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.

Once again, Medicare is asking Nurse Practitioners and other providers to hold our Medicare Claims for 10 days until Congress can prevent a 21% reduction in reimbursement to providers.  We will not know the outcome until after Congress has a chance to reconvene on April 12 and they approve a pay patch.  However, it’s unclear to me, just how long before we will be faced with this issue again.

If you have not already done so, take a look at your payor mix. Do a bit of forecasting and determine how this will impact your practice overall. You may need to make some adjustments.

I’ll post more as it becomes available.

Nurse Practitioners, along with other health care providers can expect to have payments held for “up to the first 10 business days of January”.

According to CMS:

The President has signed the Department of Defense Appropriations Act of 2010 which provides for a zero percent (0%) update to the 2010 Medicare Physician Fee Schedule for a two month period, January 1, 2010 through February 28, 2010.

The Centers for Medicare & Medicaid Services (CMS) is working with Congress, health care providers, and the beneficiary community to avoid disruption in the delivery of health care services and payment of claims for physicians, non-physician practitioners, and other providers of services paid under the Medicare physician fee schedule, beginning January 1, 2010.  In this regard, CMS has instructed its contractors to hold claims for services paid under the Medicare Physician Fee Schedule (MPFS) for up to the first 10 business days of January (January 1 through January 15) for 2010 dates of service. This should have minimum impact on provider cash flow because, by law, clean electronic claims are not paid any sooner than 14 calendar days (29 days for paper claims) after the date of receipt. Meanwhile, all claims for services delivered on or before December 31, 2009, will be processed and paid under normal procedures.

The holding of claims allows Medicare contractors time to receive the new, updated payment files and perform necessary testing before paying claims at the new rates. CMS has instructed contractors to begin processing claims at the new rates no later than January 19, 2010.  Please note that most contractors are closed on the January 18 Martin Luther King Day holiday. Therefore, even absent a new update, most claims likely would not have been paid any sooner than January 19, 2010, given the aforementioned statutory 14-day payment floor.

CMS has extended the 2010 Annual Participation Enrollment Program end date from January 31, 2010, to March 17, 2010- therefore, the enrollment period now runs from November 13, 2009, through March 17, 2010.

The effective date for any Participation status change during the extension, however, remains January 1, 2010, and will be in force for the entire year.

Contractors will accept and process any Participation elections or withdrawals, made during the extended enrollment period that are received or post-marked on or before March 17, 2010.

In addition, be on the alert for more information about other legislative provisions which may affect you.

Many independent NP practices are concerned with the proposed changes in Medicare reimbursement. At this time, it stands at -21.2% of the physician allowable. Of course, for NPs and PAs that figure is a bit more.  The good news is the proposed cuts in payment have been delayed until March 1, 2010.

In terms of the elimination of the consultation codes, there does not seem to be any changes. Those codes will be eliminated as of January 1, 2010.

In order to see where you will stand in terms of reimbursement, visit the website of your local fiscal intermediary and download the most recent fee schedule. Dont’ know who you intermediary is? You can find it here – Medicare Intermediary , which is a PDF file and will have all the contact information for your region.

Smart offices will have been looking at this information and trying to assess what changes, if any, they will need to make in 2010. How will this affect your office and your patients, and how to you think you will respond? Feel free to leave your comments below.

This proposed change affects Nurse Practitioners and  Physicians Assistants as well as Physicians, and directly impact those of us with our own offices. Read carefully.

The Centers for Medicare & Medicaid Services (CMS) announced today proposed changes to policies and payment rates for services to be furnished during calendar year (CY 2010) by over 1 million physicians and nonphysician practitioners who are paid under the Medicare Physician Fee Schedule (MPFS). The MPFS sets payment rates for more than 7,000 types of services in physician offices, hospitals, and other settings.

CMS is making several proposals to refine Medicare payments to physicians, which are expected to increase payment rates for primary care services. The proposals include an update to the practice expense component of physician fees. For 2010, CMS is proposing to include data about physicians’ practice costs from a new survey, the Physician Practice Information Survey (PPIS), designed and conducted by the American Medical Association.

The Medicare law requires CMS to adjust the MPFS payment rates annually based on an update formula which includes application of the Sustainable Growth Rate or SGR that was adopted in the Balanced Budget Act of 1997. This formula has yielded negative updates every year beginning in CY 2002, although CMS was able to take administrative steps to avert a reduction in CY 2003, and Congress has taken a series of legislative actions to prevent reductions in CYs 2004-2009. Based on current data, CMS is projecting a rate reduction of -21.5 percent for CY 2010.

