who need a catch-up point for closing notes or reviewing documents, by allocating a certain number of open (non-bookable) spots.

The big issue many providers have is the composition of the schedule and a trusting relationship between administrators and clinicians goes a long way toward harmony.  In practices where that trust has been damaged, or providers have developed bad habits, we see clinicians becoming testy with the staff (often within the earshot of patients – yikes!) or making scheduling demands as if they were self-employed.  To avoid these behaviors and the confusion they stoke, we need to establish common ground by considering the following:

  1. As the manager, look at your provider visit schedules for last six months and note any patterns. How many new patients does your office see per day? How many inpatients do you traditionally manage or have within your panel (who will need timely follow-up)?  How many walk-ins, urgent visits and no-shows do you generally see?  These basic questions will reveal trends and guide you in planning any needed schedule overhaul.  This info is also helpful when meeting with providers, who can snap about today’s or this week’s schedule without reflecting on the flow for a longer period of time. Of course, if your practice is significantly affected by seasonal variations, do consider them when identifying those patterns.
  2. When you’ve pinpointed your practice’s scheduling idiosyncrasies, draft a schematic.  How many new patients is it feasible to see each day?  If your practice is in growth mode, you don’t want a four-week (or longer) wait to see a new patient.  When do you see these patients?  The end of the day is usually the worst spot for new patients or any longer appointment type.  Do you have a lot of urgent/sick calls and need to bring those patients in?  A formula for open slots, like on the 45-minute mark (9:45, 10:45, 11:45), is a good idea; if you have multiple providers, stagger their open slots:  PCP A gets the 15-min open spots (9:15, 10:15, 11:15), PCP B gets the 10-min spot (9:30, 10:30, 11:30) and PCP C has the 45-min ones we discussed above. The key is to review patterns and determine ahead of time how many of each appointment type you will see in a given day.  
  3. A large number of no-shows- which you should be tracking anyway – can be frustrating because your staff may compensate by double-booking a slot.  This frustrates providers who fear having to rush through visits because someone else is waiting.  High no-shows should prompt an operational review:  how frequent are your appt follow-ups?  Patients may bristle at too frequent visits, or disregard them because they feel fine.  Does your staff or EMR conduct reminder notifications?  Do they contact patients one time and leave a message or make multiple attempts?  How far in advance are your reminders?  And lastly, do you charge for no-shows?  That’s a dicey question because it’s a big patient dissatisfier, and you need to strike a balance between the longstanding patient who forgot her appointment for the first time ever and the habitual no-show-er.  Charging for no-shows should be the absolute last resort after you’ve evaluated for – and fixed – any process issues in your practice.
  4. Meet with your providers.  When they complain about the schedule, they may not be seeing the big picture of the practice.  Fortunately, you’ve done your homework in numbers 1 to 3 above and can bolster your dialogue with facts.  Successful scheduling requires give and take and also must be practice-wide.  So, consider a preliminary meeting to hear their scheduling issues and where you communicate the results of your due diligence, and re-convene soon once everyone has had a chance to consider both sides. 
  5. The last step is to memorialize the “formula” for your schedule.  This will help you in training and refreshing staff and providers, and help you spot any subtle deviations from the norm that occur over time.  Nothing undermines trust like accusations of, “We agreed on X and it’s not happening.”

It may be impossible for you to make everyone happy with the practice scheduling system, but make sure everyone feels heard, and when you can’t implement someone’s suggestion – say, 30-minute slots across the board – be ready to explain why.

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