Home Forums Discussions Problems DEEP THOUGHHTS by Walter Handy

We had interns before. Selective hiring process to much a disruption to a small clinic workflow. We let them shadow our MAs, then work on our AC, many of them made lots of mistakes, like you can not drive doesn't matter how much you watch.

Our MAs became full time trainers. With larger practice, you can spare one MA. After so many interns later we got so reluctance to get them in. Many MA schools still base their teaching on paper charts.

Another example of 'our' modern referral process. We use one centralized Excel program to coordinate referrals. One patient might have multiple referrals. Each time a referral done then we date it in Excel. Older patient family members calls 'multiple' times complaints about their relatives not being accepted because docs have not received paperworks from PCP. A quick glance at our Excel, MA can tell right away if referral paper has been done and 'received'. Many times, we faxed it over and other office kept saying not receiving it.

Another sensitive issue in EMR world, those who are not going for higher degrees tend to have lower tech attitude to work in higher tech environment. We have couple of ready for IV league students, they were fantastic, very quick to learn.

Like Bert telling me to get an Ipad to have better fun with techno but seems younger people good with text/game/twitt...but not tech working environmment. Computers not yet forgiving per human sloppiness or stupidity. They force us to live in this nightmarish world, then they need to pay double so we can hire more peoples to do work of one.

I like starting with the noobs, if they are good,and training them up right. But this does take a lot of work. However, easier than untraining bad habits or dealing with someone so 'confident' they will stick an instrument in someone's ear or give medical advice over the phone. (Errr, that's probably not CP, just indigestion.. )

I'll probably get blasted for this statement. So Be It.

In our experience, the staff at many specialists offices are plain lazy. (BAMM!BLAST!) We were experiencing patients calling the specialit's office and asking if they had received their referral. They were told "no" and would then call us complaining about it. We finally had one patient that the orthopedist asked why she had cancelled so many appointments. She had 4 or 5 referrals for the same visit in her file. The staff just says "no" without checking. They also will refuse to go to the insurance company's website and print it off. Well, we no longer will fax a referral to an specialists office except under urgent conditions. If the staff wont go to HIP's or Oxford's website print it off, and the patient doesn't want to wait for me to prepare it, we will no longer refer to that specialist.

Wayne,
I agree with you. Many of the specialists in my area have their own "referral form" they want you to fill out. Often it is a photocopy of a photocopy of a photocopy. Very grainy and skewed. I hate it when staff are too lazy to locate the orignal form and keep making photocopies of photocopies.

Even though I PC fax a perfectly legible demographics page from my practice managment program which has all the insurances and numbers and even eligibility checking already done, they insist they must have "their form" done. Of course I PC fax a referral from amazing charts too and my last note and appropriate labs.

Ok, I'm off my soapbox. I know some specialists get irritated when the PCP issues a consult to the cardiologist for "heart problem" but we are a lot more specific :-)

Patients also irritate me when they call up, haven't been seen in 8 months, and want referral to specialist XYZ for some vague problem that I have never evaluated them for. The specialist gets upset if they don't have specific info. Patients don't understand this and get upset when we ask them to come in for a face to face appt.

Years ago our policy became "WE DO NOT FAX REFERRALS". Per our insurance contracts, all providers who participate must be electronically connected and access their referrals on the internet. Patients are also instructed how to access their own referrals on their insurance websites. Since it is only a payment issue for the specialist, they should be motivated to learn how to use the internet. Our patients have been highly educated by us on how the system works. If I have to pay someone to do the referral, they have to pay someone to pull it up.

I am lucky enough now to live in an area with very little HMO penetration. I accept no HMO's. Patients for the most part have open access to the specialists and don't have to go through me. But many specialists still insist they do. I think it is actually better patient care if they do.

Thankfully, I have rarely had to do this. Even when they send one over, I just send a letter and copy of my note, to which there is no objection. I think I would change my referral patterns based on this, if there is a large selection.

My worst story on this was a dermatologist that we used to refer to. The patient had HIP insurance (commerical), and they require online electronic referrals and the specialist can just print it out at the office--if the staff will just take the time to sign on and print out referrals.

This elderly patient had a suspicious-looking mole, so I did the referral and gave it to her. Well, her appointment was on a holiday and we were closed, but the derm's office was open. Since she was kind of anxious about all this, she forgot to take the referral with her. They refused to see her and refused to either sign onto HIPs website and download it, or CALL HIP's automated telephone system to verify referrals.

