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?

Every clinician, indeed every person (well almost), wishes to make a difference in the lives of others. As a Nurse  and later as a Nurse Practitioner, I’ve always wanted to make a difference in the lives of my patients and their families. In the past 6 years or so, I’ve expanded my goal to include making a difference in the lives of fellow clinicians.

I feel blessed to do the work that I do. And to be honored for it…well, it’s a fantastic feeling.  In my mind, this is recognition for all of us that are business owners or aspiring business owners.

For those of you who are interested and cannot read the small jpeg, this is what it says:

Congratulations on receiving the 2012 AANP Nurse Practitioner Advocate State Award for Excellence! This prestigious award is given annually to a dedicated nurse practitioner advocate in each state who has made a significant contribution to the status of health care delivery and the practice of NPs.

Ever wonder who are Nurse Practitioners, what we do and where to find us? Here’s a small samples of NPs and our practices from around the country. Feel free to share the video with your friends, your colleagues, your patients, your networks. Post it on your websites and your blogs. Spread the word about NPs.

All health care professionals including advanced practice clinicians (nurse practitioners and physician assistants) want to prevent any potential legal actions related to the excellent care they provide.

Let me first start off by saying, I am not an attorney and I don’t play one in real life, on TV or on the internet. I had never even been in a real courtroom until recently. However, back in 2006 became involved in an investigation of another health care professional that has only recently gone to trial, and have spent a good amount of time researching the topic for past and future presentations. Thus, I’d like to share just a few tips that you can take to protect yourself as you continue to provide excellent care to your patients.

Documentation:
First and foremost, pay attention to your documentation! Make sure it tells the story, discusses your findings, your assessment and your plan. Whoever is reading the note, should be able to understand how you got to your proposed plan AND be able to pick up where you left off, making any necessary adjustments.

Don’t assume that someone can read your mind and don’t assume you will remember 1, 6 or 52 weeks later. While not everyone is able to complete each and every chart in the room before the patient leaves, make serious attempts at getting your charting done as soon as it’s feasible. Memory fades over time. Need a refresher on documentation? Here is a primer on documentation published by CMS.

Coding and Billing:
You may not be doing the billing in your office, but chances are you are responsible for coding the level of the visit. It’s your responsibility to be aware of the requirements for level of care regardless if your CPT code reflects the work and acuity of the patient, or the time spent. Make sure you have documented accordingly. If you need to brush up on your E&M coding skills, you can get some great free education at www.emuniversity.com. Coding the wrong level of service, or even “incident to” inappropriately, can land you in hot water.

Medication Errors:
Believe it or not, medication errors continue to be quite common. In fact, according to the 2009 NP claims study*, more than 80% of medication errors are prescription-related and 1/3 of those involved prescribing the WRONG medication.

Make sure you check and double check your prescriptions for spelling, dose , indication, side effects and contraindications.  If you are using any of the electronic prescribing tools available, it should help, but they are not foolproof. Take advantage of the various tools you can use in the room with you including those on your PDA or smartphone. Epocrates, my favorite is only one of the various tools available.

Protect Yourself:
If you have legal concerns, it’s always best to check with an attorney who is familiar with health care, advanced practice issues, and is in your state.  Make sure you have appropriate liability coverage. All healthcare providers today have a tremendous responsibility to do the best they can do, often under less than ideal situations.  Despite this, we continue to do our best to provide the best level of care we can for our patients and clients. These suggestions can help protect you (and your patients) even years into the future.

Share your tips with your colleagues below:

*2209 NP Claims Study can be found at www.nso.com/NPclaimstudy2009

One of the most common obstacles the clinicians (nurse practitioners, physician assistants and registered nurses)  I work with need to overcome is fear.

Many  may be afraid of making the transition from being a paid provider in a clinic to running their own clinic and paying others, afraid of marketing themselves, afraid of learning new skills, or of any of a number of other things.

When I look at the literally hundreds (if not thousands) of questions I have received over the past few years, most of the fears can be summarized in three ways:

• Fear of Rejection
• Fear of Failure
• Fear of the Unknown (this is The big one).

