Denial Management Strategy. Key Points to Consider.

Estimates show denied claims represent over 13% of gross revenue for providers nationwide. Some studies suggest that over 90% of those denials were preventable and nearly 70% could be overturned. An additional 6% of gross revenue was lost to underpayments. These numbers are staggering when you combine lost revenue as a result with the high cost associated with resolving these denials.

To face this challenge, providers must have an effective strategy in place to identify denials, manage their resolution and analyze root cause to facilitate prevention of future denials. Some keys to an effective denial management strategy include:

1) Capturing all remittance information necessary for denial management
A primary source of denial information is the payer remittance advice (RA). Many providers focus on payment posting from the RA and neglect to capture all of the information critical for effective denial management. For denial follow-up, it is important to capture and categorize all payer reason and remark codes.

2) Paying attention to payers who provide hard copy remittance reports 
To maximize collections, providers must manage denials for 100% of their payer mix. Payers who cannot provide electronic remittance advice (ERAs) typically represent around 15% of total revenue, and many providers feel that the cost of capturing denial information from a hard copy remittance report is just too high to chase such a low percentage of revenue. A simple cost/benefit analysis will likely reveal that the cost of capturing denial information from a hard copy remittance report is easily outweighed by the denial recovery opportunity, and the opportunity to identify and prevent future denials.

3) Identifying and managing underpayments
If your denial management process does not identify and manage underpayments, you may be losing up to 6% of your annual gross revenue. Managing underpayments is frequently overlooked as part of a denial management strategy. First, you can qualify partial payment denials from remittances by looking for specific reason codes to identify charge-level denials. Second, it is critical to identify payment variances by comparing remittance paid amount to the expected payment amount. This can be challenging if HIS systems, contract management systems and denial management systems don’t work well together, however, this problem is easily and clearly worth resolving given the amount of revenue at stake.

4) Considering how denied accounts are assigned to follow-up staff
Too often, the focus on resolving EVERY denial results in chasing hundreds of low balance denials while sacrificing valuable resources who could be working on resolving collectible denials. Make sure follow-up assignments are reasonable. If a follow-up work queue has 2,000 denied accounts in it, the likelihood of staff always working on the most important account will be pretty low, and the likelihood of timely follow-up on all 2,000 denied claims is even lower. There are always exceptions that require judgment, however, consider filtering follow-up work queues to include a smaller number of high priority accounts. Also, consider setting a threshold (based on cost to collect or other defined criteria) for automating low-balance write-offs on denials, eliminating those accounts from work queues.

5) Automating or streamlining follow-up activity
Efficiency is the key to maximizing recoveries. Follow-up staff should have tools to save them time, allowing them to work and resolve more accounts. Some examples:

• Payer-specific appeal letter templates that can be auto-filled with account-level information like Patient Name, PCN, MRN, DOS, Denial Reason Codes, etc.
• Write-off authorization tools to streamline the request and approval process
• Canned follow-up actions and notes to prevent staff from wasting valuable time typing the same thing over and over again
• Quick access to view and/or print the EOB and the denied claim
• Automated alerts that notify users when a prior follow-up action has not resolved the denial within the designated period of time.

6) Tracking and analyzing the outcome of denial follow-up
Make sure the outcome of each resolved denial is clearly identified. Analyze outcomes and educate staff to evaluate processes that historically have not been successful overturning denials. If sending the same appeal letter to the same payer for the same denial reason on 100 different claims has not overturned any denials, consider creating a new follow-up plan for that denial reason.

7) Identifying root cause and focusing on prevention
Increasing denial recovery rate is good. Decreasing initial denial rate is better! The key to prevention is in identifying the root cause. When providers understand root cause, they can make business decisions to facilitate prevention. Studies suggest that almost 80% of denials are Patient Access errors, but if the cause is unknown, staff may not be solving the right problem. It is worth the effort to evaluate and assign root cause to denials whichinclude identifying trends and taking steps to prevent future denials.

8) Setting and tracking financial and operational performance goals 
Dashboard-style reporting tools are very helpful to communicate performance metrics throughout the organization and to manage performance. Important denial performance metrics includes : initial denial rate, recoveries on denials and underpayments, rate of appeals overturned, monthly denial trends by payer and error type, denial outcomes by payer and error type.

These tips are some of the keys to a comprehensive and effective denials management strategy.

by Todd Thomas, Director of Provider Product Management (Emdeon)

How Does a Practice Deal with All These High Deductible Plans?

