Rheumatology Practice Management - February 2014 by Value-Based Cancer Care

PROCESS IMPROVEMENTS TO ENHANCE PATIENT CARE™ February 2014

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Volume 2 • Number 1

PRACTICE MANAGEMENT ACR Meeting Highlights

ICD-10: Get Ready for Documentation Changes, Brush Up on Anatomy and Physiology Now By Wayne Kuznar

San Diego, CA— The first issue of Rheumatology Practice Management looked at the 4 phases for implementing the new International Clas sification of Diseases, Shelly Cronin Tenth Revision (ICD10) code sets. At the 2013 meeting of the American College of Rheumatology, Shelly Cronin, CPC, CPMA, CPPM, CANPC, CPC-I, Director of ICD-10 Training at the American Academy of Continued on page 6

From the Editor

Practice Management and Policy Changes in 2014

Iris W. Nichols President, National Organization for Rheumatology Managers Editor-in-Chief, Rheumatology Practice Management

appy New Year. Every year around December 27 or 28 we start wishing everyone a happy new year. As we look into 2014, we are trying to determine just exactly

what a “happy new year” means when we manage our business of delivering healthcare services. The new year will bring new challenges, and with new challenges Continued on page 5

Lead Your Team to Greater Success Using Gallup’s Best Kept Secret Jay Salliotte, Business Manager, Advanced Rheumatology, Lansing, MI

hink back to a time when you had a bad work experience or left a job. What happened that made you miserable or made you leave? Of course, pay is important, as are other logistical items such as commute time and flexible work schedules for

family obligations. But, when we say an employee has “left the company,” most likely it was because of a manager. You could work at the best Fortune 500 company, or at any other company voted as one of the best places to work, and still have a bad experience Continued on page 20

In partnership with

Nat ion a l O r ga n iz at ion of o R he u m atolo g y Man a gers From the publishers of

™

Don’t Face the Maze of Changes in Rheumatology Alone

NORM Keeps You Informed National Organization of Rheumatology Managers

NORM’s mission is to provide rheumatology managers, administrators and managing physicians countless opportunities to network with colleagues through our listserv and annual conference. At NORM, our goals involve addressing, educating, distributing, and functioning as a conduit for rheumatologic practice management needs and expertise. “NORM, by far, surpasses the benefits of any other organization I have ever belonged to. Through the listserv, NORM members willingly assists each other by providing solutions to everyday issues that arise while managing a rheum practice. We share experiences, ideas, protocols and procedures specific to a rheumatology practice. The annual NORM conference in September is definitely the icing on the cake as we all come away with practical ideas and tools we can implement.” Mary Jo Wideman, RN, BSN, Practice Manager

Do you have questions about coding, biologics, insurance carrier denials or personnel issues? Join NORM to help find your answers. Are your questions state specific, MAC specific or national coverage issues? NORM offers rheumatology managers the opportunity to connect across the Nation. Through our listserv you receive expert advice from professionals in rheumatology! Join NORM and network with experienced managers through our listserv, gain access to our members only section which contains sample practice forms, job descriptions, and other documents that have been shared on this listserv, a list of our members, and in the future educational resources. NORM also hosts webinars throughout the year to continue supporting the education of our members. Membership is open to rheumatology professionals including physicians and those who hold a management position in a rheumatology practice.

Save the Date for our 2014 Annual Conference September 12 & 13, 2014 ~ Louisville, KY

NORM ~ www.normgroup.org ~ info@normgroup.org

In This Issue

PUBLISHING STAFF Senior Vice President/Group Publisher Nicholas Englezos nenglezos@the-lynx-group.com Director, Client Services Zach Ceretelle zceretelle@the-lynx-group.com Editorial Director Dalia Buffery dbuffery@the-lynx-group.com Associate Editor Lara J. Lorton Editorial Assistants Jennifer Brandt Cara Guglielmon Production Manager Melissa Lawlor The Lynx Group President/CEO Brian Tyburski Chief Operating Officer Pam Rattananont Ferris Vice President of Finance Andrea Kelly Human Resources Jennine Leale Associate Director, Content Strategy & Development John Welz Associate Editorial Director, Projects Division Terri Moore Director, Quality Control Barbara Marino Quality Control Assistant Theresa Salerno

PROCESS IMPROVEMENTS TO ENHANCE PATIENT CARE™ february 2014

www.RheumatologyPracticeManagement.com

Volume 2 • Number 1

PRACTICE MANAGEMENT

From the Editor

Practice Management and Policy Changes in 2014........................ 1

™

By Iris W. Nichols

Essentials of Practice Managers

Lead Your Team to Greater Success Using Gallup’s Best Kept Secret........................................................................................... 1 By Jay Salliotte

ACR Meeting Highlights

ICD-10: Get Ready for Documentation Changes, Brush Up on Anatomy and Physiology Now......................................... 1 By Wayne Kuznar

How to Prevent Fraud in Your Practice..............................................7 By Mark Knight

Director, Production & Manufacturing Alaina Pede

Continued on page 4

Director, Creative & Design Robyn Jacobs Creative & Design Assistant Lora LaRocca Director, Digital Media Anthony Romano Web Content Managers David Maldonado Anthony Trevean Digital Programmer Michael Amundsen Meeting & Events Planner Linda Sangenito Senior Project Managers Andrea Boylston Jini Gopalaswamy Project Coordinators Deanna Martinez Jackie Luma IT Specialist Carlton Hurdle Executive Administrator Rachael Baranoski Office Coordinator Robert Sorensen Engage Healthcare Communications, LLC 1249 South River Road - Ste 202A Cranbury, NJ 08512 phone: 732-992-1880 fax: 732-992-1881

BPA Worldwide membership applied for January 2014.

Mission Statement Rheumatology healthcare requires providers to focus attention on financial concerns and strategic decisions that affect the bottom line. To continue to provide the high-quality care patients deserve, providers must master the ever-changing business of rheumatology. Rheumatology Practice Management offers process solutions for members of the rheumatology care team—physicians, nurses, and auxilliary clinical staff, as well as executives, administrators, and coders/billers—to assist them in reimbursment, staffing, electronic health records, REMS, and compliance with state and federal regulations.

Rheumatology Practice Management™, ISSN 2164-4403 (print), is published 6 times a year by Engage Healthcare Communications, LLC, 1249 South River Road, Suite 202A, Cranbury, NJ 08512. Copyright © 2014 by Engage Healthcare Communications, LLC. All rights reserved. Rheumatology Practice Management™ is a registered trademark of Engage Healthcare Communications, LLC. No part of this publication may be reproduced or transmitted in any form or by any means now or hereafter known, electronic or mechanical, including photocopy, recording, or any informational storage and retrieval system, without written permission from the publisher. Printed in the United States of America. The ideas and opinions expressed in Rheumatology Practice Management™ do not necessarily reflect those of the editorial board, the editors, or the publisher. Publication of an advertisement or other product mentioned in Rheumatology Practice Management ™ should not be construed as an endorsement of the product or the manufacturer’s claims. Readers are encouraged to contact the manufacturers about any features or limitations of products mentioned. Neither the editors nor the publisher assume any responsibility for any injury and/or damage to persons or property arising out of or related to any use of the material mentioned in this publication. Postmaster: Correspondence regarding subscriptions or change of address should be directed to CIRCULATION DIRECTOR, Rheumatology Practice Management™, 1249 South River Road, Suite 202A, Cranbury, NJ 08512. Fax: 732-992-1881. Yearly subscription rates: 1 year: $99.00 USD; 2 years: $149.00 USD; 3 years: $199.00 USD.

