12.29.15

Health Care Group Newsletter — Winter 2016
Amanda Gutierrez, Laurence Sophian

Smart Staffing in a Changing Health Care World
Amanda Gutierrez

Physician practices are being asked to assume new roles and responsibilities; even the success of the practice is often left in the hands of the staff while reimbursements are stagnant or even declining. It seems that more staff is needed to carry out these new responsibilities. Some of these responsibilities include value-based services, patient engagement and enhanced accountability. There are more efficient ways to address the concerns such as staff rations, patient focus and job descriptions.

There are several principles to a more enlightened management of practice human resources, which begin with thoughtful employment decisions. At times, management rushes to fill an open position, hiring the first qualified person who applies. In time, a mismatch becomes apparent, productivity suffers, morale declines and the employee is let go.

One improvement to avoid such scenarios is to establish detailed criteria for the position before beginning recruitment. This would require scrutinizing potential candidates so that you find somebody that meets your requirements and fits into the practice’s culture.

It has become cliché that practice personnel, particularly clinicians, should work “at the top of their licenses.” This means that each licensed person should concentrate on the highest level tasks that he or she is allowed to perform. If there are activities that both a physician and a nurse practitioner (NP) can provide, they should be handled by the NP. If there are duties within the license scope of a physician assistant (PA) and a registered nurse (RN), the RN should perform them. This often results in clinicians taking on greater patient care responsibilities.

In a cost-constrained world, it may make sense to employ more, rather than fewer, staff in different roles. The most effective practices often have greater staffing ratios for RNs, LPNs and advanced practice nurses (APNs). The cost of employing larger numbers of nurses recoups itself by allowing practices to see more patients and offer more attentive care.

It is an established norm in forward-looking practices to use advanced practitioners, such as PAs or NPs. A recent survey of 1,066 physicians and practice administrators nationwide by the Physicians Practice website found that more than 60% of them employed at least one PA or NP. Physician recruiting firm Merritt Hawkins reports that the total number of recruiting searches for NPs and PAs surged 320% from 2012 to 2014.

Although the added cost of hiring more clinicians can be outweighed by the resulting improvements to practice efficiency and revenues, NPs also have a different approach with patients. They bring a focus on patient education and counseling, care coordination and wellness promotion that is often different from that of physicians.

Depending on individual state laws, advanced practitioners are able to provide a range of primary and specialty care services that includes ordering and interpreting diagnostic tests, such as X-rays and lab work; diagnosing and treating acute and chronic illnesses; prescribing medications; and educating patients on disease management and prevention. This usually can be done independently or under physician supervision.

In summary, NPs and PAs help practices generate revenue by increasing patient volumes and allowing physicians to spend more time delivering higher-level, direct, billable patient care.

To develop high-performing staff, you must provide them with a clear vision and objectives and then follow up regularly with feedback on their performance. It is important to prepare accurate, comprehensive job descriptions and give them to all employees. Update staff whenever job content changes.

Give the practice routine and provide informal comments on employee performance. This is best done immediately after a relevant work event. Provide both positive and negative comments. Follow the rule, “Praise in public, criticize in private.” Critical feedback usually comes easily, so make sure it is constructive. Look for legitimate reasons to compliment employees, preferably in front of co-workers. It will do wonders for everyone’s morale.

It is critical that you look for bottlenecks and processes that can be simplified. Try to consolidate redundant tasks and train staff to take on more complex multiple roles. The outcome of these staff initiatives can transform a practice’s operations.

For more tips on smarter staffing practices, contact Amanda Gutierrez at agutierrez@orba.com, or call her at 312.670.7444. Visit ORBA.com to learn more about our Health Care Group.


How Not to Lose a Claim Denial
Larry Sophian, CPA

As you know, a denied claim can hurt a physician practice significantly. Losing a claim wreaks havoc on the practice by draining needed revenues. The good news is that there are ways you can avoid future denials.

Record the Reason for Every Claim Denial
The goal should be for your practice to have its claims accepted on the first submission. However, this requires taking steps much earlier in the revenue cycle.

To begin the process, identify and record the exact reason for every claim denial. This can be done quickly and easily by using a denial management module that is built into the overall practice management system. A variety of reasons will come up—the payer may insist that the stated diagnosis does not support the medical necessity of the services, or there may be missing paperwork in the documentation for the claim. The claim may be denied if the patient is not a covered beneficiary of the payer to whom the claim was submitted.

The various reasons that emerge should guide your practice to take two types of actions: 1) Make immediate efforts to correct the errors and reverse the denial, and 2) modify your practice processes to prevent the errors from occurring in the future.

Correct and Resubmit
There are several possible responses to a claim denial. For instance, once the root cause of the denial is established, try to correct and resubmit the claim. Make sure you locate any missing paperwork and then add it to the claim. You can change inaccurate codes to the right ones, or determine the patient’s correct insurer and submit the claim to it.

If the practice cannot fix the reason for the denial, or the payer refuses to accept the correction, it may make sense to drop the matter and write off the charge. A write-off is necessary if the practice cannot locate the documentation to support the claimed service or if it turns out that the service was really part of a bundle that already has been paid separately and never should have been claimed in the first place. Nonetheless, this should be the last resort to a denial.

You can also appeal the claim. In the event that your practice makes what it believes to be appropriate corrections, but the payer still rejects them, the last option is to appeal the decision. You will need to contact the payer to learn its reasoning on the matter. Then, you must prepare persuasive arguments in support of the claim. As appropriate, gather additional relevant documentation, or obtain more expansive statements of medical necessity from your clinicians. Finally, file the appeal and follow up with the payer every two weeks until the matter is resolved.

Going Forward
Your practice’s goal should be to avoid claim denials, so you will need to make systemic changes for the future. For instance, with the change from ICD-9 to ICD-10 billing codes that became effective October 1, 2015, it is possible you have encountered problems with incomplete documentation or improper coding that may require retraining staff and clinicians. The people may be fine, but the processes they perform may need to be re-engineered. In that case, your focus should be on getting all the right patient information before or during registration, capturing and entering the correct charge codes in a timely manner and correcting pre-adjudication edits returned by the claims clearinghouse on a daily basis.

By following the above objectives, your practice will be well on its way to clean claims. It is also important to understand the causes of claim denials. This starts with reporting denials at the claim level and on a line-item basis and then projecting trends over time.

The Bottom Line
Your practice was not created to lose money. So, be sure to include a chat with your health care advisor or coding professional. He or she can help you keep on the right track.

For best practices on processing and submitting health insurance claims, contact Larry Sophian at lsophian@orba.com, or call him at 312.670.7444. Visit ORBA.com to learn more about our Health Care Group.


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