Most health care providers, including nurse practitioners are ever vigilant to issues of malpractice. We all chant “do no harm”. And yet we are human. We fly through the day trying to get everything done – seeing our patients, refilling medications, filling out authorizations, reports and other paperwork; ordering consults, therapies and test; interpreting test results, and so much more. And occasionally something does not get the attention it deserves – including you!

Here are just a few tips that can serve to protect you against some of the most common complaints.

1.  Document, document, document. This means everything. Your discussions with patients, findings, results and your conversation with patients regarding results, any intended follow up and if so, with whom – including any referrals that you’ve made.
2. Medications.  Prescriptions remain a significant problem. Most commonly, it’ has to do with prescribing the wrong medication.  You’ll want to review which patient you are prescribing for, how much and how often; medication indications and likelihood of interactions.
3. Diagnosis. When you are diagnosing a problem, make sure you are ruling out the worse thing first. And pay attention to the “red flag” diagnosis – those that tend to end up in lawsuits more frequently than others. They include certain cancers – breast, cervical, pulmonary and colorectal; myocardial infarctions; and appendicitis to name a few.
4. Do not delay in making referrals or getting consultation when you are unsure. Make sure you document that you have done so, and follow up with any recommendations.
5. Talk with your patients. Make sure they get their questions answered, their concerns addressed. Work in partnership with them – it is their body after all.

Each day I receive plenty of email from Nurse Practitioners, Physician Assistants/Associates and other clinicians who have questions about starting a practice, practice models, business development or a variety of other topics pertaining to practice operations, management and marketing.

This video (below) answers a question I received from one individual but encompasses a question I hear more and more often about starting or converting to a cash practice, also known as a direct pay practice.

While many have expressed interest in either starting a practice, focusing simply on direct pay models and avoiding insurance (and its inherent cost and headaches) or switching their already established practice to a cash basis, there are some pros and cons to this. In the final analysis it will depend on the provider and ultimately, their patient base.
Take a listen (6 minutes) and see what you think. Please be sure to leave a comment.

From the Centers of Medicare and Medicaid Services, here is an important announcement on electronic health records.

As of Tue Jan 31, more than $3.2 billion in Medicare and Medicaid electronic health record (EHR) incentive payments have been made; more than 191,000 eligible professionals, eligible hospitals, and critical access hospitals are actively registered. Learn if you are eligible and, if so, what you need to do to earn an incentive. This session will inform individual practitioners about the basics of the Medicare & Medicaid EHR Incentive Programs. Remember: This is the last year that eligible professionals can participate in Medicare and get the maximum incentive payment.

Target Audience: Eligible Professionals (EPs), which include Doctors of Medicine or Osteopathy, Doctors of Dental Surgery or Dental Medicine, Doctors of Podiatric Medicine, Doctors of Optometry, Chiropractors, Nurse Practitioners, Certified Nurse Midwives, and Physician Assistants (PA) who practice at an FQHC/RHC led by a PA. (Note that hospital-based EP’s may not participate; an EP is considered hospital-based if 90% or more of the EP’s services are performed in a hospital inpatient or emergency room setting.) Medicaid eligible professionals must meet patient-volume criteria, providing services to those attributable to Medicaid or, in some cases, needy individuals.)

Agenda:
Are you eligible?
How much are the incentives and how are they calculated?
How do you get started?
What are major milestones regarding participation and payment?
How do you report on meaningful use?
Where can you find helpful resources?
Question and Answer Session
Registration Information: In order to receive call-in information, you must register for the call at http://www.eventsvc.com/blhtechnologies. Registration will close at 12pm on the day of the call or when available space has been filled; no exceptions will be made, so please register early.

Presentation: The presentation for this call will be posted at least one day beforehand at http://www.CMS.gov/NPC/Calls. In addition, the presentation will be emailed to all registrants on the day of the call.

A misconception among many nurse practitioners, physician associates and other clinicians is that we take care of EVERYONE within our area of expertise.  Yes…but. Do you really do a good job with everyone? Do all of your clients and patients really connect with you and you with them? Are you really able to help each and every one of them?  I thought so.

While we might care for “everyone”, the truth is there are certain patients that we do better with. We seem to be able to speak to them and they actually hear us…and we hear them. These are the folks we do our best work with.

How great would it be to have a practice full of these folks…your ideal patients? In truth, it’s hard to see that happening, however, you can increase the likelihood that new patients coming to see you will fit the profile of your “ideal patient”.