February 2014

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In This Issue

Continued from page 3

ACR Meeting Highlights (Continued)

Mastering the Revenue Cycle Requires a Review of All Procedures and Policies......................... 10 By Wayne Kuznar

Customer Service of High Value in Ensuring Your Practiceâ&#x20AC;&#x2122;s Profitability......................................... 12 By Wayne Kuznar

Human Resource Management Helps Establish Sustainable Competitive Advantage............... 14 By Mark Knight

Health Information Technology

Keeping Up with IT Solutions.................................................................................................................. 16 By Sandra Paton

Editorial Advisory Board Editor-in-Chief Iris W. Nichols

President National Organization of Rheumatology Managers Wilmington, NC Practice Administrator Arthritis & Osteoporosis Consultants of the Carolinas Charlotte, NC

Ana Reyes-Cartagena

Director of Clinical Practice Arthritis & Rheumatism Associates, P.C. Wheaton, MD

Allyson D. Eakin, RN, OCN, CCM

Clinical Research Coordinator Arthritis & Osteoporosis Consultants of the Carolinas Charlotte, NC

Kyle Harner, MD

Helen Hinkle

Linda McKee

Mark Post

Jay Salliotte

Practice Administrator Rheumatic Disease Associates Ltd Willow Grove, PA

Practice Administrator Premier HealthCare Associates, Inc Richmond, VA

Nancy Ellis

Practice Administrator Greenville, SC

Marjorie Collings

RHEUMATology Practice Management

Carolina Arthritis Center Greenville, NC

Administrator North Texas Joint Care, P.A. Dallas, TX

I February 2014

Office Administrator Rheumatology Associates of South Texas San Antonio, TX

Business Manager Advanced Rheumatology Lansing, MI

From the Editor

Practice Management and Policy Changes...Continued from the cover come new opportunities. When it comes to healthcare delivery, however, we face new challenges each day. Practice administrators must have the ability to address and strategically align their practice with these challenges, while delivering quality patient care.

The Challenges in 2014 There are many factors that will impact our business models in delivering rheumatology care in 2014. The question becomes, which challenge among the following factors will take the biggest toll on our practices this year? 1. Healthcare exchanges and high-deductible health plans: • There will be about 30 million newly insured Americans under the Affordable Care Act. • What will their insurance cards and benefits look like? • Will they be eligible for copay assistance programs if they are using biologic therapy? • There has been a 31% increase in high-deductible plans since 2012 (that is less than 2 years) • Relationships with our payers may become more complicated • Reimbursement may continue to decline. 2. Bundled payments: • According to the Centers for Medicare & Medicaid Services, “Traditionally, Medicare makes separate payments to providers for each of the individual services they furnish to beneficiaries for a single illness or course of treatment. This approach can result in fragmented care with minimal coordination across providers and health care settings.

Payment rewards the quantity of services offered by providers rather than the quality of care furnished. Research has shown that bundled payments can align incentives for providers—hospitals, post-acute care providers, physicians, and other practitioners—allowing them to work closely together across all specialties and settings.”1 • Will we be informed before we experience these types of payment restrictions? • How will imposing of quality metrics play a critical role? Implementation of ICD-10 The rollout of the International Classification of Diseases, Tenth Revision (ICD-10), will require input from all practice staff members. Advances in information technology and changes in HIPAA laws Patients and physicians have concerns about privacy and security. There is a consensus that although patients are excited about the ability to have their personal health information (PHI) at their fingertips, the concern is about a potential privacy breach. Will my PHI be misused? There are risks as well as benefits surrounding the participation in the health information exchange. Through office-supplied education tools, we will ensure our patients that we take their concerns seriously. At the same time, the electronic health record (EHR) system and its implementation is filled with promises of concise documentation, data-sharing, and reimbursement increases, but it also presents frustration—with major concerns about interoperability between systems,

February 2014

and with the amount of physician time that is involved with data entry.

Changes Affecting Rheumatology Practices Iris W. Nichols All of these factors will result in office flow and policy changes. There may be positions created for financial counselors, and more staff allocated to prior authorizations. There will be critical policy changes associated with a more aggressive approach to collections at time of service that will include not only copays but also deductibles and coinsurance. The ICD-10 implementation will affect all office staff. Anyone who “touches” a diagnosis code will be a critical part of this implementation. Information technol ogy changes surrounding the newly defined electronic HIPAA (Health Insurance Portability and Account ability Act) requirements and continued EHR implementation will require dedicated staff. Although these challenges sound dire, opportunities abound. We have opportunities to exercise leadership and advance our mission of innovative thinking, strategic planning, and alignment within our specialty, for the purpose of improving the access to care for our patient population. In this new year we may need to refresh our services to patients, reassess our use of technology, revise our collection processes, remind each other to better monitor population health, and engage patients in new ways. l Reference

1. Centers for Medicare & Medicaid Services. Bundled Payments for Care Improvement Initiative. September 30, 2013. www.cms.gov/Newsroom/Media ReleaseDatabase/Fact-Sheets/2013-Fact-SheetsItems/2013-01-31.html. Accessed January 29, 2014.

www.RheumatologyPracticeManagement.com

ACR Meeting Highlights

ICD-10: Get Ready for Documentation...Continued from the cover Professional Coders, Salt Lake City, UT, outlined practical strategies that practices can execute as the transition approaches. Practice managers and physicians must understand that the Centers for Medicare & Medicaid Services will not postpone the implementation of ICD-10 again. The new codes will go into effect October 1, 2014. “If you are not ready, it is not business as usual—you will not get paid,” Ms Cronin warned. ICD-10 codes will allow for greater specificity in documenting clinical diagnoses, but it will also mean that practices will need to make significant changes. “Practices must prepare now,” she said. “Thinking you’ll be able to prepare for this transition in a couple of months is not rational. It affects too much to leave it to the last minute.” Practices must first determine the areas in which diagnosis codes affect a practice. “You need to track anywhere an ICD-9 [International Classification of Diseases, Ninth Revision] code is in your practice,” Ms Cronin said, including a review of laboratory request forms, policies, administrative functions, contracts, and documentation. Because ICD-10 codes have a much greater specificity than ICD-9, the transition will not be as simple as learning a new code for a condition. ICD-10 codes require more notes, including information about anatomical location. An internal audit of the documentation that is currently used in the practice should be conducted and evaluated to determine if it is sufficient to choose an ICD-10 code. Insufficient information could lead coders to rely on unspecified codes. Using unspecified diagnoses will lead to difficulty in getting paid, and their overuse may trigger audits. “Look at your documentation care-

fully,” Ms Cronin said. “See what is required for ICD-10 and determine if your current documentation allows you to choose a specified code. If it doesn’t and you can’t assign a code or can only assign an unspecified code, you need to say why.” Learning how to avoid unspecified codes now will help with the transition to ICD-10. Ms Cronin suggests doing an audit using 10 charts and coding them according to ICD-10. Start with the most frequently used diagnosis, and review at least 10 records per quarter for each provider.

“Practices must prepare now. Thinking you’ll be able to prepare for this transition in a couple of months is not rational.” —Shelly Cronin, CPC, CPMA, CPPM, CANPC, CPC-I

A Hypothetical Case An example of insufficient documentation for ICD-10 would be the following hypothetical case. A 77-year-old Hispanic man with rheumatoid polyneuropathy and arthritis of the lower extremities comes in for a follow-up appointment. The patient is feeling much better with the prednisone that he is taking, 10 mg twice daily. The patient had his laboratory work and x-rays done and wants to go over the results with his doctor. He feels better since his last visit. In this hypothetical case, the anatomic location is not specific enough,

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Ms Cronin said. The ICD-9 diagnostic codes of 714.0 rheumatoid arthritis and 357.1 polyneuropathy in collagen vascular disease could convert to several ICD-10 codes as follows: • M05.561 Rheumatoid polyneuropathy with rheumatoid arthritis of right knee • M05.562 Rheumatoid polyneuropathy with rheumatoid arthritis of left knee • M05.569 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified knee • M05.551 Rheumatoid polyneuropathy with rheumatoid arthritis of right hip • M05.552 Rheumatoid polyneuropathy with rheumatoid arthritis of left hip • M05.559 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified hip • M05.571 Rheumatoid polyneuropathy with rheumatoid arthritis of right ankle and foot • M05.572 Rheumatoid polyneuropathy with rheumatoid arthritis of left ankle and foot • M05.579 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified ankle and foot. Similarly, for gout, the ICD-9 code 530.81 sarcoid arthropathy is ready for the ICD-10 transition (D86.86), but to allow for proper assignment of the ICD-9 code 274.9 for gout in ICD-10, the documentation needs to include the type of gout, and the location affected.