Though the sources of fear may be different, the effects are often the same: fear slows us down and can even paralyze us. It makes it hard of us to pursue our goals and dream. You know what I mean if you have ever found yourself struggling to reach a goal.

Several years ago during a personal development program I was enrolled in, I first heard a definition of FEAR described as – False Evidence Appearing Real. It made sense to me then and makes sense now. In other words, we fear the changes we need to make, we fear the unknown – we want guarantees. Humans for the most part do not like unknowns, especially in our profession.

So while fear can be paralyzing for many, it has also been called one of our most powerful motivators to move forward. But how can we make that leap from that gripping fear that holds us hostage, to one of forward moving action?

1. Identify the real issue that is keeping you from moving forward. When we understand our fear, we can begin to take small steps forward.
2.  Keep track of your progress (journals are great for this) and make sure you reward yourself for the actions you have taken.
3. Get the support you need from family, friends and colleagues.
4. Make sure you are involved with professional and business groups and organizations – not only for the support, but for education. Having the know-how to move forward will help reduce your fear and can support you in your goals.
5. To short cut your own journey through fear, many will find it beneficial to work with a coach who can expertly guide you through that which is stopping you.

Thriving as a business owner is not just about the how-to’s of starting, running and growing a business. It’s also not just about professional development. We must participate in personal development of the mind, body and spirit. That is when we will truly come into our own.

(c) 2011Barbara C Phillips, NP

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As I said above, if you really want to take a short cut, then you’ll want to join us for a free webinar happening on September 20th. More details are here http://www.prattbennet.com/barbaraphillipsSLJ.html, and here Are You Worth It?

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

Many Nurse Practitioners and other advance practice clinicians who want to start a practice, are worried about the cost to get started in a traditional office practice and are looking for options. One such option is a practice focusing long term care (LTC).

Geriatrics is one area that is vastly underserved, especially for those who reside in LTC. The need is only expected to increase as our population ages.

This is not a new type of practice. Many of us who are Geriatric Nurse Practitioners (GNPs) have practiced in LTC facilities for years. Over the years, we’ve not see more ANPs (adult nurse practitioners) and FNPs (family nurse practitioners) in LTC as well. What is becoming more common (albeit still relatively rare) is that the NPs working in LTC are doing so as self employed individuals. NPs who have businesses that focus on seeing residents of LTC facilities will tell you that they not only enjoy their work, but managed properly, it can also be financially rewarding.

So what do you need to get started?

1. Knowledge of geriatrics and common issues that are facing them.
2. And understanding of the needs of the LTC facility – this will help you structure your time, assuring you are also seeing patients within the required laws and standards
3. Access to LTC facilities.
4. Communication System
5. Determine your billing process
6. Transportation
7. Insurance credentialing.

For NPs that are in states that require you to have a collaborating physician, this type of business will guarantee you will have one, as residents of LTC facilities are required to have an attending physician.

You will want to contact LTC facilities to determine their needs in getting providers in to see patients, both at required visits and for sick calls. Find out who the physicians of record are, as well as who is the facilities medical director. You will want to contact them and offer your services to manage their LTC residents. Understand, they will likely remain the physician of record and will need to make periodic visits according requirements and the resident’s status. Most physicians who maintain office practices as well as seeing residents of LTC facilities will welcome someone managing the needs of those patients.

LTC facilities are one of the most regulated health care environments today. It’s unglamorous (you’ll never see a TV show about LTC like you do with ER and trauma shows) and unpopular. The needs of the facility in terms of reporting to providers, getting forms signed off, etc are high due to regulation. However, you’ll find that with a system, you can easily provide an excellent service to the residents and facilities, and be rewarded for your efforts. It’s a business that can truly be a win-win-win for all involved.

I am frequently asked “what kind of business can I have”? While there are several forms of business, most NPs and PAs choose a clinical practice. And while most chose primary care, more are choosing a niche or specialty practice. One such niche is urinary incontinence (UI) care.