One of the biggest trends we’re seeing in healthcare today is a shift towards high deductible plans. This shift first started as more and more employers stopped offering insurance or cut the type of health insurance they offered. This started the trend towards individuals purchasing high deductible insurance plans.

While the shift to high-deductible insurance plans started well before the Affordable Care Act (ACA), the government mandated health insurance and associated health insurance exchanges (HIX) have thrown gas on the already flaming fire. What most patients didn’t realize when they signed up for insurance on the government’s HIX is that a large majority of the plans were high deductible insurance plans. This has led to a huge influx in high deductible plans entering medical offices.

hat does this increase in high deductible plans mean?
This change is one of the most significant changes in healthcare reimbursement we’ve seen.High- deductible plans mean a major shift in who will be paying the bill. Instead of collecting most of your money from insurance companies, your clinic will need to becomeexpert at collecting money from patients as well. Yes, that’s right. You’re still going to have to collect from the insurance companies like before, but you’re going to have to build additional expertise around collecting payments from patients too.

While it’s true that clinics have been collecting payments from patients forever, that doesn’t mean that clinics have been doing a good job of actually collecting the money. In fact, I find practice after practice who hasn’t stayed on top of their patient collections. In the end, they often send their patient collections to a collections agency which frustrates the patients and tarnishes their name or they just write off the patient pay portion completely.

Suggestions to Improve Patient Collections
The first step to improving patient collections is to really understand the details of your patient’s insurance plan. This starts with doing an insurance eligibility check and verifying your patient’s plan details. We wrote about ways to streamline your insurance eligibility checks previously. Doing it right takes time, but with the right workflow automation solutions you can make sure that those working in your practice have the right insurance information. Once they have the right payment information, you’re much more likely to collect the payment from the patient while they’re standing in front of you at the office.

While collecting the patient payment from the patient while their in your office is ideal, there are dozens of reasons why this won’t happen. Some don’t have the money on them. Some walk out before you can collect. How then do you engage the patient in the payment process once they’ve left your office? In the past, the best solution was to send out bill after bill through mail service or possibly call the patient directly. This is an extremely time-consuming and costly process that can take 60 to 90 days to obtain results. Plus, it costs several hours of manpower and postage.

In the electronic world we live in, the first thing you can do to improve your patient collection process is to implement an online patient payment portal. This online payment process increases patient collections dramatically. The next generation patient is so unfamiliar with writing checks and sending snail mail, that those payments often get delayed. However, by offering the online patient payment option, you remove this barrier to payment.

The other way to improve patient collections is to use an automated messaging and collection process. This approach uses a collection of text, secure text, email, secure email and even smart -phone notifications and automated calls in order to ensure the patient knows about their bill and has the opportunity to pay the bill. Plus, these customized decision rules provide a much more seamless and consistent approach to patient collections.

This movement to the empowered patient with a high deductible insurance plan is not likely to go away. Employers are happily getting out of the health insurance business and many want patients to have more responsibility over the healthcare they receive. Being sure that you have a well- thought out-patientcollection workflow is going to be critical to the ongoing success of any medical practice.

Medicare Shared Savings Program gets tweaked by CMS

In an effort to shift healthcare from a fee-for-service payment model toward a care quality-based model, CMS continues to offer support and incentives to physicians that form or join an accountable care organization. With that in mind, CMS has released a proposed rule that aims to improve care coordination within ACOs as part of the agency’s Shared Savings Program. The industry can submit comments about the proposal through February 6, 2015.More than 330 accountable care organizations (ACOs) are members of the Shared Savings Program, and there are 4.9 million beneficiaries in the participating organizations. Fifty-eight organizations that participated in the first year of the Shared Savings Program reported earning a combined $315 million in shared savings payments.

The 110-page proposed rule aims to clarify the following aspects, among others, of accountable care.