When she told me the next day, I made a new referral to another derm who saw her right away. And it was some type skin cancer.

Needless to say, we have never referred a patient to this guy since. That was 3 yrs ago, and we do alot of derm referrals.

I am back. Been busy with multiple staff members leaving . Three good employees graduated and got higher paying jobs (RN/IT/Accounting)....what to do to keep them...not much really, they got 40K+ offers. Sad for smaller practice...

Thanks to you all, my beloved doc had many more better sleeping nights... (summer a little slower) but we should be well prepared and ready for Fall onslaught. Also a slight improvement in billing per new medicare preventive guidelines.

I just saw a new topic that our friends talking about billing service (EZ Claim mentioned) and like to know how difficult to bring it in house.

Since start, we used an outside billing service, 6 percents but I think that eating into our profit. To lessen doc stress at same amount of patients and higher monthly expenses (like our new office lease after 3 years, staff salary increase... ).

Pros and Cons of in house billing? As I've been at the office more last couple weeks, I could see that for family doc CPT codes 80% same, if the ins verification done good then claim denials quite low. My doc doesn't trust me in handle billing as I am somewhat not caring much about money, born rich mindset. But even for my older brain, couple mistakes here and there could still be less than 3, 4 K monthly billing charge, 15-25 patients a day
.

Hello Walter:
I'm glad to hear that things are going better for your wife and, consequently, for you as well.

There are numerous older posts re: office billing or 3rd party practice management software, you might find a search for those to be very fruitful.

Also, Let me encourage you that as new questions arise, go ahead and start a new post. It will be easier to respond to it, and the answers given will be easier to search for at a later date.

Hope you are taking some time to enjoy life!

Yeah, it might be too much... in a single comprehensive topic. I did search but found nothing related to my billing question above, touchy subject? I might ask Bert to help change the topic to Basic Life/Work balance in EMR Time. I almost got it all here. Tiresome to read but fun. I could go thru it in 15 minutes. A new doc can read this topic and figure how to reach his/her work/life balance.

I am old school, same mentality like docs of old age, a God like figure, could treat everything. To break thing down is quick and to the point but somehow loosing that good feeling of a know all. So could I please have your dollar idea here or in the billing/coding section. I'll copied it back here if our admin doesn't mind.

I can name it anything you want.

Bert, would you please help me change my topic title into a more serious and 'sounding' name like 'Work/Life Balance for Solo Docs'. I copied that from my IBM time, that 'work/life balance' is such a joke. One of my colleagues then died of heart attack working late to meet deadline. He got a million in his bank account at the time.

'Walter -- thanks for the post! I'm struggling with the same topic. We have an outside biller that gets 8% of the collections for the billing (not copays or cash paying patients on the day of service). I've submitted a few 10-15 "clean claims" with Office Ally and that worked fine and quick turnaround on payments (10-15 days). My concern though is having to do double entry since it is not an all in one product. You'd have to use some form of practice management software to manage payment on claims, what is pending, etc. to avoid missing out on payments. Office Ally is free for most of the services, so one huge benefit.

I haven't used EZ Claims before but that looks promising with the direct interface with Amazing Charts. I've seen some information on Kareo and wondering if anyone has any experience with this product for practice management and billing. I'd love to see what Amazing Charts has coming with their Practice Management program to see if this will provide an all in one option to bill, manage/keep track of payments, etc.
_________________________
John Carstensen, MD
Carstensen Internal Medicine
Key West, FL '

John, our billing company uses Kareo and setup website access for our staff including myself. Probably all billing software would be same just need time to be efficient.

We pay 6% so your 8% is too much. I think billing price structure based upon old paper claims, too much hassle then but since claim moving into web base programs, all claims verified before sending to ins companies,chances for mistakes should not be that high. We have our trusty staff in their spare time to input payments info into AC accounting, so missing claim easy to spot.

Kareo tracts claim and let users know if claim has been approved or rejected. My concerns is all billing data and insurance/medicare payment info is with the billing company, how to transfer all that back into our control smoothly.

Per my experience with most things in life, any change is ready for transition headache. Anyone know how to do with this transition process, to fire a billing company and take billing in please give your 20 to a dollar sense. Seems we got into a messy addiction started out by outsourcing.

Quote from Billing/Coding section:

'Notice of Full Disclosure: I am IT and software development for a billing center.

Let's be clear about something: Hiring a billing center to do your billing is nothing short of outsourcing. And outsourcing is about one thing: money.

The question is does your current billing center save you money?