In order to do this, one of the first things you need to do is to identify just who is “ideal” for you? Here are just a few of the questions you may want to ask yourself:

• What do you know about them? Who are they? How old are they? Where to they live? Do they have families? What kind of problems and concerns do they have? How do they like to solve their problems?
• Where do they hang out? What are they looking for in a health care provider? What kind of assistance would they need? Where and how to they like to access care? What’s important to them?

The answer to these questions will help you identify who your ideal patient is, the messages you want to create for them (so they can HEAR you through all the marketing noise), and deliver it to them where they will SEE it.

While it would be nirvana to have a practice full of ideal patients, chances are you may still run into folks where the two of you don’t connect well or work well together. That’s part of the work we do. But how much nicer would it be if that was not your entire day.

Take the time to identify your ideal patients and then adjust your marketing practices. I think you’ll be pleasantly surprised at how your practice will change.

Many Nurse Practitioners are frustrated in their day to day work.  They feel rushed to see lots of patients.  Of course, that goes against our nature – we want to take the time to really hear our patients, to communicate with them and to really address issues that are affecting their health. Sometimes there is no way around those longer visits.

And this is where the frustration comes in. It’s hard to see patients in 10 or even 15 minutes. I understand this. Our patients are often complicated and it’s nearly impossible to do an excellent job in just a few minutes.

However, there is a disconnect and we need to address it. I’ve heard too many times that physician practice owners “only care about money and generating revenue”. “They don’t care about the patient”. Gee…I’ve heard that same thing said about NP owned businesses and practices from my colleagues – we only care about the money.

Let’s set this record straight. What all of us need to understand is that healthcare is a business. You cannot maintain an office, hire staff and provide services without thinking about the money you are generating and spending. Health care is not free. The owner of the practice has overhead that has to be paid. Landlords don’t care if Medicare cuts reimbursements or if they decide to delay payment. For that matter, most employees don’t care either – they want their employer to pay fairly (with benefits) and on time.

The practice/business owner (NP, PA or MD/DO) is not the enemy here. If we must have someone to blame, then we only need to look to our current health care system that is full of regulations that are inefficient and make little sense, and third party payers who decide if and when they will pay, the amount they will pay, and if they will let us keep the money.

Nurse Practitioners, indeed all health care providers, need to understand, as a revenue generating practitioner…we too are a “business”!  It doesn’t matter if you work for your own business or someone else. The more we understand how this works, the better for all involved.

So the next time you or one of your colleagues says the NP or the MD/DO only cares about money the business can make, think again. Think about how you can support and contribute to the health of that practice, so it becomes a win-win-win situation. The patient gets services, the practice continues to provide services and the staff gets to keep their jobs. Oh, and a bonus win…the practice continues to contribute (physically and fiscally) to the local community. That makes it WIN x 4.

Stay tuned as this is a business topic that needs a lot more conversation.

Every day, your business accepts money…cash, checks and credit cards. All of these can be an issue, but cash is the biggest issue of all. You know that $25 (cash) copay that was just received – where did it go? Did it make it to your cash drawer, or your employee’s pocket?

In a survey done with practice managers, nearly 45% of them report some degree of cash taken from a practice. Lest you think that embezzlement is limited to health care practices think again. The US Department of Commerce estimates that embezzlement costs US business an estimated $500 billion annually. Yes, that’s “B” as in billion.

Let’s look at seven ways to minimize the risk of this happening to you and your business.

1. One is a dangerous number. One person accepting money, logging the payment, making the bank deposit and reconciling the books at the end of the day/month is asking for trouble. If at all possible, divide the process up between staff members and yourself. Monitor closely.
2. Internal audits should be done on a regular basis and on a “surprise” as needed basis.  Having this as part of your standard operating procedure may cause the less than honest person to think twice about proceeding and getting caught.
3. Mandatory vacations can help flush out the problem. Often times the person engaged in embezzlement will avoid going on vacation for two reasons…they want to have continued access to the cash and if someone fills in for them, there is a greater chance of being found out. If you find that you’ve got greater cash flow in your business when someone is on vacation, dig deeper.
4. Cross train staff and mix up assignments from time to time.  The guilty person will avoid help and want to avoid having someone see what they are doing in their position.
5. Safeguard business credit cards.  Think and think again who has access to business credit and debit cards, and who can sign and call in orders as well as sign for checks. Make sure you have procedures in place to make this a multi-step procedure.
6. Who’s managing the books? Are fake bills from fake vendors just written off? Are expenses being written? Are patients and their insurance companies really being billed? You may want your CPA to do a quarterly audit of the books, just to be sure.
7. Most importantly, before you hire do a background check. How did it go at their previous employment?  Did the company have any concerns? If it’s hard to get direct information, listen between the lines. Make sure you also do a criminal check.

