Cheryl Toth

Reducing medical practice embezzlement risk with cash controls

Several years ago, we visited a practice in which the receptionist drove a Jaguar. We were particularly intrigued about this after we learned that her husband had been in and out of work for several years. As part of our engagement, we observed the receptionist checking in and checking out patients, and noticed fairly quickly that the encounter forms for several patients who paid in cash had "disappeared."

The next day, the receptionist called in sick and within a few days had resigned. In the end it became clear she had been tossing encounter tickets and pocketing cash for years. But because the practice didn't require anyone to account for all the day's encounter forms, nor balance money collected against what was posted to the computer system, no one was the wiser.

Front-desk embezzlement schemes are not uncommon and they are typically the result of loose protocols and lack of oversight. Reduce your financial risk by tightening cash controls using these proven practices.

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Front-desk embezzlement schemes are typically the result of loose collection protocols and minimal oversight. Don't be caught lacking


Giving staff feedback can strike fear in the heart of many practice managers. It’s uncomfortable. For some, it feels confrontational.

Which is probably why Gallup data show that nearly half (47 percent) of employees say they received feedback from their manager "a few times or less" in the past year.

With a bit of insight from brain research and a little practice, managers of any experience level can make feedback conversations more comfortable. If your goal is to support staff learning and improve performance, here are 4 tips that can help you get it right.

1. Make it frequent, short, and specific.

More than 50 percent of Millennials and nearly 40 percent of non-Millennials prefer receiving feedback monthly. And nearly 20 percent of Millennials say they’d like feedback weekly. In this same study, Millennials said that their number one source of development is their manager, but only 46 percent say they are getting the feedback they need from him or her.

Don’t wait until the annual performance appraisal; make feedback an ongoing conversation. The discussions can be as short as five minutes - as long as you focus on specifics.

For example, instead of, “great job!” you might try, “I heard you diffusing that patient’s anger when we ran 40 minutes late. You did a great job staying calm and explaining the situation.” 

And if the feedback is a learning opportunity, think like a coach: Let them know what they are doing well, and how that impacts the outcome on their productivity, the patient experience, etc. Then, teach by asking questions that ignite insight and learning. 

For instance, instead of, “I heard you talking with that patient about her bill. Here’s a better way…,” you might try, “I heard you talking with that patient about her bill. You stayed very composed. Why do you think she got upset? What might you do differently next time?”
	 

2. Build on existing skills instead of delivering “constructive criticism.”

Research indicates a rather shocking truth when you consider how long managers have been delivering constructive criticism to employees. Not only does telling people how to improve keep them from exceling and thriving, it actually hinders learning and growth

ACP: 10 goals for a healthcare system for all

Neurologically, we grow more in our areas of greater ability. Science shows that our brains grow far more neurons and synaptic connections in places where they already have the most neurons and synaptic connections. In other words, people learn when they recognize how they might improve on something they already know and understand. Thus, it’s more effective to capitalize on what staff do well and grow their skills from that place of strength.

I remember a practice manager who was quite introverted. She didn’t do well at training or developing the staff, but she excelled at data analysis. Instead of using “constructive criticism” to improve the manager's training and relationship management skills, we stepped up her authority over financial and report analysis. We also moved hiring, training, and onboarding to a supervisor with a workstyle better suited to these tasks.

You can’t build up staff from a place of weakness. Leverage and build on staff strengths instead of trying to develop skills they have limited aptitude for.

Up Next: Word Choices and Feedback Styles

 immediately puts staff on guard and makes them defensive. From a physiological standpoint, the brain responds to this type of feedback as a threat, triggering what’s commonly referred to as “fight or flight” behaviors, which limits the brain’s ability to learn. 

Instead, frame statements and questions in the first-person; use “I” and “my” instead of “you.” It takes the focus off the employee and provides an opportunity for a productive conversation to unfold. Some examples:

Here’s what I would do/how I would handle it.