Medical Contracts Medical contracts will need to be modified, Ms Cronin said. Practice managers should identify contracts in which reimbursement is tied to particular diagnoses, and contact payers to discuss potential changes to existing contracts. The timing of contract negotiations should be determined, and agreements should

ACR Meeting Highlights

be modified as needed. Contract changes should be communicated to the appropriate staff. Insurance coverage determinations also may change, and practices may need to develop written educational materials to assist patients. This will be a time-consuming process, Ms Cronin warned.

What You Should Do Now Ms Cronin suggests that in preparation for the switch, practice managers should engage heavily with

vendors and determine if hardware and/or software updates are needed. Ask the vendor when it will be tested, “and ask if you can be included in the vendor’s testing,” she said. Start budgeting for changes now. Devise a training plan. “Every single person will need some level of training,” she said. Coders must brush up on anatomy and physiology to make ICD-10 code assignment easier. “Coders need an in-depth understanding in order to assign codes appropriately,” Ms

Cronin said. They will need to work with clinicians, because clinical documentation will be crucial. Clinicians must be aware that clinical documentation will need to adhere to ICD-10’s higher level of specificity, and that unspecified codes may cause a loss in revenue. The additional documentation that will be necessary may affect productivity, as will the long code descriptors that will take time to read and assign for electronic medical record use. l

How to Prevent Fraud in Your Practice By Mark Knight

San Diego, CA—Fraud and embezzlement are prevalent in US businesses, including medical group practices. Knowing the conditions that provide an environment for embezzlement and implementing controls to prevent these conditions are paramount to combatting fraud and embezzlement. The what, who, why, and how to detect and prevent fraud and embezzlement was the subject of a presentation by Linda L. D’Spain, CMPE, CMCO, CMC, CMIS, CMOM, faculty consultant at the Practice Management Institute, San Antonio, TX, at the 2013 American College of Rheumatology meeting.

Fraud or Embezzlement? Fraud is the use of deception for unlawful gain or advantage. Embezzlement is the theft or use for one’s own purpose of money or other property that has been entrusted to an employee, a servant, or an agent. Employee embezzlement costs US businesses an estimated $500

billion annually. A 2011 survey by the Medical Group Management

A 2011 survey by the Medical Group Management Association revealed that nearly 83% of the 688 practice managers who responded were at some point in their careers affiliated with medical offices where employee theft occurred. Association revealed that nearly 83% of the 688 practice managers who responded were at some point

in their careers affiliated with medical offices where employee theft occurred.1 Of the reported incidents, 18% involved the theft of $100,000 or more, and the thefts were usually taken in multiple small amounts by the most trusted employees in the practice.1 Theft can take many forms, Ms D’Spain explained, from pocket ing a cash payment made by a patient to overbilling an insurance company and stealing the excess funds. “Medical practice fraud often involves the manipulation of billing records and patient accounts,” she said.

Who Are the Perpetrators? Recognizing who is most likely to embezzle is the first step to prevention. According to the Association of Certified Fraud Examiners, only about 7% of embezzlers have been convicted of a previous crime, and about 33% of embezzlers have financial problems.2 Healthcare ranks as the third most embezzled industry, Continued on page 8

February 2014

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ACR Meeting Highlights

How to Prevent Fraud in in Your...Continued from page 7 behind banking/financial services and government.

Why Do Employees Do It? Examining the Fraud Triangle The fraud triangle is a model that is used to explain the personal factors that cause someone to commit occupational fraud. It consists of 3 legs that lead to fraudulent behavior. The first leg represents the incentive or other pressure that motivates the fraud. An employee has a financial problem that he or she cannot solve legitimately, so the employee commits outright theft or falsifies a financial statement to solve the problem. Having negative work-related feelings may also be an incentive as a way to “get back” at an employer. The second leg is perceived opportunity. The fraudster is often in a position of trust and figures out a way to abuse this trust. Weak internal controls create a perception that the perpetrator has little chance of being caught. The third leg is rationalization. Most people who commit fraud are first-time offenders with no criminal history and, therefore, do not view themselves as criminals. They rationalize the act by convincing themselves that they are honest people who are trapped in bad circumstances. In this way, they can justify the act. How to Detect and Prevent Fraud The conditions that provide an environment for embezzlement to occur include a failure to present and enforce company policies, said Ms D’Spain. Internal control structures should be in place.

Antifraud controls include creating policies and procedures for handling company assets and segregating cash-related functions, she said. Job functions can be rotated. A system should be established for authorizing transactions and related activities. Ongoing antifraud training should be provided to all employees. The costs of fraud to the practice, including lost profits, job

“The biggest deterrent to a potential embezzler is the knowledge that someone will be reviewing their work.” —Linda L. D’Spain, CMPE, CMCO, CMC, CMIS, CMOM

loss, and a decrease in morale and productivity, should be made clear to employees. Documents and records should be designed to help ensure the proper recording of transactions and events. Adequate safeguards for accessing and using records and assets should

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be instituted. Independent checks of the internal control process and periodic validations should be conducted. Consider installing surveillance cameras to monitor areas where financial transactions take place. Risk areas should be assessed and prioritized. “Areas at risk include payment or disbursement by cash, insurance filings, accounting adjustments, and supplies,” Ms D’Spain said. Internal control processes should be monitored, with corrections and improvements made as required. Any problems that are detected through these internal controls should be investigated. An accidental discovery of something wrong with the books is an alarm that requires investigation, she said. A sudden change in an employee’s lifestyle is a red flag. A zero tolerance for fraud should be communicated to all employees. It should be made clear that reports of suspicious activity will be promptly and thoroughly evaluated. “The biggest deterrent to a potential embezzler is the knowledge that someone will be reviewing their work,” Ms D’Spain said. The Association of Certified Fraud Examiners advises medical practices to performs surprise fraud audits in addition to regularly scheduled fraud audits, as well as the acquisition of continuous auditing software used to detect fraud. The use of such software should be made known throughout the organization. l

References

1. Elliott VS. Medical office embezzlement risk heightens at beginning of year. January 17, 2011. www.amed news.com/ article/20110117/business/301179972/5/. Accessed January 14, 2014. 2. Lowes R. Office embezzlement: are you losing money you do not even know about? December 3. 2009. www.medscape.com/ viewarticle/713181_4. Accessed January 14, 2014.

Invitation to Join the RPM Editorial Board The publishers of Rheumatology Practice Management™ (RPM) are inviting qualified rheumatology practice owners and administrators to participate as members of the RPM Editorial Board. As an Editorial Board member, you will play an active role in helping to shape the content of this exciting new publication. Rheumatology Practice Management is a niche publication focused on process solutions for rheumatology practices. RPM is designed to provide the rheumatology care team—medical, practice administrators, coders, and billers—with the knowledge and skills required to keep abreast of today’s fast-changing business environment, allowing practice professionals more time to concentrate on high-quality patient care. Each issue of RPM will focus on various areas of rheumatology practice, featuring current topics such as: • Healthcare technology • Models of care • Staffing • Reimbursement and coding • Drug updates

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ACR Meeting Highlights

Mastering the Revenue Cycle Requires a Review of All Procedures and Policies By Wayne Kuznar