When it comes to office embezzlement – everyone is potentially a suspect – even that long time trusted employee. Protecting your business has nothing to do with who you like or even trust.  Good policies and procedures, including safeguards and audits will not only protect your practice and your employees.

Share with your colleagues the tips and strategies you use to protect your business from practice embezzlement below.

Millions of people (and thousands of health care professionals)  saw this Superbowl video ad and were moved – deeply.  I know it… affected me, and everyone I’ve spoken to about it. (No, I did not watch the game). I suggest that all of us take another look, this time for the marketing lessons within. What do you see and how can that apply to your business or practice? Leave your comments below.

Medscape  recently posted the results of a survey where physicians rated insurance companies in terms of best and worse to work with and the factors that lead into those ratings.

This got me to thinking about us. Insurance reimbursement for NPs and other Advanced Practice Nurses is all over the board. Some companies recognize Nurse Practitioners and reimburse them for the work they do, other companies seem to be ignorant of the work we do. Then it also varies by state and region.

For example, here in Washington State, for the most part, I don’t have difficulty with insurance reimbursement. I am credentialed with the two “Blues” in our state, yet I hear from NPs in another state where the “Blues” refuse to credential NPs. Does not make sense does it.

If you have having difficulty, contact the American Academy of Nurse Practitioners and get in touch with the Multi-State Reimbursement Alliance people for your region.
OK. Let’s hear from you. What state are you in? Who is credentialing and who is not? What have you found that works and what doesn’t. Advice for others in your area about insurance reimbursement?

Nurse Practitioners and other  Clinicians can no longer continue business as usual.

Our patients (clients, customers) deserve and expect much more. Gone are the days when a white coat gives one cart blanche to treat patients and staff indifferently behind the ruse of being busy. There is no doubt that you are busy. But just as you want respect from your patients, they are now expecting it from you as well.  Addressing one of the most common concerns patients make about provider offices will go a long way.

You are no doubt familiar with this complaint: “Every time I go to that office, I have to wait for hours!” I trust patients waiting in your office, wait for a much shorter time. There is much we can do to reduce wait times, but waiting is a reality for both patients and providers. It’s a fact of life that emergencies and other situations can and do happen.

So what can we do to minimize the impact of waiting? Well, it turns out there is much that can be done.

1. First – stop calling it a “Waiting Room” and rename it a reception area or something similar. Waiting Room implies that I will be waiting, no matter what. Changing the name can help reduce that perception and soften the idea that there will be a short delay before seeing the provider.
2. Make your patients comfortable. Patients have been invited into your office to see you. Think of this as your work “living room”. Make sure the reception area is comfortable for your guest. Take a seat…are the chairs comfortable? What about the room temperature? Too warm? Too cool?
3. When we are waiting (and idle) time can seem to drag on and on. However, when we are distracted or better yet engaged, time flies. Do you have a variety of reading material that is up to date? And while you are at it, is the lighting appropriate for reading? I’m not a fan of TV’s in reception areas, but perhaps you may want to consider a TV or video screen that is playing something engaging and appropriate (maybe even educational)?
4. Comfort Station. If possible, it’s nice to have a restroom available to those who are waiting as well as water or other appropriate beverages depending on your office situation.
5. Children. It can be quite irritating to a non-parent (or parent!) to listen to a child who is bored and tired. If you see children, or the family members of young children, consider having appropriate items that may keep their hands and minds engaged.

Most important, if you have patients waiting to see you, make sure they are keep up to date on any delays. Consider offering them the option to reschedule. Respect your patients and their time. It will go a long way in making them happy, satisfied patients.

What changes can you make in your reception area today?

This is literally the most common question I receive from Advanced Practice Nurses (NPs, CNMs, CNS, CRNA’s) and Physician Assistants/Associates (PAs). So this week, I thought I would create a video to answer just that question. It’s short, about 10 minutes explaining the framework I teach in practice and business startup.

Please share your own tips with your colleagues below.