  • Requirements for ACO participant agreements, the application and application review process. This provision was added because past Shared Savings applications contained incorrect information which caused them to experience processing delays. CMS recommends ACOs view itsACO Participant Agreement Guidance to confirm their application will be accepted.
  • The identification and reporting of ACO participants. This step specifies that an ACO must include a list of all its ACO participants during the application process and submit an updated list annually.
  • Eligibility requirements based on the ACO’s number of beneficiaries, structure and governing body. A section of the ACO agreement clarifies participating ACOs must “include primary care ACO professionals that are sufficient for the number of Medicare fee-for-service beneficiaries” and that the amount of beneficiaries must be 5,000 at a minimum.
  • The two-sided performance-based risk tracks for ACOs. Track 1 is a shared savings only option, while track 2 applies to ACOs that take on performance-based risk. Upon reviewing these two choices, CMS has proposed the creation of a third track in which providers would accept even more performance-based risk. Track 3 ACOs would have greater incentive to improve their care quality because doing so could maximize their cut of any shared savings.
  • ACO public reporting and transparency. This can be accomplished by each ACO maintaining a website that lists the organization’s name, identifies ACO participants and discloses data on their shared savings and losses owed to CMS.

The new proposed ruling is a clear indication of how important health IT is to the success of an ACO. As detailed in the document, the rule would require an ACO to outline in its application what technologies would be used to promote more coordinated care for their beneficiaries. Examples of things that could be listed in an application include the use of EHRs to track patient’s data, telehealth services to remotely monitor patients and the electronic exchange of patients’ health information.

CMS is working to document the success of ACOs and share insights and accomplishments with the healthcare industry to spur the creation of more accountable care groups. The proposed rule offers a template for participating ACOs to make to make certain information — such as the identification of ACO participants, governing body members and the amount of any shared savings or shared losses incurred — available to the public on a website that meets CMS requirements.

The need for an outcome-based payment model and a reduction in healthcare costs are the leading forces behind the creation of ACOs. Some of the first ACOs faced significant challenges during the early adoption stages due to a lack of supporting technologies and health information exchange platforms. Due to the public disclosure of ACO success stories, along with a helpful push from meaningful use criteria, physician-led groups and hospitals have a growing interest in signing up for ACOs.

Article by: Reda Chouffani

Future of Healthcare is Telehealth. Know Your Training Resources.

Adopting new technologies can be a difficult, often times daunting task. Fortunately, if you’re entertaining the idea of practicing telehealth there’s some great telehealth training companies out there to get you started. Here’s list of top five trainingsitesforteleheath


The Telemental Health Institute was one of the first organizations to offer evidence-based online training for behavioral health providers seeking to deliver online services that are legal, ethical and clinically sound. It provides 100% online training for both graduate students and post-graduate seeking continuing education units for psychiatrists, psychologists, social workers, counselors, nurses and coaches (CEUs and CMEs). You can also benefit from:

  • A secure forum with access to 2,000 professionals from over 36 countries worldwide.
  • Mobile compatible coursework packaged in various Levels, leading to the TMHI Certificate.
  • Monthly, topic-specific webinars via telephone, computer, and app-smart devices     Podcasts, kindle books and CD formats for onlineconference topics.
  • A low-cost “Inner Circle” option that allows you to start with dipping a toe-in-the-water.
  • Tools and successful strategies to develop your online presence, products and services.
  • Yearly online conferences with experts from across government and health care explaining key licensing and reimbursement strategies.
  • Mini-training videos at no additional cost.

One of the best things about this program is that you can get fully-certified in as little as one week. So if time is a matter of concern, this might be your best bet.


Allceus has been providing e-therapy certification training since 2006. They offer a simple system towards getting certified regardless of work setting, approach, and educational or professional training. Allceus’s e-therapy course abides by general education requirements for certification in online therapy. You can also expect to complete the e-therapy coursework within 20 credit hours, broken down into:

  • 4 hours of best practices.
  • 4 hours of clinical principles/treatment modalities.
  • 2 hours of legal and state jurisdictions.
  • 10 hours of electives within the course schedule.

To start the e-therapy certification process you will need to buy a 90-day interval priced right under a Benjamin Franklin, if coursework isn’t finished under that time frame you will have to buy an additional 90-day period. Certificate can be saved as a PDF or printed upon completion.


This Alaskan, FDA listed, and maker of medical devices also provides an assortment of telehealth programs. AFHCAN Telehealth Solutions started in 1998 with a mission to making healthcare accessible to rural Alaska. The result of such a mission was tCounsult, a store-and-forward method that utilizes an interim lock-point between the point-of-delivery and point-of-receipt, a form of encryption for successful eTheraphy and training. They offer both group and individual online therapy training courses worldwide. You may choose from three different courses:

  • Understanding Telehealth & the Role of the Coordinator (you).
  • Becoming a Certified Telehealth Coordinator
  • Knowledge and skills needed to manage a telehealth program

Within three 10-week courses you can expect to be proficient in all of these areas.