1. How much are you paying your employees now?

2. How much does a billing center charge?

3. What are your current collection rates through the patient statement?

For example, let's say your are a single provider podiatry clinic and you have four people working on your staff. You have the office manager, the front desk clerk, the assistant, and the biller. The biller probably costs you at least $20,000 per year in salary alone. Plus, you have the billing software you have to pay for. A billing center that collects 94% of all money billed out for you through the patient statement and charges you 8% is going to beat having your billing in-house hand-over-fist no questions asked.

The question then, is finding a billing center that is that good.

Other things to consider:

1. Does your billing center offer a termination clause whereby either one of you can terminate the relationship with a three day written notice?

2. Does your billing center guarantee that you will get your data in an easy format, such as CSV, should the relationship terminate for free?

3. Does the billing center provide monthly reports along with their invoice to show you where things are and how things are going?

4. Does the billing center provide you with access to your data?

All things to consider.

JamesNT


Edited by JamesNT (Today at 12:03 PM)
_________________________
James Summerlin
Information Systems and Software Development
'
end quote

James, yes that what we had thought about when we started our billing outsource. I excused myself from billing involvement at the time. Our billing service company is small and local . We did not pay much attention to all point 1,2,3,4 you mentioned then.

My point is not how expensive the service if you hire a full time billing staff, billing service is more cost effective no doubt about that also no worry about staff turn over, take away most billing headaches. But if solo doc started out with heavy debt or has spousal support (who working for free or in exchange of romantic candle light dinners, not talking about expensive vacations many times a year here) then doc can save 6-8 percent in billing code. For our practical situation, client base almost same due to doc work/life balance issue, all expenses are up.. to the point, gross income is much higher than national average, but net income is much lower. We are not that efficient compared to larger practices.

One example, most ins try to squeeze dry smaller docs. As family PCP we have to stock expensive preventive/treatment injections, but they only pay couple dollars higher then purchased prices, hundred dollar shots are norm. One bottle might be for five shots, but if staff makes mistake then only 3, 4 shots available, wow, we might want to save money on 0ne dollar paper tissues but lost tons of money in med. Drug companies bill us thousand of dollars every month.

Open a can of worms here, any inputs on how to deal with this issue? I am thinking of create an inventory system on med inventory to control ins and outs, like a fancy loss prevention term, but my doc said that might create another burden on staff, but that should be done.

So back to billing question, now you could tell that we don't make enough money and want to take the billing back, temporary at least, until we feel comfortable enough or make same salary like doc working for someone else. Then 5-7% increases in profit. My friend said he doing his billing now later at night but he is still able to manage it without his spousal support. He also said many older docs in area still doing paper submitting themselves, he lives in a smaller town.

As you are an insider, how to re channel all ins info back to us smoothly and only give billing company tree days notice. Like job security everywhere, a fire not that simple, it might back fire.

There are other advantages to doing your billing in house. You can reduce your other staff positions and cross-train the biller to fill in up front or in the back when other staffers are off. A solo doc should not really need someone doing nothing but billing 8 hours a day. The employees also clean, do light maintenance tasks like replacing the front door threshold and grill steaks for lunch out back.

Leslie, what time is lunch break?

From Billing/Coding:
Quote:

'
I'd be interested in how many doctors do their own coding/billing submissions. For internal medicine, we don't have a ton of codes to worry about -- so 95%+ are fairly straightforward. I just have a hard time signing those checks for the billing company when they are coding what I tell them to already. They are good at following up though on unpaid claims -- so is it worth the 8% for this or are you better of doing it on your own or with the help of the office staff on following up on these claims. Just curious to what other doctors are doing.
_________________________
John Carstensen, MD
Carstensen Internal Medicine
Key West, FL

'
end quote

Over the years, we have tried outsourcing the billing a couple of times. Both attempts were disasters, and James touches on some of the reasons.

First and foremost, all of your billing data... that is, effectively, all of the money you have earned that is not in your bank... can now effectively be held hostage. If you decide that the arrangement is not working and wish to fire your billing service, you have to assume that you will not be on the best terms. Sure, maybe there is an agreement to get a CSV file, etc. but the billing service will at this point have absolutely no incentive to do so quickly or have any interest in resolving issues. ("Here is your CSV file; oh, what do you mean, what do the numbers in each of those 35 columns represent? We said we'd give you the data, and there it is. We consider the description of those fields to be a proprietary part of our source code. We did not say we would translate it for you or assist in putting it into your new program/service. That's your problem.") In a couple of cases, the service suddenly decided to impose huge fees to get our data back. Importing your billing data into a new system is never as smooth as it is supposed to be, and there is always corrupt data. Having been through this maybe 5 times over the years, the only way that works is to keep the old system alive on a computer in the corner someplace and just start fresh, and re-register everyone in the new system. If you don't have access to the old system, then you are left with a mess, or perhaps a foot high stack of printouts.