San Diego, CA—Every area of a practice’s revenue cycle represents an opportunity to enhance revenue. Current processes will not succeed without an assessment of the current revenue cycle procedures from start to finish in all areas, said Maxine Inman Collins, MBA, CPA, CMC, CMOM, CMIS, a healthcare consultant from Wichita Falls, TX, at the 2013 American College of Rheumatology meeting. Ms Collins also said that education and training are imperative to master the revenue cycle, but unfortunately many practices fail to provide their employees with adequate resources to ensure compliance with coding and documentation, resulting in insurance denials and lost revenue. Viewing the organization as a whole is essential to mastering the revenue cycle for the practice. The revenue cycle starts with accurate scheduling and patient registration and follows through to coding/ documentation, claims processing, payment posting and adjustments, denial management, and accounts receivable management. Collections and billing are usually the focus of revenue management of medical practices, Ms Collins said, to the detriment of other pieces in the system. “Most of the billing occurs at the front desk, as the receptionist or supervisor at the front desk is gathering that information,” she said. “As we are out doing practice reviews and audits, we are finding that they are not taking the overall view of the practice when thinking about the revenue cycle.” In the coming months, it is going to be more important than ever to take this overall view because of the many challenges with the

implementation of the Affordable Care Act (ACA) and as the state exchanges become operational, Ms Collins noted. Unfortunately, the front desk staff has, historically, been the least trained and the lowest paid staff members despite having the great responsibility of gathering insurance and billing information from patients, verifying eligibility, and implementing the practice’s policies and procedures as they relate to the revenue cycle. These policies and procedures will only get more complex with the various individual plans and the myriad copays and deductibles that can be purchased under the ACA. “That puts the burden on the rheumatology practice because it provides services that involve a lot of medications, infusions, and injections, and [requires keeping track of] the fluctuating average sales price of these drugs,” she said. “If we don’t get a handle on the revenue cycle and manage it effectively, we’re going to be behind, we won’t function efficiently, and it will cost us money.” The value-based payment modifier under the ACA will represent a revenue challenge because uncertainty exists over the comparators that are used to evaluate a practice group’s performance. By 2015, the Centers for Medicare & Medicaid Services (CMS) will begin to apply a value modifier under the Medicare Physician Fee Schedule. Practice groups must have chosen a quality reporting system method by the end of 2013 to avoid a negative 1.5% value modifier adjustment to 2015 payments. Final rules may apply to practices with 10 or more eligible professionals as opposed to practices

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with 100 or more eligible professionals that are currently subject to the modifier for calculating payment, said Ms Collins.

Establish a Compliance Program The goal in establishing a reimbursement compliance program is to create a more accurate accounts receivable process and to allow office staff to identify potential problems in billing and to identify systems problems that may be amended through physician and staff education. Practices must adhere to the coding and billing guidelines defined by CMS for all government payers. As such, an effective compliance program that meets the regulatory re quirements must be implemented. All coders, billers, and providers must receive training in coding, documentation, and billing compliance issues on at least an annual basis. Internal or external coding quality audits also must be completed on a regular basis. Findings from the audits must be used to improve coding and health record documentation practices and for education purposes for coders, billers, physicians, and other providers. Invest in Training As a result of understaffing, investment in education for coding, documentation, and claims processing is often lacking. In training classes, “I can’t tell you how many students don’t even have current coding manuals,” Ms Collins said. “They say that their physicians won’t invest in those. When we do realize the importance of training and education in our practices, we could solve a lot of our problems.” The electronic health

ACR Meeting Highlights

record (EHR) was envisioned as a method to promote easier and more efficient documentation. The reality has been something else, Ms Collins said, as errors in the EHR often lead to failing the medical necessity test for ordering tests and procedures. In doing practice audits, Ms Collins said, “I am amazed at the errors in the electronic medical record. The flow of information is incorrect. It may show in a review of the systems that there are no problems, or it may show that there are, but that particular area will not have been examined or it will be shown as normal. They think that they can then order the testing and it won’t tie back to the information in the medical record. I believe we’ll have a problem there if we don’t get a handle on our coding and documentation.” Baseline audits are mandatory in the fraud and abuse compliance program for Medicare. “If you read commercial carrier contracts, you quickly realize that you have to do it for them too,” Ms Collins said. “We conduct the baseline audits and construct the compliance program based on the results of the audit.” Incentive bonuses handed out to practices that have implemented EHRs in a meaningful way are subject to mandatory audits to ensure compliance with the Health Insurance Portability and Accountability Act (HIPAA). Practices must conduct or review a security risk analysis and implement security updates as necessary, and correct identified security deficiencies, as part of its risk management process. The purpose of the risk assessment is to identify conditions in which electronic protected health information could be disclosed without proper authorization, improperly modified, or made unavailable when needed. “CMS has been coming to offices and asking for the incentive money

Table. Most Common Reasons for Insurance Denials • Missing or invalid information • Beneficiary not covered • Medical necessity not established • Duplicate billing • Unbundled code • Diagnosis/procedure code does not match the service provided • Procedure code does not match the patient’s sex • Lack of authorization or referral • Service provided is not covered • Service is not reasonable and necessary • Invalid date of service • Missing or invalid modifiers • Incorrect place of service • Diagnosis is inconsistent with age, sex, and procedure

back if the practice doesn’t have a written security plan in place,” Ms Collins warned. HIPAA training is mandatory within a reasonable amount of time after hire, and then annually or when procedures have changed, but the timing can vary by state, she said.

Important Measures to Gauge Performance Important measures in a practice assessment include revenue and cash flow, the number of days a claim is in accounts receivable, the number of rejected claims, the number of insurance denials, the amount of money assigned to collections, performance by payer and contract performance, and the number of compliance audits. Too often, practices don’t know how many days receivables are in accounts receivable, their percentage of write-offs, their cost per patient versus revenue per patient, and they don’t calculate denial rates, Ms Collins said. Some performance goals resulting from the establishment of best practices to improve these measures are an insurance verification rate of

February 2014

95%, collection of copays prior to service of 95%, a clean claims rate of 95%, an overall denial rate of <5%, and an overturned appeals rate of >80%. Employees who are responsible for final code assignments should review all claims denied based on codes assigned, and do so in a timely manner to correct errors and resubmit claims. The most common reasons for insurance denials are listed in the Table. “For example, I’ll audit charts and see that the respiratory or cardiovascular system was shown as normal in the exam, but the chart says that a CT [computed tomography] scan of the chest was recommended,” Ms Collins said. “Medicare will want to know who ordered it and why—was it medically necessary?” According to CMS, the chief complaint and the history of the present illness must guide the rest of the notes. “If you don’t establish in those 2 items the necessity of reviewing all of the systems, they won’t give you credit for reviewing that system, unless you find something in the exam,” Ms Collins advised. l

www.RheumatologyPracticeManagement.com

ACR Meeting Highlights

Customer Service of High Value in Ensuring Your Practice’s Profitability By Wayne Kuznar

San Diego, CA—A customer service–oriented practice in which staff members work as a team to increase productivity will enhance your practice’s profitability now and in the future, said Audrey E. Coaxum, CHI, CMCO, CMC, CMIS, CMOM, faculty consultant at the Practice Management Institute in San Antonio, TX, at the 2013 meeting of the American College of Rheumatology. Ms Coaxum offered advice on staff management and development for high performance. “We in healthcare don’t always think of ourselves as having to be customer service–oriented. What’s important to keep in mind is that the patients are our customers,” Ms Coaxum said. “Each patient is our source of revenue. If we’re not conscious about customer service, then we don’t have patients, and we don’t have a business.”