Kate Anthony and DeeAnna Merz Nagel, two accredited psychotherapists inducted their personal goals onto an online setting with hopes to disseminating their experiences and knowledge on health and technology. In light of such a unique mixture, The Online Therapy Institute and Online Coach Institute were created. These two institutes offer an array of training opportunities that help providers become comfortable and familiar with practicing in an online setting. You can expect training in the following areas:

  • Working therapeutically using asynchronous email.
  • Working therapeutically using asynchronous chat
  • Working therapeutically using audio
  • Working therapeutically using video and blended technologies


If none of the telehealth programs mentioned above appeal to your current telehealth needs or if you believe that you still need a further understanding of how to properly approach telehealth than the Telehealth Resource Center (TCR) is your best bet. This organization is the heart of 14 other TCRs across the nation and is sponsored by our very own U.S. Department of Health and Human Resources office for telehealth advancement. TCR will help you develop and identify:

  • A training strategy that best fits your schedule
  • A telehealth training program that best fits your location and circumstances,
  • All the factors that contribute to successful telehealth integration

Best of all, in addition to helping you find the strategy, program, and factors, this centers’ resources can all be accessed at little to no cost. For more information on telehealth subscribe to our blog in the form provided!

By Giovanny Ayala

4 P’s of Marketing Plan for Medical Practices

I would like to start this post with a sentence from an enlightened spiritual maestro

“This world was not built with random bricks of chance
A blind god is not destiny’s architect;
A conscious power has drawn the plan of life,
There is a meaning in each curve and line”.

Success in establishing any business including Medical Practice/Clinic is not a random brick of chance, a conscious process and planning is required to achieve what we call a business success story.

Marketing Plan is an essential element of any business including Medical Practices (or) Multi-Specialty Clinics (or) Out-patient Diagnostic and Surgery Centers.

4 P’s of marketing plan comprises of PRODUCT, PRICE, PLACE and PROMOTION

Let’s see how to approach each of the four classic Marketing Fundamentals.


Healthcare is a services industry. In a services industry, the production and consumption of the product are simultaneous and the product is intangible, diverse and perishable. The nature of this ‘product’ allows for on the spot customization. This also means that the point at which this activity is occurring becomes very important. Ideally, to ensure repeat experiences of similar quality and a consistently good user experience, most service providers aim to give some customization within an overall standardized mode of delivery.

In a nutshell ‘product’ in healthcare is an assurance of good care (or) clinical decision making that patients’ get from providers towards their health issues. Providers’ ultimate goal is to reduce or eliminate health concerns from patients.

It is essential that Providers’ maintain their experiential and evidence based knowledge base to an extent that they can customize and deliver this product (clinical decision making) with required expectations from customers (patients).


The amount paid in exchange for the product (or) value received. Price is one of the Marketing Elements that is less leveraged in a Medical Practice. Invariably payment towards healthcare services rendered is controlled by Insurance Companies’ through a terminology called “Approved Amount” or “Contracted Amount”. This applies to most Medical Practices that are participating with various Health Insurance Plans.

A practice may participate in various incentive programs from insurance companies or quality initiatives to curtail overall cost of care for patients. This may lead towards an additional financial reward from various Insurance Companies’.

A practice has a choice to stay out-of-network with Insurance Companies’ and define their own price based on “Quality of Care”, “Experience”, “Ambience” and “Overhead”. This may require an excessive scrutiny of patients’ benefits with their Health Insurance. It is essential that Health Insurance covers care provided by out-of-network providers. Patient may have to contribute a portion of this cost towards co-insurance or deductible.

In a nutshell, the price is not a competitive advantage in a Medical Practice Marketing Mix.


Place (Product Distribution) is the process of making a product or service available for use or consumption by a consumer or business user, using direct means, or using indirect means with intermediaries.

The healthcare service is produced and consumed in the same place. It cannot be owned and taken away from the location. This is why the place at which this transaction occurs is of vital importance. The location of the service provision is carefully analyzed to allow ease of access and the desire to make the effort to reach it.

It is essential that Providers’ from Medical Practices are providing services to their patients in an entire spectrum of care. This includes office, skilled nursing homes, hospitals, daycare centers (or) adult homes.

Providers’ can do quarterly analysis of services rendered by location and decide to consolidate their service locations based on patient volume and time spent in providing services. A conscious planning of ‘Place’ or ‘Servicing Locations’ can result into spending time where it’s most needed.

