Home Forums Discussions General Discussion Be careful with templates!

I just went to the Kilo Diabetes Symposium in St. Louis and thougt I would be upset that they had a talk about health care reform. I am glad I heard it. The speaker was a jd/md named John Irwin from Ohio who put the fear of God in the entire audience.

He reports that one of the areas that Medicare deficits are going to be made up is from AUDITS. He reports that they will come in an review maybe 25 charts. If they find "issues" they can extrapolate that to your entire practice. The HEADHUNTERS/AUDITORS get to keep 12.5% of all the money they recover so they are very motivate to find problems.

Happy Sunday!
He especially warned about the use of templates. If you have cookie cutter looking notes, this is considered FRAUD and they can send you up the river or take your money.

I use templates and have been changing them as I go, but I am going to watch even more carefully.

IGNORANCE OF THE STANDARDS IS NOT AN EXCUSE. Can't blame the biller, the front desk, etc, it is all on our shoulders.

He gave several horror stories.

I am just going to add this to the list of motivations and business reasons to reconsider taking government payer money in the future.

Of course, I can't take David's thunder - he makes a great argument about his reasons.

Not taking Medicare or Medicaid isn't a financial option where I live and practice.
It would be nice to be a concierge doc or cash only, but that isn't financially feasible.
My seniors are some of my favorite patients-many of them are lucky to be able to afford a supplement, and/or buy part D.

It would be much simpler.
He also said that the private payors are employing the same techniques in a slower, but soon to be more aggressive fashion as they watch and learn from the Medicare auditors.

I understand that the math isn't going to work for every practice.

Here are some prime motivators we have heard, and then the math you can consider.

Motivators:
<1>Their most complex and least compliant patients are government payer
<2>Patients that have no insurance and are compliant, but you cannot take less than the government price - that they don't pay.
<3>The increasing risk that the government comes in and destroys your practice based on their unilateral evaluation of your charting - or worse.

Considerations:
<a>How many cash paying patients could you see if you weren't seeing 1. above?
<b>How many 2. patients could you see if you could apply your judgement to what they can afford and you charge?
<c>If making the change means less patients - hours open, do you have the options to do house calls, SNF visits, or other medicine that doesn't require a full office staff overhead load?
<d>How much is taking 3. off the table worth?

For many reasons, our nation and it's medical system are headed for some wrenching changes. It irritates me that independent Doctors are the ones that expected to take it and keep saying thank you.

Great thoughts Indy.
Thanks
Makes me wonder if I just did a flat rate and pull it off.

The irony is playing gotcha.
The govt forces us to use an EMR that can have some ways of making our lives more simple and then they say we can't use the tools (like templates)

uggghh!

Thanks for the kind words.

I have done hundreds of cost-benefit analysis business models, and would be glad to help you craft a model that reflects your active patient population and billing/revenue history over the last year or two.

We have actually invited a MD/MBA to do one of the sessions (not sure if it will be a one of the CME sessions) when we get together in San Diego in March, because we believe that Docs could use more business insights.

Unintended consequences. Bureaucracies are largely staffed by low to mid-wits, and so they tend to craft rules that fit their unimaginative proclivities. Now mandate that Doctors start using software tools to document patient encounters, and then pay the Doctors based on how well they use those tools.

Not surprisingly, Doctors tend to be smart, motivated, detail-oriented people who can quickly adapt.

Now comes the hue and cry that bureaucrats and politicians are "Shocked!, Shocked!" that Doctors are better documenting using the mandated tools, and that leads to better payment to those Doctors. That really makes me wonder if the mid-wit brain-trust figured that you give Doctors 'extra work' in these software tools, and they will see less patients or otherwise bill less.

Smart people react to changing circumstances, they don't do less.

A recent example with specific stats available; the UK instituted a new millionaires tax. In 2010 there were 16,000 that fit that population, in 2012 the number was ~ 6000.

This is just what we did when we made the decision to opt out of Medicare, a decision that was almost entirely driven by a desire to avoid the sorts of threats that started this thread. Yes, the math did work for us. Not because we made more money (we didn't), but because our lives are less stressful and our jobs are more fun. Lots more fun. Fun is not a term that I see being used much as relates to medical practice. It makes me sad... all that work, and people end up doing something that seems to make them unhappy.

I don't agree with the idea of templates... I think they make for voluminous cookie cutter records of limited use... but I agree that they were an inevitable result of the "bullet point" method of reimbursement.

I do not see how they can call it fraud if you examined every bullet in the list. You are documenting exactly what you did. If anything, perhaps your exam has been conformed to the bullets/billing. I do not see how they could make this argument. They forced us here through their system of paying for bullets. There are only so many bullets you can use. At least AC is better than some charts, where you are forced to click on the bullets and it puts them into the chart for you. i.e. Patient has NASAL DISCHARGE, and ITCHY EYES. Abdomen shows NO GUARDING and NO TENDERNESS. We all love reading notes like this!

When Medicare developed their bullet points, the first thing I did in my practice was make a paper template to document my notes based on their bullet points. This is NO different.
Even before templates how many times did you write

LCTAB
RRR s M
Abd- soft, NT, ND BS+
Ext s edema

Or something to that effect?

Would they have said, "gee doc, you wrote the same thing on 5 patients in a row". I don't think you REALLY did that exam.

The biggest risk I would think is if you just plop the template in without thinking about what it is you are saying. Worth the extra few seconds to be sure you are saying what you mean to say. Beyond that, I see no problem with templates. Just my 2 cents.

Yes, I think that is the main issue. If you are seeing someone on follow up for their mitral regurgitation, and you plop in a template that says no murmurs, it is going to look suspect! But I do examine the same things over and over, and I have found some real heart problems from my RRR x a million!

Anyone know of check off templates? That way you only doccument what you want with out beeing a cookie cutter. Mike

Just my two cents. My practice is set up for families who are uninsured or underinsured and I don't deal with insurance companies at all. Flat rate appointment or flat rate membership and I pass on the cost of everything over $1 (so I buy my suture for $2 a piece, sterile gloves for $1.50, sterile water for $1...cleaning and stitching a simple wound costs $4.50) An appointment is $60 no matter how much or how little I do. A membership is $30 a month for each of the first two members of a household and $15 a month for each household member after that. I have no staff (other than my husband, who I don't have to pay and doesn't do much) and have really worked to keep my overhead low. I broke even in 2 months. I can "squeak by" support my family on about 200 members (most people prefer the membership option) or we live like kings on 500 members (we aren't there yet). Squeaking by, I'm only seeing a few patients a day (2-3 on average...I live 3 blocks from my office so if no one is scheduled, I go home). I'm assuming at the living-like-kings level, I'll be working half-days. I'm on call 24-7 but it barely affects my life and my patients have never abused it. I have another solo practitioner to trade call so I can still go on vacation.

Some people would say that I'm depriving the world of a full time doctor by doing this, but between my small children and a VAD/stroke, I wouldn't be practicing medicine at all if I couldn't do it at my current pace. And my patients LOVE it. I have several families who have one or more family members on medicaid or medicare who see me for almost everything and have those for back up. They appreciate the time I spend just listening and straightening things out medically. It can take a couple hours to sort out a medicare patient who has been getting disjointed care from a disjointed conglomeration of family and home health and rushed PCPs and rushed specialists and in the end is time well spent...even though medicare wouldn't pay for it. I don't deal with auditors or insurance rules...I just provide the medical care people need.

I spend my time doing what I love.