Leaders versus Managers Identifying the leaders on your staff and offering them encouragement can help in goal achievement. Leaders are not always staff managers or practice administrators, and the 2 often have different characteristics. Managers establish and implement procedures to ensure smooth functioning, whereas leaders motivate others to act in order to help achieve the practice’s goals. Leaders look to the future and chart the course for the organization, said Ms Coaxum. “Leaders are typically self-appointed,” she elaborated. “Because of the skill sets they possess and their interest in a project, they’re motivated to want to lead the project and provide oversight. If you’re a manager, you

are appointed to oversee the project, whereas a leader inspires others to go through and change or improve the work environment.” The 6 traits of effective leaders are: • Job-relevant knowledge • Intelligence • Self-confidence • Desire to lead • Integrity • Drive. Leaders must be aware of how a particular project can potentially affect the practice. People are motivated to follow leaders, Ms Coaxum explained. Whatever a leader’s platform or objective, if people are inspired by a leader’s charisma, personality, eagerness to complete a task, and desire to want to achieve and be successful, they will assist a leader in achieving a goal. “If you’ve identified a person that has these characteristics, even though he may not be in a managerial position, you definitely want to encourage him by giving him the ability to do oversight and management of a task,” she said. “Give him the resources and tools needed to accomplish tasks. If additional education and training are needed to ensure success, make that available. You always want to encourage and nurture those characteristics.” One of the most important elements of a leader is trust. “If people don’t trust your judgment or insight, then they are not going to want to follow you,” Ms Coaxum warned. “The whole crux of being a leader is having a team of people you’re working with.” Leaders create the desire for continuous improvement. They create an environment that nurtures mutual respect among people, pro-

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vides encouragement, and promotes cooperation. Most of all, they lead by example and demonstration. “Modeling what you want from others is one of the most important responsibilities of being a leader,” she said.

Developing Your Staff Staff development is an essential element of a successful practice. Your philosophies for development should be shared with the staff, employee development plans should be created, and resources to assist in development should be identified. These resources can be new software programs to help process claims more efficiently. Share what you know of the organization’s future needs, Ms Coaxum advised. The staff should be involved in planning and team-building meetings. “Sometimes the managerial staff doesn’t always focus on development when doing performance reviews and staff evaluations,” she said. “You need to understand the vision of your practice and the goals, but you do need to talk to your employees and find out what their positions are as far as working with your practice as well as personally wanting to grow and develop themselves, because you may be able to nurture and encourage that type of relationship so that you can have another leader coming through the ranks.” Ms Coaxum gave the example of a front desk specialist who had a thorough understanding of the operation of the practice, and after gaining an appreciation for clinical care, wanted to go to nursing school. Once she shared that vision with the administration, her schedule was altered to allow her to attend classes. The

ACR Meeting Highlights

opportunity to eventually return to the practice in a different capacity was one that could enhance the practice’s goals. Development plans should be monitored regularly. In the example cited, practice administrators were able to monitor the employee’s progress in completing her curriculum.

Employee Motivation and Morale Motivation starts with good employee morale, which is the mental attitude of employees toward their employer and jobs, Ms Coaxum said. High morale is the sign of a well-managed organization. Poor morale may show up as absenteeism, employee turnover, decreased productivity, and employee grievances. “Be honest with your employees about the position of your practice, which is especially important during a time of many transitions in healthcare in general,” she advised. “Reassure your employees that you are going to stay open, you are not going to close your doors, or that you’re staying as an independent practice instead of consolidating with another facility. Share the goals of the practice—where you plan to be for the next 10 or 15 years.” There are times when you may not be able to financially reward employees for the job they’re doing, but they can still be recognized for their efforts. “One of the clinics I worked with had a computer glitch and we lost 3 months worth of data in our system,” Ms Coaxum shared. “We had to have the staff come in on the weekend and input 3 months worth of data in 2 days. The staff successfully completed the task. I purchased thank you cards for all of the employees and the physicians signed them, and we put $25 gift cards in them. It was important that it come not just from me as a practice administrator but from the physicians.”

It’s Not “Us” and “Them,” It’s “We” The entire staff must have the mind-set that it is working together as a team for the sake of the patient. “If I’m working at the front desk, I’m receiving patients, I am trying to get everything prepared so the patient can be transitioned to the back office area and the phones are ringing off the hook, there’s nothing wrong with a clinical staff or managerial person pitching in and answering the phones and trying to help get the patient through the process,” Ms Coaxum said. “It’s not ‘us’ and ‘them,’ it’s ‘we,’” she added.

“Be honest with your employees about the position of your practice, which is especially important during a time of many transitions.” —Audrey E. Coaxum, CHI, CMCO, CMC, CMIS, CMOM

A practice that is not customer service–oriented or cognizant won’t make for a good patient experience. The first opportunity to make a positive impression is the reception at the front desk, and the final encounter is equally important. Every person involved in the patient’s experience can make or break a practice. Ms Coaxum related the story of a patient who had a wonderful experience with the reception and the clinician, “but on her way out, she asked the checkout person where the exit was. Instead of telling the patient the correct door, she was directed to use a closet door. The front desk staff person

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thought it was funny but the patient was embarrassed and humiliated, and she said that she was never coming back to that practice again,” she said. “The practice administrator unfortunately was not there at the time, but in finding out about the patient’s experience and how it ended, personally called the patient and apologized for the behavior of the front desk.”

Evaluating and Rewarding Performance Performance evaluations should not necessarily be tied to a financial review, Ms Coaxum said. The performance evaluation starts with reviewing the employee’s job description, and based on that description, a determination of whether he or she is successfully completing the task. If you identify an employee who is excelling, provide some type of reward system. “It could be that the person has the opportunity to take time off from work because she successfully completed a task in a short amount of time,” Ms Coaxum said. “One facility had a bonus opportunity. They received customer service buttons from other staff members or patients, and their buttons were put into a bowl. At the end of the year, employees with more buttons in the bowl had a greater chance of winning a pot that was established. The practice gave a $500 end-of-year bonus to the staff person who was most customer service oriented based on those buttons.” To ensure profitability, practices need volume, but patients should never feel as though they are being rushed through the system. Take personal notes from encounters with established patients and bring up any tidbits at the next visit, Ms Coaxum advised. For example, if a particular patient noted that he or she was taking a vacation soon, ask about that vacation at the next appointment. l

www.RheumatologyPracticeManagement.com

ACR Meeting Highlights

Human Resource Management Helps Establish Sustainable Competitive Advantage By Mark Knight

San Diego, CA—A major goal of human resource management is to help the medical practice establish a sustainable competitive advantage. Linda L. D’Spain, CMPE, CMCO, CMC, CMIS, CMOM, faculty consultant at the Practice Management Institute in San Antonio, TX, provided tips for successful human resource management at the 2013 meeting of the American College of Rheumatology. Among the functions of human resource management are providing support and advice to line management, ensuring that competent employees are identified and selected, and affording employees with up-todate knowledge to do their jobs. “Your employees are your greatest asset,” she said. “A strong human resource management team provides strong leadership to our greatest asset.” Because the front desk is the first and most lasting impression of your practice, the personnel must receive support not only with respect to customer service but also for compliance in all areas of healthcare, including the Health Insurance Portability and Accountability Act (HIPAA), Occupational Safety and Health Administration (OSHA), and the prevention of fraud and abuse. Various tools can be used in the selection process. Performance tests are becoming more common. Online personality tests can help to determine if candidates can assert themselves when the need arises, “especially in that front desk role, because they truly are the front line in the battlefield,” said Ms D’Spain. “They are the line of defense for patients who may be getting upset because of wait times or having to pay a copayment or fill out paper-

work.” These tests may also indicate whether the candidates are well suited for a team environment. Practical performance tests are also valuable. Candidates for the front desk can be tested on their ability to check a patient in and gather the patient’s information. “If we’re hiring a coder, I would give them a coding test. It could be available online but it could be something that the practice actually wants to create,” she said. “I would give coding scenarios based on rheumatology to see if they can actually code med-

“Your employees are your greatest asset. A strong human resource management team provides strong leadership to our greatest asset.” —Linda L. D’Spain, CMPE, CMCO, CMC, CMIS, CMOM ical records to extrapolate proper diagnostic codes, proper modifiers, and proper procedure codes in order to see if they would be an appropriate biller/coder.” Potential collectors may be tested on their ability to appeal a claim. “I would give them an example of a denial and ask how they would fix it,” Ms D’Spain advised.

