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.

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

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

Family, partner, stranger or just walk away…which is right for you?

When it comes right down to it, there are only a few ways to getting out of your professional practice. Only you can determine which option is best for you. Here are some points to consider.

1. You could pass on your practice to family. However, a professional practice, like your primary care practice, may present a bit of a challenge. You may not be able to give your practice to a family member, unless he or she is professionally qualified to work in the business or is willing to hire a provider to do so. Therefore option one generally tends to be more feasible with small businesses like crafts stores or gift shops rather than a professional practice.
2. Another option might be transitioning the practice to a partner. If you already have a partner in your practice you might simply sell your part of the partnership to your partner (as outlined in your partnership agreement). Or, you may consider bringing in a partner(s) with the intention of transitioning the practice to the partner(s) within a certain time frame.
3. Of course, you can always sell the practice to an outside third party: either to another provider, provider group, local clinic or clinic chain. However, depending on the type of practice, the practice structure and overall condition of the practice this may be very doable or proof to be challenging.
4. And lastly, you can simply walk away from your practice. This option is always available to you. Here you simply notify your patients and close your office. You may choose to sell any business assets or donate them, it’s up to you.

As you may have already guessed, selling a professional practice presents unique challenges different from most other businesses. Here are just a few of them:

1. Typically the owner, you, provides the core services of the business.
2. Patient loyalty is with you and not with the “business” per se.
3. Goodwill, an intangible asset, is the main asset for most professional practices (unless the practice owns real estate and/or high ticket medical equipment).
4. The selling provider is concerned with the quality and continuation of care for his/her patients.

These issues may take on greater importance depending who will buy your practice. A clinic chain or provider group probably won’t lose any sleep over any of these issues. However, if you sell to a solo provider or small partnership it will be a different story. Here are some of the questions a solo practice owner might ask:

1. Is the practice solid?
2. Is there enough goodwill and can that be transferred to me?
3. Will the patients accept me? Will it be a good fit for me?
4. Will I be able to retain the established patient base?

To counter these issues and increase the chances of success, frequently buy/sell agreements provide for seller assistance during the transition period. This simply means that the seller agrees to help the buyer, the new provider, either by working with him/her side by side or by introducing (and hence endorsing) the new provider to the established patient base. Either way, providing seller assistance as part of the sale will help make the transition go much smoother.

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

Recently, I responded to a thread on the allnurses.com forum where the issues was about patient care vs the business of medicine (my summary).  Many nurses and nurse practitioners, as well as other clinicians, do not understand the business of healthcare and how money is indeed the major player. Healthcare is not free, someone is paying for it. And early on, I didn’t understand that.

While working as an RN (and later as an NP) being paid an hourly wage, or even when on salary, I never worried about the overhead cost of seeing patients. Now, as a practice owner, I understand the reality all too well that time truly does equal money. Unfortunately, not everyone understands this reality.

Stop for a moment and consider the overhead (ie, cost to run the business) of any practice, hospital, community clinic. Overhead include (and are not limited to): lease/mortgage; salaries and taxes (often the highest/2nd highest expenditure); utilities (heat/air, water, sewer, garbage); phone and internet access; liability and business insurances; licenses; housekeeping; office supplies; medical supplies; lab costs, including those utilized for POC); billing personnel or billing service (quite high usually); EMR costs; professional services such as the CPA and attorney and a myriad of other costs…before the practice owner ever gets a dime.

Now look at the other side of the equation: a practice owner only makes money when patients are seen (unless you are seeing pts under a capitated plan – which also has it’s limits).  There are several ways to look at this: cost per patient, cost per day, break even points.

Let’s look at a simplified example with made up numbers. If the overhead cost per month is $5,000 (this would be a small office), and your average reimbursement is $40.00 (it’s often lower than this for Medicare/Medicaid), then the practice (and often the practice owner) does not make any money until 125 pts are seen that month. However, just because the patients are seen, does not guarantee that the practice will get paid.  I am only half joking when I say that insurance companies are not in business to pay your claims.

There are many more variables that go into this, but I write this to give an example of what every practice owner must consider. Nurses and Nurse Practitioners and other clinicians who are employed, we would do well to learn a bit about the business of healthcare.

No one can provide services for free. Even if you volunteered your time entirely, someone has to pay for the cost of providing the service. There is no such thing as free health care. Period. Someone is paying.

And as a professional, don’t you deserve to be paid?

Should nurse practitioners communicate with their patients via social networking sites? This is a questions I am frequently asked. It’s been a topic of conversation on email list, social networking sites and at NP conferences. While I have written about it before (link to Advance article), I think it’s time to revisit this question.

My answer is simply no.

Here’s the deal. Communicating with your patients on a social networking site opens you up to potential for HIPAA violations. Additionally there is the possibility that patients may ask emergent questions which you may not see, or answer in a timely manner. And any communication online is subject to discovery should there be any legal incidents.

So how do I recommend that you communicate with your patients online? I think one of the simplest ways is for a nurse practitioner or the practice to have a Facebook page that is simple for businesses. The page is used to make practice wide announcements, do some patient education and remind patients to come in for things like flu vaccines or sports physicals.

It’s highly advisable to have a disclaimer on the site letting patients know that if they have questions they must contact the office directly as the FB page is not monitored regularly. You may even want to consider disabling comments on your page .

Make it an office policy that you and your staff will follow. Communicate this to patients. Let them know they can “Like” your page in order to get up to the date information and education from your practice, but it’s in their best interest to keep communication to the traditional lines…at least for now.

I love social media as a marketing tool, but I don’t feel it’s a smart communication tool. As far as I know, there has not yet been case law regarding communication via social networks. But as we all know it’s only a matter of time.

A perk of being a Nurse Practitioner or other Clinician Own business is that you have the ability to contribute to your community, not only through your services, but also by providing jobs. However, finding the most qualified individual for the job you offer, can be a challenge.

In most businesses, the cost of staff and related human resources expense is often the biggest part of overhead. Thus it’s important to hire and retain good personnel in your business. However, most business owners will tell you it’s frequently difficult to find the right people that you can work with. Let’s review some ways you can increase your ability to attract the best candidates to the interview table.

1. Get very clear on exactly what it is that you want someone to do. Have a clearly written job description.
2. Identify your ideal employee. Just like in marketing where you identify your ideal patient, you want to identify your ideal employee. It will make it much easier to craft the announcement of your opening with clarity.
3. Clearly identify instructions in how to apply for the job. You may consider including a small phrase that you want them to reference. This insures that they have actually read your requirements and instructions. This will immediately eliminate those who cannot follow directions.
4. Ask them what they feel their biggest strength and weakness are.
5. Then ask them what their former employer would say their biggest strength and biggest weakness is.
6. Let them know up front that prior to the final job offer they will be asked to arrange for a reference check interviews between you and their former employer and co-workers. This will likely reduce your application pool further – leaving you with individuals are motivated go-getters.
7. Depending on the position, I will often give candidates test scenarios to gauge their response time, creativity and composure. The scenarios are usually everyday scenes from any practice, with one or two “emergency” type situations.
8. As you narrow down your pool of applicants, consider doing 2nd or even 3rd round interviews.
9. Considering doing a background check on the final individuals. There are many firms that for a small fee will do background and criminal checks on individuals for you.

Many people are applying for jobs these days, but not everyone is qualified for the job you may be offering. You’ll want to narrow your interview process down to the most qualified individuals. Taking the time, as well as the expense to hire correctly to begin with promises to deliver the right hire and a good return on investment.

©2011, Barbara Phillips, NP All Rights Reserved.