Here’s what you need to do to improve your status reports to the physicians.

When I’ve been in this situation, I’ve found these things work best for me, because...

You need to be more organized.                    

When I see you getting stressed about the paper on your desk, and the patient calls you have to return, I get concerned you may be taking on too much.

What you are doing at the front desk is not working.

I had a similar thing happen and here’s what I did that might work for you...

Contributing source: The Feedback Fallacy, 

, Harvard Business Review, March–April 2019 Issue, 

https://hbr.org/2019/03/the-feedback-fallacy

4. Recognize the difference between delivering 

 is fact-based. For example, correcting a billing team employee who is not following the practice’s procedure for denial management. Or, telling a medical assistant that he or she has been incorrectly completing forms for the outside lab. Correcting how an employee performs specific tasks is useful and straightforward. Think of it as a form of refresher training that ensures tasks and procedures are followed.

 is subjective. Telling people what we think of their productivity, supervisory skills, or problem-solving abilities is a stickier discussion. With performance feedback there are no fact-based measures to rate or assess. (Appraisal rating scales are a form of subjective scoring.) Further, data show that 61% of how you rate the staff is actually a reflection of your own characteristics, not theirs. In other words, how you rate the potential of employees is based more on how you define good performance than who the employee is or what they are capable of. This is called the 

Delivering performance feedback is more challenging and takes some practice. Don't beat yourself up if it's uncomfortable at first. Learn from each conversation and have the self-awareness to continuously improve.

 delivering management coaching and professional development services.

It's the Manager, Jim Clifton, Jim Harter, 2019, p 80.

Millennials Want to Be Coached at Work, Harvard Business Review, Karie Willyerd, February 27, 2015. 

https://hbr.org/2015/02/millennials-want-to-be-coached-at-work

The Feedback Fallacy, Harvard Business Review,Marcus Buckingham, Ashley Goodall, March–April 2019, 

Tips for delivering feedback based on brain science

"We've never had a budget for staff training."

After years of working with physician practices, I've heard this more times than I can count.

If it holds true for your practice, here are five reasons why 2017 should be the year you shift away from this mindset and get serious about investing in employee development.

1. Reduce the risk of lawsuits, paybacks, and audits

Managers and staff who don't refresh their knowledge regularly (

 annually) are working under outdated, often false, and sometimes even illegal assumptions. Just as physicians are required to take CME courses, administrators and managers must attend professional association meetings in their specialty. Billing staff need coding and billing regulation updates. And annual HIPAA training is a must for everyone.

Failing to budget for these updates will leave your team frozen in time, following old rules. Simply put, 

putting your practice at risk of violating current regulations or laws or maintaining costly or inefficient operations.

The manager of a large orthopedic group insisted that refunds were not to be made unless patients or plans requested them. Had her knowledge been current, she would have known that the $75,000 in credit balances our consulting firm identified should have been refunded long ago - regardless whether patients or payers asked. CMS requires providers to 

 within 60 days of identification. And according to healthcare attorney Michael Sacopulos, founder of the Medical Risk Institute, most managed-care contracts have clauses that state overpayments must be refunded upon discovery. Sacopulos also notes that even out-of-network claim refunds must be refunded to patients, based on certain language in the Affordable Care Act.

And, we regularly observe under-trained billing staff following procedures that put their physician employers at risk for False Claim Act and HIPAA violations, as well as payer audits. Unbundling procedures because they don't understand current coding rules, naively submitting level 4 and level 5 E&M codes when the physician's documentation and/or medical necessity does not support them, and emailing protected health information (PHI) to patients or third-party billing services instead of using secure messaging, are a few examples.

2. If you budget for it, you will spend it

Funny thing about earmarking dollars for something specific. They typically get spent. And, you will be more apt to seek out training opportunities knowing there is a budget to cover them.

Our firm has worked with thousands of managers and staff for more than 30 years. A constant and consistent request we hear from them is that they'd like more training so they can do a better job.