For start-up Medical Practices, it may be worth to look at ratio of demographics and population versus provider availability. This would help the practice in determining proper geographic location for services rendered.


Promotion fulfills the same role as it does in any other marketing context.

A healthcare service may not be more easily replicated than a physical product. There are various parameters beyond the scope of service provider that control delivery of a good healthcare service or clinical decision making for patients.

The promotion is a process of establishing communication with patients and outside world to show that the ‘Practice’ delivers an accessible and accountable care. Practice provides an assurance of quality towards the clinical decision making provided by caregivers.

To prevent a service becoming interchangeable with its competitors, it becomes vital to create a desirable brand image and name in the market. Differentiation becomes a key goal in order to attract both new and repeat patients.

In order to highlight practice’s Accessibility, Accountability and Assurance part for patient care, it may be essential to highlight some of the testimonials from patients. Practice may explore an option of consistent brand building through a website, smartphone application or social media. All of these efforts should lead to an increased accessibility for patient care and concerns.

All of the above 4 elements of Marketing Mix are extremely important in deriving an effective Marketing Plan for Medical Practice that results into Horizontal and Vertical Growth for the practice.

In the next post we will explore additional 3 P’s of marketing that includes ‘PEOPLE’, ‘PROCESS’ and ‘PHYSICAL EVIDENCE’.


4 ways your practice can benefit from a mix of technology and human touch

One of the biggest misnomers about an EHR implementation is that it will replace many of the human elements of your practice. While the EHR can replace some of the tasks and processes that were done by humans, the reality is that EHR software is most powerful when paired with human touch. This concept is infused into our Ideal Medical Practice Workflow whitepaper and should be infused into every clinical practice.

As we enter 2015, here’s a look at 4 more ways your practice can benefit from a mix of technology and human touch:

  1. Rescheduling Patients One of the biggest forms of lost revenue for a practice comes in not rescheduling patients who missed their appointment. While some of these missed appointments represent low quality patients, many missed appointments happen for a good reason and are an opportunity for more revenue for your practice. Unfortunately, most practices don’t consistently reach out to patients and reschedule their appointment. Along with providing additional revenue for your practice, this extra patient outreach is a great form of customer service that will be appreciated by many of your patients and shared with their friends. While some of the rescheduling can be done using technology like emails and text messages, nothing shows a patient you care about them more than a telephone call about a missed appointment.
  2. Complete Eligibility Verification I’ve written previously about the importance of complete eligibility verification and a quality eligibility verification team. While having the correct eligibility information is always important, I can’t stress how much more important eligibility verification is at the start of a new year. At the start of a new year, patients once again are working to meet their deductible and therefore have a higher patient pay amount. Plus, the new ACA insurance plans means many patients will start the new year off with a new insurance plan. If you don’t have a 100% consistent process for verifying a patient’s eligibility, then you’re office is likely working off of old information which will hamper your ability to collect the correct payment from the patient.
  3. Referral Tracking Not appropriately tracking referrals is a big issue in many practices that can easily be handled with a mix of technology and human follow up. Not tracking these referrals is a big clinical compliance issue for your practice that has the potential to lead to a lawsuit. Along with the potential legal liability, I believe having a dedicated team following up on these orders will become extremely important in the new world of value based reimbursement and ACOs. In this next generation of reimbursement, your payment will depend on your ability to ensure patient compliance with outside referrals.
  4. Annual Well Visit Reminders Annual Well visit reminders are another great way to increase high quality visits to your practice. Many practices convert a regular visit into an Annual Well visit. While this may seem convenient for the patient, it usually means you’re cutting the patient short in the care you could provide them. You just don’t have the time in a sick visit to do a thorough well visit exam as well. Even more important is reaching out to those patients you haven’t seen for a while. It’s incredibly valuable to have a dedicated person or team who identifies all of these patients and sends them a reminder or calls them about their annual well visit. Plus, these annual well visits are a great way to add to your bottom line.

As you look at each of these 4 ways to improve your practice, they all require the right mix of technology and human touch to be done properly. In a busy practice, that can often mean hiring more staff or outsourcing some of these processes to an outside company. Either way, the value created for your practice by implementing these small but important changes will easily offset any additional costs. Plus, you’ll have happier and healthier patients in the process.

Technology’s Double Edged Sword

I came across a remarkable article by Henry Powderly (Managing Editor) of Healthcare Finance talking about small hospital CFOs’ taking a back seat on upgrading Technology/System for Revenue Cycle as challenges with EHR upgrades, MU and ICD-10 are taking away all their money and focus.