Yes, it looks a lot cheaper on paper to outsource. But it is necessary to look at this a lot like getting married. You have just handed access to your entire life savings to this sweet young thing, and it is amazing how expensive it becomes when the time comes for a divorce, and how ugly your relationship suddenly becomes. Keeping it in-house is cheap insurance.

I agree with David. No one is more interested in your money than you. Knowing where it is and where it is not is critical. When I changed from a Dos-based billing system to a Windows one we did exactly what David suggested....we kept the old system until it was cleared out of old charges, either paid or written off, and entered all new charges in the new system. It was a little hectic at times but ended up working out with very few complications. After the old system went untouched for a year, a paper AR was printed out and stored and the system was ditched.

Quote from CrestonDoc/Coding and Billing :

'

John:

We outsource billing at 7%. Ithink I do this for the convenience. Yet, I know they don't care about my money as much as I do. I don't have the right staff to help with bringing it back in house....and I'm getting a little lazy about wanting to take on another job.
_________________________
Tom Young, DO
Internal Medicine Consultants, PC
Creston, Iowa

'
end quote

Quote from Gregg Philips /Billing and Coding

'
I find the main advantage is staffing reliability.
I am in solo practice. I could get by with a receptionist and MA and have the billing outsourced. But I prefer to have 3 staff members, reception,billing and MA. When someone is ill or goes on vacation I can get by with just 2 people. This would not be the case if I only had 2 employees. I would need to find temps for coverage.
The other issue is SoCal is the paperwork for insurance referrals, the outside billers don't handle this.
The fact that I have full control of the process is just an extra advantage. I have been lucky and have only had 3 different people doing the billing in my 28 years of practice.

Greg

'
end quote

Outsourcing billing for a solo doc is crazy in my opinion. This isn't hard at all and doesn't take a lot time. I code all of my own stuff...many surgeons do. My office manager punches it into the PM system and off it goes. She spends about 5-10 hours per week on billing. That's it. The she helps run the clinic. You don't need an extra person. It saves me tons.

Walter,

You have to work on quotes. I have no idea what you just wrote or in what context.

Solo practice guy here. I used to have an inhouse biller. She was excellent. She could do reception, billing, and medical assistant work. Then she went to R.N. school and went on to bigger and better things.

Currently rather than outsource, I "co-source" billing and pay about 5%. We enter charges into the practice management system. They are scrubbed immediately and checked for errors. If any obvious errors we correct them (ie, like "patient is enrolled in a hospice, if you are not an employer of hospice enter modifier GV to indicate such".

Then the claim goes off to the billing company. They send it to the primary /secondary/tertiary insurance. They pay clearing house fees. They apply the insurance and patient payments. They get on the phone and followup on unpaid claims. They adjudicate complicated claims where there are takebacks and rebills. This is where I think billing companies excel. They do this stuff all the time. Clean claims that go through on first pass that are paid are easy for a solo office. Throw a monkey wrench into the claim and it's no longer easy.

So in summary, I think that the doctor should choose the codes. However, if you are in solo practice, In my opinion , better to let professional followup on claims, unless you are just dang lucky enough to be able to employ an experienced biller.

One more point, I will second what Leslie and someone else said. We switched billing systems back in 2002. We just kept the old billing computer going for like 4-6 months and put all new charges on new system and manually inputted patient data into new system. Maybe things have progressed since then, but there is little incentive for old billing company to hand you data on silver platter in easy to import format.

Here is another tidbit from our experience of using a biller we did not "own."

The billing service gets a fixed percentage of what they bill. They need to keep their costs down as well, so they hire the minimum number of employees they need. On any given day, they get charges from several different doctors to process; multiple $100 charges from the primary care clients, $3,000 charges from the proceduralists. It takes the same amount of their time to process one as the other. It does not take a genius to figure out where the billing management is going to direct their employees to put the effort. I got real tired of being their lowest priority.

Taking a break from Game of Thrones to respond...

I can't really say any of the responses here surprise me at all. There are a lot of billing centers are there that just plain suck. I know because I've had to clean up their messes. At the same time, I've also met what I thought where potential clients that had no reason to use our services. They had things they way they wanted them and had a good biller on staff. Although we could save them some money, it's hard to make such a big decision when things are overall good.