The Interview Process She also advises spending an adequate amount of time with the appli-

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cant when interviewing him or her, and suggests structuring a fixed set of interview questions for all applicants and providing detailed information about the specific jobs for which the applicants are interviewing. “Ask behavioral questions that require applicants to give detailed accounts of actual job behaviors,” she said. Short interviews that encourage premature decision-making should be avoided. The 80/20 rule is a rule in business that also can be applied to the interview process. The 80/20 rule assumes that the top 20 procedures will generate 80% of a practice’s revenue. “It’s important for a manager or a human resources person to listen 80% of the time,” Ms D’Spain said. “Ask open-ended questions and listen very carefully to the answer, and extrapolate more questions from the answers. This will help in making the right hiring decision.” “To be compliant with all of the labor laws involved, there are many questions we cannot ask during the interview,” she warned. “Some people go into an interview with their ears open, just waiting for someone to ask an illegal question. They can go back and sue the practice and they can win the suit.” It is illegal to ask a candidate how old he or she is; what his or her marital status is and/or whether he or she plans to have a family; whether the candidate has ever been arrested; and what his or her native language is. Instead, you can ask if the applicant is willing to relocate, is authorized to work in the United States, or has ever been convicted of a crime that is reasonably related to the performance of the job. A good job description is the cornerstone for recruiting employees,

ACR Meeting Highlights

Ms D’Spain said. An up-to-date job description will help a manager understand exactly what is expected of a potential candidate. “As we’re interviewing staff, we need to keep the job description in front of us and in our minds,” she said. “The interview should be conducted with the thought ‘can this person do this job?’”

Training Methods New employees must be oriented to the job. The employee handbook, which should be given to all employees on their first day, sets the guidelines on office policies, including the obligations of the employee and the obligations of the employer. On-the-job training should ideally come from a person in the same department or a mentor. That mentor or coach should serve as a “goto” person for the new employee. Technology-based training methods can be added to the traditional training methods. One that Ms D’Spain prefers is webinars. “They can help in all areas of practice management, from customer service to compliance,” she said. “It’s also important to send employees out to live classes so that there’s a bit more networking. Questions might be asked that the employee may not think of or might be afraid to ask, so it stimulates good discussion.” Performance Appraisal The performance appraisal provides managers with the information they need to make good human resources decisions about how to train, motivate, and reward organizational members. Performance appraisals must be conducted solely to appraise performance and not discuss salary increases, Ms D’Spain noted. “The manager should have taken the time to go back and read the job description, see what is expected of

the employee, find out the employee’s strengths, and determine the opportunities to improve,” she said. An opportunity for employee feedback should be provided. Expectations, goals, and timelines to improve on areas where improvement is needed should be provided at the performance

Expectations, goals, and timelines...where improvement is needed should be provided at the performance appraisal. appraisal. Employees should be given a reasonable amount of time to improve before another evaluation, perhaps 3 months or up to 6 months if additional education or training is needed. At the follow-up evaluation, compensation can be discussed. The management by objective performance appraisal method is one that Ms D’Spain favors. It is a results-oriented method that focuses on specific behaviors and end goals. Although comprehensive, the disadvantage is that it is time-consuming. The management by objective approach offers potential solutions to correctable problems. For example, if an employee is consistently late because he or she has to drop a child off at school at a certain time, changing the arrival and departure time could be an option to explore. “Our goal is to salvage the employee, not drop him or her,” she said.

Entice with Good Compensation Those employees who show

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superior skills should be enticed to remain with good compensation and benefits, in addition to career development, Ms D’Spain said. As important as money, “people want feedback and recognition for their performance,” she said. Remind employees that their compensation includes not only their salaries but their benefits as well. Some practices may be able to compensate for lower salaries by offering better health insurance plans or offering both a defined contribution plan and a profit-sharing plan. “It’s important to educate employees that they don’t get a raise just for working there. They need to meet all of the expectations and bring something to the table instead of throwing a dollar at them on their anniversary date,” she said.

Dismissal and Downsizing Employees who do not meet expectations should undergo immediate verbal counseling followed by written counseling signed by the employee if he or she continues to fail to meet expectations. The written counseling should lay out the steps that will be taken if the employee continues to lag in performance. Termination should be immediate for certain infractions such as stealing, drug abuse, or fraud. Some practices with declining reimbursement may find it necessary to downsize. In the event of downsizing, every employee will feel threatened. “The best thing that a manager or physician can do for their staffs is to be honest,” Ms D’Spain advised. “Tell them up front that you have to eliminate positions.” Good human resource management in this case involves offering assistance to downsized employees, such as services that will help update their resumes and recruiters who can help with job searches. l

www.RheumatologyPracticeManagement.com

Health Information Technology

Keeping Up with IT Solutions By Sandra Paton

ll rheumatology practices are facing serious changes brought about by government and healthcare reform, some of which have not been fleshed out clearly enough. In the midst of this flux, practice managers must assess their practice’s performance and needs and make decisions that will affect the continued health and financial success of their business operations. Calling in a practice management consultant to help your practice wade through the mountains of healthcare reform regulatory requirements—as well as to help keep your practice abreast of normal industry changes, identify opportunities for growth, and prevent potential disasters—is more of a necessity than a luxury these days. But where do you go for guidance when it comes to determining the best electronic medical records (EMRs) or electronic health records (EHRs) for your practice? Even if you are already satisfied with your system, this is no time to relax. Constant surveillance of the ever-changing technological world should now be a part of your routine, particularly where reimbursement is concerned. You may recall the old saying, “You are what you eat.” The adage for your practice today may be better expressed by saying, “You are what your data say.” If you have accurate charge and payment data, you are halfway there. When it comes to medical information technology (IT), how fast you can supply medical records, how accurate those records are, and how good your technical support is when problems arise all play a part in this picture. To this end, we have listed and described a few EMR software systems that you can use in your practice. Bear in mind that change is

occurring rapidly. So even if you are satisfied with your current system, consider reviewing some of the other systems that may solve problems for your practice down the line. If IT demands are dogging your practice, keep this caveat in mind: “Keep up.” The following “bytes” were adapted from a variety of reviews.

ADP AdvancedMD ADP AdvancedMD (www. advancedmd.com) offers a blog to help improve clinical documentation and facilitate coding for International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). The company recently released a white paper entitled, “A Case for EHR: 5 Status Quo Myths that Hold You Back and Reduce Your Bottom Line.” The idea was to urge practices to adopt change and overcome the myths that reduce their bottom line. The 5 EHR myths outlined in the paper include: • Maintaining the existing paper chart system makes sense financially • Paper charge slips are the quickest and easiest way to enter visit charges • Lost charts, orders, and notes are an unavoidable part of a busy private practice • Electronic records are not as secure as paper patient files • Portability of patient records is a luxury reserved for large practices. Allscripts Allscripts (http://clientconnect. allscripts.com) provides EHRs for private practices, hospitals, and other healthcare providers. Their services include electronic prescribing, care management, and revenue cycle man-

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agement software. Their products are currently used by more than 180,000 physicians, 1500 hospitals, and 10,000 post–acute care organizations. Their website offers online client discussions (through “ClientConnect”), online learning modules, online issue or enhancement requests through their support team, web referrals, and a provider search through an extended-care database.

Benchmark Systems Benchmark Systems (www. benchmark-systems.com) offers cloud-based software featuring scheduling, EHR, practice management, and billing and collection services. Their templates are customizable and can be set up to function as your practice requires. They also provide a patient portal through which patients can access their own medical records, billing statements, and appointments. Their systems automatically receive and scrub coding information for billing and offer comprehensive revenue-cycle management services. Benchmark operates its own claims clearinghouse, complete with statement processing and electronic remittance management. A variety of administrative processes—such as billing and collection, scheduling appointments, and core accounting functions—can be outsourced to Benchmark’s “Virtual Practice Management Services.” eClinicalWorks This software is designed for ambulatory care environments. The system has been touted as usable and efficient, featuring single-click patient accessibility, mobile support, and a patient portal that allows patients to access their billing and scheduling. eClinicalWorks

Health Information Technology

(www.eclinicalworks.com) can be integrated into community or statewide health record networks. Their cloud-based EHR can be accessed by computer, smartphone, and tablets such as the iPad. They developed the “Care Coordination Medical Record” (CCMR), a platform that supports the components of the Affordable Care Act. The CCMR provides population health data and health alerts; cost utilization dashboards; clinical quality measures specific to patient-centered medical home and accountable care organization measures; patient engagement via apps on smartphones and patient responses at the point of care; and a patient referral and consultation network.