Some of the findings highlighted in this article are mind boggling:

  • Two-thirds of hospitals polled in 2012 that intended to replace their RCM platform with a comprehensive solution still had not upgraded by 2014.
  • Black Book’s third quarter study found 83 percent of financial leaders at hospitals under 250 beds expect their RCM systems to become obsolete by 2016 if not replaced or upgraded.
  • 51 percent of small, under-250-bed hospitals plan to delay RCM upgrades until after the ICD-10 deadline in 2015.
  • Small hospital CFOs list ICD-10 coding and electronic records integration well above claims and billing.

As we all know “Technology is a double edged sword”, if not handled correctly, it can cut your pockets both ways.  If handled appropriately, it can certainly reduce your costsboth ways.

One of the key reasons why CFOs consider EHR and ICD-10 as key priority and compromise on upgrading RCM platform or Technology is because they fear more revenue loss due to integration issues and possible massive rejections from payers’ due to transitional phase of ICD-10.

Most hospitals have two challenges while implementing or bringing any chance in Technology/Process for Revenue Cycle Management.

  • Financial Burden required in terms of Licensing Costs for New Software
  • Human Resources required for implementation/training/transition and accounts receivable follow up

Most hospitals don’t want to experiment with outsourcing as they can’t let go their existing staff members, if they try to outsource by hiring additional resources, it would require more funds on top of technology investments. This creates a chain reaction in terms of investment required to implement new RCM Technology and/or Processes.

I would like to highlight one of the low hanging fruit that most CFOs should consider. It has been observed that Denials’ from payers have increased over the past 2-3 years.  It is recommended to create an accounts receivable taskforce or audit team that identifies denied claims and puts them into an organized strategy for follow up. Those claims that are not paid for following reasons

  • Payer doesn’t have claim on file due to EDI issues
  • Payer has denied claim for Authorization issues even though Auth was taken
  • Insured information is incorrect.
  • Claim applied to deductible
  • Non covered services

Most of above denials can be resolved effectively by dedicating RCM taskforce to make a phone call to payer/patient promptly. It may require few calls over a period of several weeks.  These kinds of denials are easy to outsource and hospitals can negotiate an aggressive rate towards outsourcing these calls to payers/patients.

There are other categories of denials such as

  • Required appeals for Medical Necessity
  • Request for Medical Records
  • Required appeals for inclusive procedures that should have been paid separately

A hospital’s key knowledge Denials Team can focus on categories named above. They should implement a necessary action and outsource the follow-up part to an “outsourced team”.

With proper planning on Accounts Receivable Follow up from payers, Hospital CFOs can easily bring in additional 10-15% revenue that can help in funding this technology transition.  In fact, such planning would be required even more so during the ICD-10 transition.

I would like to end my note with a statement “Money can find more money”.   We may have to first find our lost funds to discover more of it from Technology/Automation.

Patient (customer) Engagement is all about “Accessibility, Accountability and Assurance”

We have been hearing a lot that Future of Medicine is “Patient Centric”.  Patient Engagement is crucial for clinical and financial outcomes. I have observed that almost 50% of articles or whitepapers are talking about Patient Engagement either through Technology (or) proactive interactions.

I would like to draw a parallel between “Customer Engagement’ and “Patient Engagement”.

It is essential to have accessibility, accountability and assurance for products and services sold by the company for customer engagement. This principle of business is equally true for “Patient Engagement” as well.

Let’s look the role of Accessibility, Accountability and Assurance in creating Patient Centric Medical Practice or Patient Engagement.

Accessibility refers to the quality of being available when needed.

Patient Engagement starts with the “Accessibility” factor of the medical practice. How many times does a patient need to call the office in order to get answers for his/her questions? How soon can a patient find an appointment when they don’t feel well? Can a patient pick up the phone and reach out to his/her doctor on the weekend, with ease? How soon do patients hear back from the office staff in regards to their referral (or) authorization requests?

The above questions define accessibility factor in patient engagement. Several providers are concerned about clinical compliance and medication adherence by their patients. However it is observed that both of these are achieved easily if the patients don’t have to make several calls to reach their clinical coordinators or physicians.

