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.

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.

Hopefully you’ve never met Godzilla, but statistics tell me…you have. In fact, Godzilla may even be working for you right now!

Godzilla Characteristics: Godzilla can be quite cunning in how he/she undermines the fabric of your business, and often times its quite insidious making it hard to detect at first. It can be a very subtle attitude that undermines your team, your position as the business owner, and the value of your patients/customers.  Sometimes Godzilla just likes to “stir-the-pot” causing a feeling of “unrest” and other times he/she can be outright rude to co-workers and patients.

If your patients, your staff or even you feel as if you are intruding or bothering this employee during the course of your daily work – then you may be dealing with a Godzilla.

Identifying Godzilla: The person channeling Godzilla may be anyone in your office; your clinical assistant, receptionist, biller or office manager. What for inconsistencies in behavior of staff members, or a change in behavior when certain people are around.  You may note a change in behaviors or the atmosphere when one person is away for the day.

If you are lucky, patients and staff will begin to mention things to you, but most often what happens is that you’ll learn from your patients after the person has left that you had a Godzilla on your hands. (Note: you’ll also begin to wonder how many patients/customers you’ve lost because of this person).

At this point you might be asking yourself how you can identify a problem before damage is done.

Godzilla Alert!

None of us willingly brings Godzilla on to join our staff. More often what happens is after that honeymoon period (read: probationary period) some people will morph from a pleasant Gecko to Godzilla.  If staff or patients are not letting you know about their experiences, you may not find out for a long time. After all, most of us don’t have time to ethically “spy” on our staff.

This is where a “mystery shopper” or, more appropriately a “mystery patient” can be very handy. You can certainly hire someone to play a patient, or hire an agency who handles this. You’ll just want to make sure that this person is unknown to your staff, and even perhaps to you. You’ll get a detailed report back about your staff and the processes you take your patients through.

As a general rule, it’s always good to foster a relationship with your staff and well as your patients where sharing important information, and listening/acting on that information is taken seriously. Allowing for suggestion boxes and/or periodic surveys may help those come forth that may not otherwise.

Avoiding Godzilla in the first place

This is where your interviewing and hiring skills and processes come into place.

The first thing you will want to do is to screen your potential employees as thoroughly as possible. Make sure you get references and then follow up on those references. Talk with former employers and co-workers. Let them know that you will hold their confidence.

Be aware however, that some companies will have a policy to only confirm that the individual worked for them and if they would hire them back or not. I’ve run across this before, and sometimes a casual conversation about how hard it is to find good employees will open the door for you to get further information.

During the interview process, I find it helpful to throw out some scenarios that you want them to quickly respond to. This may give you a few hints as to what may be lurking below that poised exterior.

Once you bring someone on board, make sure you have a solid policy in place about your probation period. Having language that indicates that employment status is dependent upon satisfactorily completing the probationary period will help you later on should you find a monster lurking.

No room for Godzilla

In any business, at any time, Godzilla and relatives are not welcome. You want your patients/customers to feel welcome in your office and be comfortable making referrals.  You want a solid team that can work together. Godzilla and company only make our work more difficult and less profitable.

Have you had this experience in your office? What was your solution?

Those of you practicing in California during the summer of 2009 likely remember all too clearly when the state of California issued IOU’s for health care services you provided. This came to mind this past week when an insurance company in my state was “outed” for delaying over 300,000 claims to providers since Jan 2011 when they took over the state employee health care plan.

Given the current economic and health care crisis, I fear we may experience more situations where payment is not forthcoming, or significantly delayed. While there are many ramifications, the issue we need to discuss today is this: are you prepared for slow-downs or lapses in getting paid in your practice? And what can you do to get prepared?

To begin with, take a good look at the mix of payers you work with in your practice.  How many are commercial insurances and how many are Medicare and Medicaid or other state plans, and even cash? And even if you have a big percentage of commercial payers, you’ll want to make sure that you have different payers in that group. You want to make certain that in the event something happens to one of your main payers your practice will be able to continue.  Remember your mothers advice…“Don’t put all your eggs in one basket!”

Once you know your breakdown by payer, you’ll calculate what percentage of your patients are covered by each payer. With this information, it’s time to play some “what ifs”. To do this, calculate the percentage of income you receive from each payer. Set up a spreadsheet and enter your data and you should be able to run some scenarios to see how your income and practice might be impacted by the loss of one or more payers.

Next, you’ll want to come up with some possible responses to the loss of a payer regardless if it’s a slowdown in payment or a complete loss of that payment source. Ask yourself how you would handle this right now? What resources do you currently have at your finger tips to help you deal with such an event?

Do you have cash reserves your practice could draw from? Or do you have an established line of credit you could fall back on? If your answer is “No”, ask yourself what contingency plans you need to put in place to be prepared?

As a practice owner you must be monitoring your accounts receivable (AR). Work closely with your billing person to make sure it’s watched daily. Know the average length of time it takes for you to get paid from your payers. And if payments are not coming in as expected does it just involve a few claims or does it involve numerous patient and claims?