Epic Systems This company (www.epic.com) offers a “one patient, one record” approach to simplifying administrative duties. Their “Single Billing Office”—a single bill and payment plan—simplifies accounting, administration, patient follow-up, and can streamline back-office staffing, not to mention that it offers convenience for patients. Patients can access their records via “MyChart,” where they can schedule appointments and access their test results. An interoperable health diary can be connected to or disconnected from MyChart as required or desired. A “Call Management” feature stores patient information and service issues in a central location, allowing users to resolve inquiries from patients and analyzing your practice’s overall customer service effectiveness. GE Centricity EMR and Centricity Group Management Both products from GE Healthcare (www3.gehealthcare.com) work together to coordinate practice management, while offering a

single vendor for service and support. This system provides both clinical and financial management, from practice administration to EMRs, in large practices. It can integrate with medical devices, medical imaging, and other GE Healthcare products. The EMR system is designed for community hospitals, academic medical centers, and integrated delivery networks. It features clinical, financial, and administrative software to help manage patient billing, revenue cycles, and closed-loop medication. The system is certified by the Certification Commission for Healthcare Information Technology (CCHIT), an independent 501(c)3 nonprofit organization whose mission is to encourage the adoption of interoperable health information technology. CCHIT certification ensures that an EHR has been thoroughly inspected for functionality, interoperability, and security of patients’ personal health information.

Greenway Medical Technologies PrimeSUITE PrimeSUITE (www.greenway medical.com/solutions/primesuite) was designed for easy adaptability to any office’s workflow. It is based on a database that supports all EHR and practice management requirements, ensuring the seamless flow of clinical, administrative, and financial data from one to the other (ie, from registration, scheduling, revenue cycle management, and reporting). Templates are customizable. There are currently 3500 clinical templates. Users have access to a “Clinical Content Library,” where they can share clinical information with their peers. Efficiencies have been recorded in coding improvements, elimination of transcription and chart expenses, and improved collections.

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Kareo The Kareo EHR (www.kareo. com) was designed by a practicing physician for use on the iPad and the web, and can keep the physician connected to a patient during an examination while taking and building patient notes. The program is integrated with third parties for prescription and lab orders. It is certified by the Office of the National Coordinator–Authorized Testing and Certification Body (ONCATCB). The system permits transition between the mobile and web versions without restrictions. It was designed on a knowledge base by Epocrates to help physicians readily access clinical information. MediTouch This EHR can be accessed as a web-based system and touchscreen interface. It provides management for charting, medication, electronic prescribing, allergy checks, clinical orders, lab tests, and documents. Forms are customizable. The system can be used as a stand-alone or with HealthFusion’s practice management system. It is certified by ONC-ATCB. The system is entirely hosted by HealthFusion (www. healthfusion.com), obviating installation or maintenance of software. It is accessed through a web browser and is usable on iPads, being touted as the fastest iPad EHR. It is provided via a monthly subscription, which includes all customer support and training. Conclusion There are many more options specific to oncology. Most companies offer resource and support centers. Check with companies directly before making a decision about your practice’s needs. Do your homework in person and online and check with practices that are using the systems for realworld advice. l

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Essentials of Practice Managers

Lead Your Team to Greater Success...Continued from the cover because of one manager. Thus, as practice managers, it behooves us to create great work environments so we do not lose talented employees. In addition, it is our job as practice managers to improve and maintain key performance metrics, including revenue, cost-containment, productivity, safety, patient satisfaction, etc. At first glance, it may seem these 2 directives are at odds with each other, but in reality, they can be quite closely related. The Gallup Organization, famous for their opinion polling, has been studying businesses and managers for decades. One of their many important research topics is how great managers get great results from their teams. Gallup first presented their work to the masses in the 1999 best-selling book, First, Break All the Rules: What the World’s Greatest Managers Do Differently.1 In 2006 Gallup released a follow-up book, 12: The Elements of Great Managing.2 Since then Gallup has continued its research on an annual basis. According to the Gallup website, as of 2013 the company has surveyed more than 25 million employees.3 In addition to quantitative surveys, Gallup has conducted thousands of qualitative interviews with employees and managers to provide a deeper understanding of the topic. Why Gallup? There must be thousands of new management books released every year. I have read my share, and they are all filled with commonsense wisdom and “howto.” However, this series has caught my attention for very specific reasons; namely, it is truly universal and it is scientifically reproducible. The Q12 Meta-Analysis is based on quality data, has consistent findings and measurable outcomes, and is straightforward in implementation. After all, we work for physicians,

and, in their world, the only way to prove worth is through solid data with measurable outcomes. Although I strongly recommend that all managers read these books, the revelations can be summed up in just one statement: Great managers foster a work environment that engages their employees, and in turn, engaged employees produce positive results. In essence, this embodies the entire philosophy.

The Q12 MetaAnalysis Jay Salliotte is based on quality data, has consistent findings and measurable outcomes, and is straightforward in implementation. Engaging Your Employees The evidence from analyzing the data speaks for itself. To summarize the data in terms that are meaningful to the everyday manager, Gallup parsed the data in the following manner. First, they looked at employee engagement scores across different business units, where a unit could be a team within a company, or the entire company itself. Based on the scores, the business units were grouped into quartiles. Then they cross-referenced the employee engagement scores for the business units against key performance metrics, such as revenue, profit, customer satisfaction, safety, quality, and employee retention. The most recent data are from 2012 and can be found on the Gallup website.4 Based on these 2012 data,

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compared with business units in the bottom quartile, the top quartile units have4: • 37% lower absenteeism • 25% lower turnover (in high-turnover industries, such as retail) • 65% lower turnover (in low-turnover industries, such as healthcare) • 28% less shrinkage (loss due to theft) • 48% fewer safety incidents • 41% fewer patient safety incidents • 41% fewer quality incidents (defects) • 10% higher customer metrics • 21% higher productivity • 22% higher profitability. These results were nearly identical to those discussed in the 1999 and 2006 Gallup books.1,2 If you are a data geek like me, a full 32-page scientific description of the objectives, methods, results, and conclusions can be found under the “Outcomes” section of the Gallup website.5 The many years of research that Gallup conducted on this topic have culminated in a set of 12 questions that measure employee engagement. Gallup now refers to this set of questions as the Q12 MetaAnalysis. These 12 questions are the same 12 elements outlined in 12: The Elements of Great Managing. The answers are given on a scale of 1 to 5, where 1 is “strongly disagree” and 5 is “strongly agree.” • Q1: Do I know what is expected of me at work? • Q2: Do I have the materials and equipment I need to do my work right? • Q3: At work, do I have the opportunity to do what I do best every day? • Q4: In the last 7 days, have I received recognition or praise for good work? • Q5: Does my supervisor, or someone at work, seem to care about me as a person?

Essentials of Practice Managers

years ago. At the time, our practice was still in its infancy, so I do not have a “before and after” picture from which to draw a contrast. However, I believe to my core that this system has strengthened our work environment, and I can share some of the observable benefits with you.