Accountability is nothing but an obligation or willingness to accept responsibility. This simple word defines a lot of expectations from Patients, from Medical Practice, Staff and Caregivers. Some of these expectations are;

  • Appointment Reminder from practice.
  • Proactive notification for test results.
  • Clinical reminders for Risk Management including tests/referrals/blood work or therapy.
  • Reminders for Annual Well Visits.
  • Prompt call back for left messages.
  • Timely completion of referral/authorization completed for medications/diagnostic tests.
  • Call back from providers’ for seeking answers to their health related questions.

So accountability in patient engagement means assuming responsibility for above expectations from patients.

A positive declaration intended to give confidence; a promise or pledge that a patient’s health related problem will be resolved by his/her doctor. It is utmost important for caregivers or providers to keep themselves well educated with diseases, medications, diagnostic tests and resolutions.

This part of patient engagement requires “Providers” to be knowledgeable enough to identify and cure health issues for the patients. Knowledge is nothing but experience. Providers’ may have to be well read and well informed through real-life case studies or evidence based medicine in order to treat their patients.

We have seen several examples wherein providers’ have lapsed in care or decision making resulting in adverse clinical outcomes and possible law suits.  It is essential that providers understand the “Assurance” part of patient engagement and thrive to keep themselves well educated and informed.

Assurance also puts reasonable expectations from Triage Staff or Clinical Assistants. They need to make sure that they have taken a detailed interview of the patient and identified social and family risk factors. They need to make sure that medical history or surgical history is properly documented.

I would like to conclude this article by stating that Patient (Customer) Engagement is no different than any other business success stories.

Daily Scorecard can transform Medical Practices

In this post, I would like to highlight how a “Daily Scorecard” can transform any Medical Practice. We all know that in sports, a scorecard is a sheet, or a book in which scores are entered. In business terms scorecard means a statistical record used to measure an achievement or progress towards a particular goal.

We have often heard about “Balanced Scorecard” in the corporate world. The balanced scorecard is a strategic planning and management process that is used extensively in business and industry, government, and nonprofit organizations worldwide to align business activities to the vision and strategy of the organization, improve internal and external communications, and monitor organizational performance against strategic goals.

Taking the concept of a scorecard and introducing it in Medical Practice under “Daily Scorecard” can bind all the team members of a practice into one common string. Let’s look at some of the possible daily scorecard items for a practice.

  • Daily Number of appointments scheduled and seen.

This provides a complete analysis of NO SHOW ratio. So if a provider complains that he/she was very slow, the scheduling team knows what to do. It also helps in forward thinking for practice’s workflow planning.

  • Daily number of patients’ who paid their outstanding balances from the total, who have some kind of balance towards co-insurance/deductible or non-covered charges.

This provides an indirect audit on the financial counselor within a practice or front desk team member.  No one likes to have bad looking numbers on the scorecard, so it brings a sense of accountability among the team members to outperform day-by-day.

  • Daily number of patients’ scheduled and eligibility checked.

Affordable Care Act has created thousands of insurance patients’ in the past several years; it has also given a way to increased patients’ responsibility.   Eligibility Verification is such a crucial part in workflow planning for Medical Practices. This scorecard serves as a quick tally between patients’ scheduled and eligibility checked. Any performance less than 100% shouldn’t be acceptable unless a known factor exists. A known factor could be patients’ who have been seen regularly in practice for their risk management.

  • Daily number of patients’ seen by providers with ratio of number-of-patients to work-hours.

It is often observed that patient flow is a big problem in a busy practice. Patient wait time is a big topic for discussion in workflow planning and patient satisfaction survey. We have seen an increased number of technology initiatives to calculate patients’ wait time in reception, exam room, triage and face-to-face time with physicians. A simple scorecard can provide an accurate insight into providers’ performance and keep them focused on their core objective.

  • Daily number of claims billed.

It is necessary to have insurance claims billed out in timely manner. This scorecard can provide a pace of billing.   Practice sees 150 patients daily however claims going out daily are not keeping up with this pace or claims billed out are sporadic, it would obviously create a disruptive cash flow for the practice. This serves as an immediate audit on the billing team members and provides possible statistical cash flow predictions for the accounting team based on procedure/payer mix.

  • Daily $$ amount posted.

Payment posting is one of the most neglected functions in a Medical Practice.   It is very important that payment posting is kept in pace with daily cash flow. It is a first and fundamental step in wholesome Revenue Cycle Management and Planning.  If money is not posted in a timely manner, you can’t balance bill secondary or patients.  It creates a work queue for AR follow up / Denials Team.

  • Daily number of denials worked on (or) outstanding claims followed up.