A continence practice is a fantastic opportunity for the advanced practice clinician. There are three very important factors for this type of business. First, there is a huge need; second there are few clinicians involved and finally, the evaluation, management and procedures are reimbursable.

A flexible, scalable model

What is nice about this type of practice is that it can be set up to work within office (yours or someone’s), a long term care facility and even within the home using a house call model. It can be full time or part time. And for those that already have a primary care practice, this is a great add-on service that can help build your practice revenues.

For those that like to work with a patient for a specified length of time, have them get better, and only see them back for “tune-ups”, an incontinence practice is ideal.

This business model is also scalable. You can start of doing it all yourself and as the business grows (if that is your plan), you can add additional providers and staff in order to accommodate your growing business.

Reimbursement

Medicare and most insurance companies will reimburse for assessments and procedures that are done in an incontinence practice. This will include your initial assessment, urodynamic testing (simple or advanced), microscopy, ultrasound, laboratory testing (both send-out and point of care), patient counseling, pelvic floor rehabilitation and more depending on how you set up your practice.

Often, tools that patients might use are hard to find and this can be an additional source of revenue. You can offer hard to find items to your patients in your office or through your website.

A Day in the Practice

As with any practice, your day will vary depending on location (office vs long term care facility for example) and other factors, however the basics are the same. Your job will include (but is not limited to):

• Evaluation of incontinence for pelvic floor dysfunction, overactive bladder or other issues that may be causing or contributing to UI. You will likely perform simple cystometrography as part of your workup.
• Counseling patients regarding behavioral modification, prevention and treatment of constipation, diet modification, fluid management as well as exercise they can perform.
• Treatment of the cause with medications and pelvic floor rehabilitation and electrical stimulation as indicated.

Getting Started

Like any business, you have perform the necessary analysis and evaluation to determine if this is the correct business for you. You’ll need to learn how to get reimbursed and how to maximize those reimbursements as well as know what it takes to operate a business. And of course getting started and finding your patients and referral sources (ie, the marketing) is key.*

Continence is a state that all people strive for. When it’s not present, it affects an individual physically, emotionally, financially and socially. This is an area that clinicians can make a huge difference in the lives of their patients. The need is great, the need is now.

For more information on building a business and building a continence practice, Helen Carcio, NP @ The Health & Continence Institute (HCI) offers an opportunity for the entrepreneurially minded NP to establish a lucrative continence care program of excellence.  She offers course intensive courses a few times per year and it’s a training well worth going to.

© 2011 Barbara C Phillips, NP

Billing incident to is a question I frequently find in my inbox, on listserves, social media groups and at conferences. I’ve even seen this discussed, often erroneously on medical billing and coding discussion groups and listserves.

In most situations, this applies to  Medicare, but it is possible that your state Medicaid payer, as well as some commercial insurers have adopted, or will adopt these rules.

So what’s the deal about incident to?  Many practices that employee advanced practice clinicians (NPs and PAs) like to bill incident to. Why? Billing incident to allows a practice to collect 100% of the Medicare physician allowable reimbursement. As you know, advanced practice clinicians (NPs and Pas) are allowed only 85% of the physician allowable. Since profit margins are low, it makes sense that a practice wants to collect 100%.

Of course, it makes sense for clinicians to be paid for the same work…but that’s another story for another time.)

However, there are several rules which must be met when billing under incident to. It is your responsibility to understand the billing that takes place in your name. Ignorance is not a defense should the office be investigated for billing fraud.

Here’s a run down on the incident to requirements (references at the end of this article):

1. The Advanced Practice Clinician must be employed by or contracted to the physician or physician group.
2. The physician must see the patient first, establish the diagnosis and the treatment plan and remain actively involved in the patients care.
3. The services must be an integral part of the patient’s normal course of treatment, and are generally included in the physician’s bill.
4. The APC is follow up on the established treatment plan and is NOT addressing any new problems.
5. The physician must be immediately available and in the suite at the time the APC is seeing the patient to follow up on the previously established plan.