If you run into problems with receiving timely reimbursement, check with the payer to see if there is an issue. Make sure you document who you have spoken with and what their response is. You will need this later on when you follow up with them.

Depending on the size of the problem, you may want to let your patients know what is going on. Often times the plan members can do much to move the process along.

Unfortunately, there is no such thing as free health care. Without income you simply cannot run your practice and provide services for long. Obviously the last resort may be to no longer accept plans that don’t provide timely (and competitive reimbursement). There may come a time when you have to rethink which payer you can and cannot work with.

This is a situation we don’t like to think about. However, it’s happened before and it will likely happen again. Being prepared for cash flow disaster, just like being prepared for natural disaster, can help your practice get through potential rough spots, survive and thrive.

(c) Barbara C Phillips, NP

Nurse Practitioners that accept Medicare in their practices need to be aware of how this will impact their practices. With the exception of Midwives, NPs are allowed only 85% of the physician allowable. Here is the update:

The Continuing Extension Act of 2010, enacted on April 15, 2010, extended the zero percent (0%) update to the 2010 Medicare Physician Fee Schedule (MPFS) through May 31, 2010. At this time, Congress is debating the elimination of the negative update that took effect June 1, 2010. The Centers for Medicare & Medicaid Services (CMS) is hopeful that Congressional action will be taken within the next several days to avert the negative update.

To avoid disruption in the delivery of health care services to beneficiaries and payment of claims for physicians, non-physician practitioners, and other providers paid under the MPFS, CMS had instructed its contractors on May 27th to hold claims for services paid under the MPFS for the first 10 business days of June (i.e., through June 14, 2010). This hold only affects MPFS claims with dates of service of June 1, 2010, and later.

Given the possibility of Congressional action in the very near future, CMS is now directing its contractors to continue holding June 1 and later claims through Thursday, June 17, lifting the hold on Friday, June 18.

This action will facilitate accurate claims processing at the outset and minimize the need for claims reprocessing if Congressional action changes the negative update. It also should minimize the provider and beneficiary burdens and costs associated with reprocessing claims.

We understand that the delayed processing of Medicare claims may present cash flow problems for some Medicare providers. However, we expect that the delay, if any, beyond the normal processing period will be only a few days. Be on the alert for more information regarding the 2010 Medicare Physician Fee Schedule Update.

Source: LEARNRESOURCE-L Email Update, National Institutes of Health, U.S. Department of Health and Human Services dated June 14, 2010

Posted: 6/14/2010

One of the challenges for any practice is collecting payments from payers, including our patients. However, most practices do not utilize all the options available to them.

On Sunday June 13th, we will be talking with Nurse Practitioner Carolyn Zaumeyer. She has combined her expertise in Independent Practice and Patient Payment Options – which will be the topic of our discussion.  Carolyn’s goal is to help you along the way to success in your practice which means, showing you ways to keep more of your hard earned money.

She has authored two books on Independent Practice for Nurse Practitioners. She has also written over 27 publications and has given over 73 presentations at national and international conferences.  Zaumeyer is a pioneer in the field, establishing and operating her own Women’s Health Watch, in Ft. Lauderdale in the early 90′s.

You are invited to join us on Sunday June 13, 2010 @ 5pm Pacific, to evesdrop on our conversation, ask your own questions, and expand your knowledge about the business of practice.

If you have not been receiving our notices for these interviews, sign up at www.NPInterviews.com to receive your special link to this interview.

Nurse Practitioner Business Owner, hosted “Getting Started in your OWN Practice” teleseminar on Sunday April 25, 2010. There were RECORD numbers of Nurse Practitioners and Physician Assistants in attendance.  The questions sent in before and during the event were fantastic. I did not get a chance to answer all the questions, but watch this blog for updates and answers to questions.

If you missed it, you can listen to it here:  www.nursepractitionerbusinessowner.com/startupsystem-replay.html

On this teleseminar, we introduced the NPBO™ Practice Startup System Program which starts Wednesday May 5th. I’m so excited to be actually teaching this course – I’ve had so many requests for something like this, and I believe it will make a huge difference for the NPs that are already participating! You’re invited to check it out, but you’ll want to do so before May 1st at 12 midnight Pacific (hint: the special pricing ends then).

Hope you’ll join us on May 5, 2010!

A common concern of practice owners, especially with the real and potential cuts in reimbursement is “How can I generate more revenue?”  The topic is discussed not-to-infrequent in the NPBO™ forum, on health care provider social media groups and the subject of questions I receive in my in box.

On Thursday 4/22/2010, we will be talking about practice revenue with NPBO™ Members on our monthly Practice & Business Issues teleseminar. Open to current members of NPBO only, it will begin promptly at 5pm Pacific. You can check your timezone at www.Time.gov.

Not a member? Visit www.NursePractitionerBusinessOwner.com to find out more.