Healthcare is the only services industry where you are paid after services are rendered. Most service industries in the country charges their fees upfront.  It is essential in a Medical Practice Workflow planning that Denied or Outstanding Claims are followed up periodically or promptly. This is a time consuming process and each claim can take up to 30 minutes or more. The scorecard helps a practice to establish a bench mark and dig into reasons for denials proactively.

We all agree that Numbers have power. A series of numbers put together convey a whole story about any business or organization. Daily Scorecard turns out to be a simple but powerful tool in building an effective accountability into the practice. It keeps everyone connected towards one common goal “Recognition, Recommendation and Revenue”.

Bringing Corporate Culture in Medical Practice Management could lead to 3R’s: “Recognition, Recommendation and Revenue”

“Management” is a process of dealing with or controlling things, processes, technology or people. Just like any other business, we find success and failure stories in Medical Practice Management as well.

While working with several practices nationwide, I come across practices that are well recognized, well recommended and doing very well financially. In a nutshell, we come across practices that have mastered processes, technology and people management. I call these practices “3R” or well recognized, well recommended, and financially stable institutions.

Let’s analyze the reasons behind the success of “3R” practices. Uniformly, these practices adopted what I call, a “Corporate Culture”.

Corporate culture refers to the shared values, attitudes, standards, and beliefs that characterize members of an organization and define its nature. Corporate culture is rooted in organization’s goals, strategies, structure, and approaches to labor, customers, investors, and the greater community”.

I would like to describe some of these attributes and their relationship to “3R” (Recognition, Recommendation and Revenue).

  • Practice has a Mission Statement.

What’s a mission statement anyway? A practice’s mission statement should represent core values and ideals of the founder’s vision for their practice. It should be a constant reminder to the practice’s employees and clients (your patients) of why the practice exists. Furthermore, a good mission statement is the tool by which the practice navigates, and by which patient-centric decisions should be made and measured. This results into recognition, recommendation and financial stability as the practice is driven by a common goal or objective.

Here is an example of a mission statement “It is our Mission and Our Pride to provide excellent quality primary healthcare to every individual, regardless of differences in cultural background or language”.

It is necessary to keep in mind a practice’s ultimate objective while defining the mission statement. These objectives could govern internal and external factors and can clearly define an actionable plan.

A well-defined mission statement leads to establishing core values. The core values are basic elements of how we go about our work. Let’s look at some of these elements.

  • A practice has a defined language and customs for interaction with their patients.

Standardization in language, customers and interactions lead towards replicable patient experiences.   It creates such a positive and motivational environment for patients. They feel well respected and enjoy coming back to his/her doctor. This can be a possible referral business as a happy customer will bring good referrals.

A practice systematically records, analyzes and shares patient feedback internally.

Patient survey or feedback results into an indirect evaluation whether our processes/people are working as per the core values. It is an invaluable tool for self-learning and improvement. It makes patients’ feel connected with the practice.  It truly brings out a feeling of “My Doctor” with pride.

  • A practice places greater emphasis on patients’ retention and recall for clinical management.

We have been seeing increased new patient volume in most medical practices due to Obamacare. It is necessary to emphasize on established patients’ clinical care coordination along with taking care of new patients.  A practice should utilize Disease Management and/or Clinical Alerts to make sure that patients’ follow a required care plan for better risk management. A well-defined Risk Management or adherence to a Care Plan can benefit patients and earn additional incentives from payers.

A practice empowers employees to make on-the-spot decisions that enable value-added and personalized experiences to occur.

It is necessary to define role of each and every individuals in a practice. It is necessary to decentralize power and responsibilities within a practice so that patient concerns are resolved promptly.

  • A practice believes in Tasks, Milestones and Reminder management.

Most of the complaints in practice management are “Poor Response Time” from staff.  A patient may have called in to find out details of blood work or test results, he/she may have to call a few times before someone gets back. It is necessary to have well-defined tasks, milestones and reminder management in place. Most patients’ require reminders for various things including appointments, outside diagnostic tests or medication adherence.  A practice utilizing technology/system for above functions would come out ahead compared to others.

Bringing corporate culture into your practice can help many practices tackle their day-to-day management problems.

In the next article, we can discuss most common problems faced by medical practices and how bringing corporate culture into practice can resolve these problems.

I encourage participation from all of you, please add to this article.  What is your story, your process, your corporate culture, your success, or challenge? This will certainly help many practices tackle their day-to-day management problems.