There are several problems here for any APC. The most common is the fact that when we are seeing patients, there is almost always something new to be discussed. A visit is rarely just about the hypertension and the medication that the physician prescribed. A new problem that must be addressed negates the visit as being incident to.

For those of us that are practice owners, it is highly unlikely there is a physician on the premises and we are not employed or contracted to a physician or physician group and a physician has not seen the patient first to establish the diagnosis and treatment plan.

As you can see, meeting the incident to rules is something that does not happen in our day to day clinical lives, regardless of who we work for and how we practice. It’s imperative that we understand and adhere to these rules, and that we educate those we work with.  If your practice is billing incident to, you’ll want to proceed with extreme caution. Being associated with healthcare billing fraud is something you want to avoid…like the plague.

You can learn more about the Medicare incident to rules as well as brush up on health care fraud at the sites listed below

• MLN Matters Number: SE0441 http://www.cms.gov/mlnmattersarticles/downloads/SE0441.pdf
• Medicare Information for Advanced Practice Nurses and Physician Assistants http://www.cms.gov/MLNProducts/downloads/Medicare_Information_for_APNs_and_PAs_Booklet_ICN901623.pdf
• Stop Medicare Fraud:  http://www.stopmedicarefraud.gov/
• Office of the Inspector General:  http://oig.hhs.gov/

(c) Barbara C. Phillips, NP, All Rights Reserved

Time to Clean House!

Now that you have an understanding of the issues involved in selling a practice, let’s look at what you can do to prepare and position your practice for eventual sale.

Before you ever think about listing your practice for sale there are a number of things to do … in other words it’s time to clean house! You might compare this to getting ready to sell your home. You don’t just put your house on the market; typically you make some repairs, spruce up the house and the yard. Because a clean and clutter free house shows and sells better!

The same is true for business! Nobody wants to buy a messy business or a practice that looks bad: looks bad to the eye and looks bad on paper. Here are some of the areas to examine and get in order, preferably months before ever listing the practice.

1. Business and accounting records: your records must be up to date and complete.
2. Medical records: make sure all records are up to date and well organized, particularly if they are paper charts.
3. Accounts receivables: make sure your accounts receivable (AR) has been worked and is current; resolve any outstanding disputes.
4. Office policies & procedures, employment, training and safety manuals: make sure your documentation is up to date and complete.
5. Tax records: all must be up to date, organized and complete. Resolve any outstanding tax issues including employment, federal, state and local taxes.
6. Inventory your medical and office supplies  and equipment.
7. Staffing: fill any necessary open positions.
8. Clean and brighten up your office if need be. Remember first impressions are everything!

Next then, how do you go about finding a buyer for your business and what price should you ask? As you may suspect, determining the sale price for a professional practice is not an exact science. Most practices will be sold for multiples of available cash flow, annual net earnings, annual gross collections, or any number of formulas.

With respect to finding a buyer, there are many options available to you as well. These range from contacting your local hospital to getting your business listing in front of the graduating class of different medical schools, to placing newspaper and online ads.

Another venue to consider is to utilize the services of a business broker, just like you would utilize a real estate broker when selling your home. A business broker will be able to assist in setting a realistic sales price and list your business within their network.

Visit the links below to get information about the services different brokers offer and to find listings for medical offices that might be similar to yours. Please note we do NOT endorse or recommend these brokers, the links are simply included for your information.

• http://www.medicalbusinessexchange.com
• http://medicalbusinessbroker.com
• www.medicalpracticebrokers.com
• http://www.businessbroker.net/Keyword/Medical-Businesses_For_Sale.aspx
• www.sunbeltnetwork.com
• www.vrbusinessbrokers.com

Finally, take time to consult with both your legal and tax advisors to help you plan for and construct a favorable sale. And remember, anything will sell as long as the right buyer comes along and the price is right!

©2011, Johanna Hofmann, MBA, MAc, LAc. All Rights Reserved.