Happy Nurses Week!  Hear more about Nurses and Nurse Practitioners and the Affordable Care Act.

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

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

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

Practice acts (ie, what we are allowed to do legally) for Nurse Practitioners vary across the country. Many now have practice acts that allows Nurse Practitioners to practice autonomously, which is a good thing as NPs should be able to practice to the extent of the educations preparation and experience. Even the Institute of Medicine’s report attests to that.

However, Nurse Practitioners in Florida have been faced with lots of challenges. One of them has to do with prescriptive rights.

The following interview was done on a local Florida station interviewing Jennifer Scott, NP. Take a listen to what she has to say. Feel free to spread the word.

You can learn more about Jennifer and what’s going on in Florida at her blog www.ARNP.blogspot.com.

By the way, this years annual conference for the American Academy of Nurse Practitioners, the largest NP conference in the country is set to unleash thousands of NPs in Florida. The possibilities can be endless!

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.

I am often asked by Nurse Practitioners which states are best to own your own practice/business? Let me start off by saying that you can have your own practice in any state by following what ever rules and regulations (scope of practice) are in place.

In addition to looking at practice acts for each state, you’ll want to look at the rules and regulations for business for that state. Can you own a practice outright? Do you have to own the practice with a physician? Who else can own a practice with you? What other potential barriers are there to owning a practice or any other business in your state?

Obviously the first place to start is going to be with your own state’s board of nursing to learn about your own practice act. Make sure you check at least annually, as SOP is constantly being update. What if you are looking for other states? My go to reference is the Pearson Report, which is updated annually and an excellent business resource.

That said, according to my list and information I have from NPs around the country, states without any sort of collaboration are included in the image below. Those with an asterisk are those with independence after meeting a requirement. This slide is from a presentation I did last year, which will be updated to reflect changes that took place in 2011.

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

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

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

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

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