As part of health care reform, the Administration supports comprehensive, but fiscally responsible, reforms to the physician payment formula. Consistent with this goal, the Administration announced in the FY 2010 President’s Budget that it would explore the breadth of options available under current authority to facilitate such reforms, including an assessment of whether the cost of physician-administered drugs should continue to be included in the payment formula. Thus, while working with Congress to develop a more appropriate mechanism for updating physician payment rates, CMS is proposing to remove physician-administered drugs from the definition of “physician services” for purposes of computing the physician update formula in anticipation of enactment of legislation to provide fundamental reforms to Medicare physician payments. While the proposal will not change the projected update for services during CY 2010, CMS projects that it would reduce the number of years in which physicians are projected to experience a negative update.

CMS is also proposing to stop making payment for consultation codes, which are typically billed by specialists and are paid at a higher rate than equivalent evaluation and management (E/M) services. Practitioners will use existing E/M service codes when providing these services instead. Resulting savings would be redistributed to increase payments for the existing E/M services.

CMS is proposing to increase the payment rates for the Initial Preventive Physical Exam (IPPE), also called the “Welcome to Medicare” visit to be more in line with payment rates for higher complexity services. The IPPE benefit was mandated by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 to pay for an initial assessment of key elements of a beneficiary’s health status within six months of the beneficiary’s enrollment in Medicare Part B. Subsequently, Congress extended the time period for the IPPE benefit to within one year of the beneficiary’s enrollment in Part B.

In addition, CMS is proposing to refine how Medicare recognizes the cost of professional liability insurance in its payment system. While these changes would have a modest impact, they will promote payment equity by redirecting the portion of Medicare’s payment for professional liability insurance to those physicians that have the highest malpractice costs.

Taken together, refining the practice expenses, eliminating payment for the consultation codes and revising the treatment of malpractice premiums would increase payments to general practitioners, family physicians, internists, and geriatric specialists by between 6 and 8 percent (before taking into account the proposed update and other proposed changes to the fee schedule).

The proposed rule would also implement provisions in the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) that added new Medicare benefit categories for cardiac and pulmonary rehabilitation services, and for chronic kidney disease (CKD) education, beginning January 1, 2010. The proposed rule outlines what these programs would entail, how they would be paid under the MPFS, and the criteria for covering these services.

CMS is proposing two changes to address concerns from the Medicare Payment Advisory Commission (MedPAC) and the U.S. Government Accountability Office (GAO) about rapid growth in high cost imaging services. First, CMS is proposing to reduce payment for services that require the use of expensive equipment which would produce a redistribution of the resulting savings to increase payments for other services, including primary care services. The current payment rates assume that a physician who owns this type of equipment will use it about 50 percent of the time, but recent survey data suggest this expensive equipment is being used more frequently. As the use of this type of equipment increases, the per-treatment costs for purchasing, maintaining and operating the expensive equipment declines, making a reduction in payment appropriate.

Second, CMS is proposing to implement a requirement in the MIPPA that suppliers of the technical component of advanced imaging services be accredited beginning January 1, 2012 by designating accrediting organizations (AOs) for these suppliers and utilizing the imaging quality standards that have been developed by the AOs. The accreditation requirement would apply to mobile units, physicians’ offices, and independent diagnostic testing facilities that create the images, but would not apply to the physician who interprets them. According to the GAO, spending on advanced imaging services, such as computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET), is growing almost twice as fast as spending on other types of imaging services, and is a significant contributor to the rapid growth in health care spending in recent years, but there is little administrative oversight to ensure the quality of care. In a separate regulatory action, CMS will address suppliers’ accountability, business integrity, physician and technician training, service quality, and performance management.

The proposed rule contains a number of provisions to promote improvement in quality of care and patient outcomes through revisions to the Electronic Prescribing Incentive Program (e-Prescribing Program) and the Physician Quality Reporting Initiative (PQRI). Eligible professionals or group practices that meet the requirements of each program in CY 2010 will be eligible for incentive payments for each program equal to 2.0 percent of their total estimated allowed charges for the reporting periods. CMS is proposing to simplify the reporting requirements for the electronic prescribing measure and to provide eligible professionals with more reporting options. CMS is also proposing a new process for group practices to be considered successful electronic prescribers.

In addition, CMS is proposing to add more measures and more measures groups for eligible professionals to report under the PQRI, to provide a mechanism for participants to submit quality measure data from a qualified electronic health record and to create a process for group practices to use for reporting the quality measures.

CMS will accept comments on the proposed rule until August 31, and will respond to all comments in a final rule to be issued by November 1, 2009. Unless otherwise specified, the new payment rates and policies will apply to services furnished to Medicare beneficiaries on or after January 1, 2010.

Source
Centers for Medicare & Medicaid Services

CMS Proposes Payment, Policy Changes For Physicians Services To Medicare
Beneficiaries In 2010
06 Jul 2009