On the other hand, out of the 80 clients we have many of them were near bankruptcy when we met them. Either they were working long hours (seeing patients during the day and doing billing at night), conscripted a spouse who didn't want to be there to begin with, or had some incompetent dolt doing their billing in-house.

So when you add all this up what do you have? Simple. Outsourcing isn't for everyone but a godsend for some.

Surprise, surprise.

JamesNT

@ Bert, I didn't want to miss any responses from billing and coding. Ah, wrong term used what I was thinking..

Life is not getting any simpler than this. I love Dave inputs (on many things), Alaskan honesty or remote roughness your choice.

When we started our clinic, we didn't know anything about billing and 6% percent then was not that much or greed comes with time. 3, 4 years later and 6 percent of 200K not same as 6 percent of 500K or going 1 Mil. The agony of writing out 6% of something we feel we could do ourselves is much higher than 6 % itself, not taking into account that 6% of 'easier money' then might be equal 10-12% EMR time.

We are being pushed hard, not much control of anything anymore. If payments getting lower, expenses higher and billing rates still sick at 5-8% then billing outsource pros is not longer an attractive option if not 'crazy' option like Travis'. Also web based billing programs not that popular 4 years back then.

Solo docs have to adapt to survive, I think billing model also need to be changed.

My 2 cents for new doc still thinking of solo practice is that you need to investigate in doing billing yourself first per web based programs out there then to decide .

Walter, I didn't get that?

Bert, I just copied (whole) any responses in 'Billing and Coding/ Billing In House - Pros and Cons' back into this 'Basic Life/Work Balance in EMR time' topic. I should put term 'copy' instead of 'quote'. haha, math term, this topic is a superset of any inputs related to solo doc work/life balance.

Another question for established docs. I mentioned about this problem previously.

Due to highly competition in our area, we have to stock immunization injections and others. We currently not accepting medicaid so we have to buy them at market prices (low volume pricing). Some injection bottle cost 500-1000 each. Insurance pays almost same cost plus injection fee (couple dollars). It clearly that we are loosing lots of money either by keeping them in the fridge or MA mistakes. I've read and many docs don't do those immunization or expensive shots any more but due to our highly competition environment, we still have to do those injections. Drug companies withdraw funds directly from our credit accounts and monthly cost are even much higher than billing fee ( I complained about monthly 6% billing fee )...

I find it is not worth my while to compete with the pharmacies and clinics in the area. I keep state supplied immunizations for kids but all adult immunizations I have the patient get through their pharmacy. I may lose some business this way but it sure decreases the overhead of stocking expensive vaccines.

I do adults only. I keep Pneumovax / Tetanus-Diptheria and Influenza onhand. I have some Zostavax but that is a goat rope to get reimbursed on as you have to bill online to Medicare Part D. I used to do more vaccines like Hep A , Hep B, Meningococcal, but found the reimbursement poor and also ran into vaccine expiration issues.

Td only here. I used to give them all. Too expensive up front and too bothersome to have to keep records on my refrigerator temperature.

I see a lot of kids so am pretty much forced to stock vaccines. It's one of my least favorite aspects of private practice, especially since many patients seem to think I'm making a big profit on them.

My meningococcal supplier maintains the stock in the freezer and only charges as they are used, which is working out pretty well. I wish other vaccine suppliers would do it that way.

Any efficient way to tract vaccines/supplies in inventory?
Our MAs let my doc know when to order more ....

We have two MAs certain busy days of week. I suggested we'd need another computer in the stock room ( my beloved doc doesn't want any more computer! and concerns about more workloads for MAs ).

We never kept tracts of how many patients and numbers of shots given. I don't know if child wellness payments (once a year) are more than enough to recover these source of income leaks. I don't think we can drop vaccination as patients would look for others who can provide a one stop service.

Seems most of us don't do anything to the vaccines/supplies inventory control other than checking fridge temperatures..I'll try to do the inventory control in our clinic myself and give you an update and how to list. One of our friends give a company credit card to his trusty employee who handle all the orders for him. He always keeps more than 10K in card's available credit. My wife is much more prudent than myself, like looking for a cheaper vaccines suppliers, but not knowing much what is going on in the back room.

probably the cheapest place to get vaccines is from the actual mfg. Purchase direct from Merck, Glaxo and Sanofi. At least for the adult vaccines. We don't do peds.