Figure. The Order of the 12 Employee Engagement Questions: An Uphill Climb

Q11 & Q12 Q7 – Q10 Q3 – Q6 Q1 – Q2 Source: Wagner R, Harter JK. 12: The Elements of Great Managing. New York, NY: Gallup Press; 2006. • Q6: Is there someone at work who encourages my development? • Q7: At work, do my opinions seem to count? • Q8: Does the mission/purpose of my company make me feel like my work is important? • Q9: Are my coworkers committed to doing quality work? • Q10: Do I have a best friend at work? • Q11: In the past 6 months, have I talked with someone about my progress? • Q12: At work, have I had opportunities to learn and grow? The order of the 12 questions is very intentional. In 12: The Elements of Great Managing, Wagner and Harter use the analogy of climbing a mountain (Figure).2 If an employee is struggling with Q1 and Q2 at “base camp,” their basic needs are not being met. How could they possibly worry about someone encouraging their development when they do not know what is expected of them? Similarly, if employees feel that their opinions do not matter (Q7), how could they be concerned with opportunities to learn and grow at work? Thus, followers of this system should be most concerned with consistently

achieving high marks in the first few questions. If we do not, the entire effort will crumble. In our practice, we conduct the Q12 Meta-Analysis once every quarter. The survey is intended to be completely anonymous; thus, we take great care in our methodology to safeguard that promise. We also remind the staff to be completely honest, because their candor will help us to understand where our practice can improve. I compile the results as soon as possible so I know if there are issues to address. At our next scheduled staff meeting, we publish and discuss the results with the entire team. The data from our last survey and the averages since inception are listed in the Table (page 22). Achieving the numbers shown in the Table was no easy task. I worked very hard, along with the other practice leadership, to build and maintain our results. Our ongoing goal is to have all averages (individual questions and total) at 4.0 or above with a stretch goal of 4.5. Anything below 4.0 means there is serious work to be done.

The Results We implemented this system in our practice a little more than 2

Staff Appreciation The staff knows exactly why we conduct this survey, they understand the implications, and they share their appreciation with us on a regular basis for striving to make our practice the best place to work. Track Trends over Time Looking at the data over time reveals patterns where we are strong and places where we are slipping. Thus far, there has always been a clear explanation for the trends, and it has helped our management team to maintain the correct focus. Identify Red Flags We normally get great marks on Q9, coworkers committed to doing quality work. However, during one survey we had a drastic drop in responses for Q9, but only from a handful of staff members. This raised a red flag for us. After some further analysis and pumping my trusted sources for information, we identified a problem within our patient services team. We had 1 employee who was careless with the work and, after being confronted by team members, showed no interest in changing. No one told our leadership of the situation, because we are a loyal and tight-knit team. But, clearly, it was causing resentment. This employee was promptly coached and placed on a generous performance improvement plan, which ultimately failed, and the employee was terminated. It was a difficult situation, but we are now a stronger team for it. Continued on page 22

February 2014

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Essentials of Practice Managers

Table. Advance Rheumatology Practice: Employee Survey Data in 2013 Q1

Q10

Q11

Q12

Average score

September 5.00 2013 survey

4.70

4.80

4.10

4.80

4.50

4.30

4.50

4.30

4.78

4.50

4.85

Average over time

4.94

4.57

4.95

4.76

4.77

4.84

4.58

3.86

4.58

4.78

4.71

4.96

Note: The N for each quarterly survey is typically 10 to 12 responses, depending on part-time schedules and absences; the average over time includes 10 data sets (or 2.5 years worth of surveys).

Improvement That Is Relatively Cheap This system helps you to focus your efforts and communications as a manager. With so many responsibilities competing for your attention, it helps to remind you of the importance of employee engagement and the 12 essentials of great management. Committing to this philosophy will certainly cost you time, but in all honesty, you will see such great results in the key performance metrics that the benefits far outweigh the costs. Avoiding the Pay/Benefits Fallacy Good pay and good benefits are crucial in recruitment. Good pay, good raises, and good benefits play a role in keeping good staff members; it is an ongoing cost of business that you cannot avoid. However, it is so easy to assume that if we pay employees well and offer great benefits, we will get great performance. After all, they are lucky to have a goodpaying job and should work hard for us in return, right? Wrong. Pay and benefits alone will keep employees showing up for work, but rarely will they motivate them to do more than the bare minimum. If your goal is to engage employees and improve key performance metrics for your practice, simply throwing money at your team is not the answer.

Things to Consider Before Implementation If you are considering implement-

ing this system, and I highly recommend you do, here are a few tips from someone who has been down this road. Frequent and Consistent Praise Is Hard Q4 sets the expectation that employees should be praised at least once every 7 days. This will be a challenge for you and your management team. Weeks can pass since you last praised an employee and it will feel like just a few days. It can be mentally exhausting some days, so dig deep to find that commitment, because your employees are not mind readers. Once you start making this element a habit, you will see how just a few simple words can brighten someone’s day and build a loyalty that will pay endless dividends. A Best Friend at Work Really? Seriously? That was my first reaction. But, when you really dwell on it and read what the Gallup authors say on the topic, it is an important element. It is essential that each employee has one person who makes them feel like they belong. The trouble is you cannot force it. These relationships must happen naturally, and all you can do to foster them is create opportunities for your teams to bond socially. Also, make sure from the outset that your employees understand what this question is really asking.

RHEUMATology Practice Management

I February 2014

I found out months into surveying that some employees thought the question was asking if their absolute closest friend in the entire world happened to be someone at work. That is not the point of this question. Rather, the question is asking if they have a work best friend. In other words, someone at work who they trust, can confide in, and would consider a good friend.

Conclusion Essentially, that is it. This system as laid out by Gallup’s Q12 MetaAnalysis is quite straightforward and is not terribly convoluted. It will take buy-in and commitment from your leadership and effort on your part as a manager, but it is well worth the endeavor. I can practically guarantee your employees will appreciate it. In addition, if you track your practice’s key performance metrics alongside this effort, you will be able to demonstrate real value. What do you have to lose? l References

1. Buckingham M, Coffman C. First, Break All the Rules: What the World’s Greatest Managers Do Differently. New York, NY: Gallup Press; 1999. 2. Wagner R, Harter JK. 12: The Elements of Great Managing. New York, NY: Gallup Press; 2006. 3. Gallup Employee Engagement Center. The only 12 questions that matter. 2013. https://q12.gallup.com/Public/ en-us/Features?ref=homepage#sectionAct. Accessed January 17, 2014. 4. Gallup Employee Engagement Center. Engagement at work: its effect on performance continues in tough economic times. 2013. www.gallup.com/file/strategicconsulting/ 161459/2012%20Q12%20Meta-Analysis%20Summary%20 of%20Findings.pdf. Accessed January 17, 2014. 5. Gallup Employee Engagement Center. The relationship between engagement at work and organizational outcomes. 2012. www.gallup.com/file/strategicconsulting/126806/2012% 20Q12%20Meta-Analysis%20Research%20Paper.pdf. Accessed January 17, 2014.

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VOLUME 1 • NUMBER 2

PRACTICE MANAGEMENT

Reflections on the NORM 2013 Annual Conference

By Jay Salliotte Business Manager, Advanced Rheumatology, Lansing, MI

Long Beach, CA—As I was packing up my bags to return home from the National Organization of Rheu matology Managers (NORM) 8th Annual Conference, I had the television on in the background. I over heard part of a poem that I later learned was written by Wendell Berry. The poem is entitled, “In A Country Once Forested,” and the lines that most struck me were: “...and the soil under the grass is dreaming of a young forest/and under the pavement the soil is dreaming of grass.” As tired and travelweary as I was, my mind was still in spongemode—ready Continued on page 10

From the Editor

Sharing Our Success

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By Iris Nichols President, National Organization of Rheumatology Managers

fter months of preparation, the National Organization of Rheu matology Managers (NORM) 8th Annual Conference was held the weekend of September 1314, 2013, in Long Beach, CA. This year’s conference brought together managers from 150 practices in 35 states.

We had our first practice from Hawaii represented this year. The conference began with a welcome reception where new and established members, vendors, sponsors, commit tee members, and board members were identified by unique ribbons on their badges. Many of our members had asked Continued on page 9

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NORM Meeting Proceedings

Healthcare Reform: Stakeholder Integration Is Key to Improving Care By Sandra Paton

Long Beach, CA—Healthcare expendi tures in the United States are currently approximately 18% of the gross domestic product (GDP), and this is projected to rise, unless there is a change in the way care is delivered in the United States.

A considerable part of the healthcare costs is spent on chronic diseases in the United States. For baby boomers, this often means 2 or more chronic illnesses. Continuing or adding to the current cost trend would be devastating to the US Continued on page 13

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