I can almost guarantee that establishing an annual budget for professional development will be a positive and welcome announcement for your team. I frequently see it perk up the attitude and performance of employees who are in a rut or looking for opportunities to advance.

An educated and informed team does things right. Typically, that bodes well for the bottom line. When front desk staff are trained to ask patients for money, daily revenue goes up. When billing staff understand how to code correctly - and are kept abreast of rule changes - it's more likely that all your billable services will actually be billed and paid.

5. Monitor and benchmark learning investments

A training budget gives the practice a benchmark against which to measure expectations against reality. With "staff training" as both a budget and expense item, managers can monitor the percentage being spent each month and quarter. If you've set aside, say, $5,000 for the year, and have spent $6,500 by August, you can adjust next year's budget accordingly, as well as benchmark how much you've invested in employee development, year over year.

Fall is the perfect time to initiate a training budget for next year. Whether it's a specific dollar amount or a percentage of total expenses, set aside an amount, inform the staff, and spend the money. Your team and your bottom line will benefit from the results.

is a consultant and trainer with KarenZupko & Associates, Inc. She brings more than 20 years of practice consulting, training, and technology product management experience to her projects.

When it comes to belt-tightening, staff training is usually one of the first places managers look to cut back. Here are five reasons why you shouldn't.   

Five Reasons for Medical Practice Staff Development

The first spring after planting peach trees, I was thrilled to see bees pollinating the hundreds of blossoms that appeared. When clumps of little green peaches developed, I started gathering recipes for pie and cobbler.

Unfortunately though, few peach baked goods came out of my oven that year. Why? I didn't get the yield I was hoping for because I didn't understand the concept of "thinning" - picking off some of the small or too-clustered fruits so that the larger and healthier ones could mature.

The practice team is like my peach tree. You must tend to it regularly, give it nutrients, and thin it when necessary. It might be hard for some managers to face that last one, but it's true. And it's important for the overall health and success of the team.

As you look ahead and plan for 2016, ask yourself these questions:

. Just as my peach trees needed water and nutrients, your strong performers need inputs to thrive. Are you taking the time to teach and mentor them so they can ultimately assume more advanced roles (maybe even yours)? Do you give them opportunities for learning? Not just the annual CPT code changes, but 

 that results in them bringing you innovative, new ideas? Are there projects that your star employees could take on next year? This is the time of year to ask these questions and factor the answers into next year's budget, so your top performers don't stagnate.

2. Is there a plan for training and coaching your average performers to go from good to 

If the answer is no, it's time to develop one. And it doesn't have to be complicated. Start by considering each employee's current knowledge and what you feel would build it. Assigning self-paced learning such as journal articles, e-newsletter reading, or webinars is a good start. Then, meet with each employee to discuss the kind of additional training, knowledge, or support he feels is needed, and set some goals and a budget for this in 2016. You'll find this conversation can be a great motivator, especially for staff who are less likely to take initiative, and those who may feel the need for your "permission" and a nudge to further their learning.

Admit it: You know who these people are. Maybe you've been too busy juggling multiple priorities to schedule time to talk with them. Or, maybe you're giving these folks some time - hoping things will get better.

Before the year draws to a close, confront these employees, tactfully, of course, to determine what's going on. Finding out the "real story" behind lackluster performance is the first step toward motivating employees to do better. 

 Boredom, fear of change, overwork, stress at home, lack of sleep or exercise, or some story the employee has in her head that you don't think she's doing a good job. All of these things can affect productivity. Your first action is to identify those who have been slipping, and schedule a meeting to find out what's up.

4. Could some employees benefit from coaching? 

Coaching is a one-on-one empowerment process that can build employee confidence and improve performance, enabling employees to think differently and assume new roles. Coaching is different from training and it's useful when you are grooming employees to move into supervisory positions or when you are expanding someone's role. A coach acts as a sounding board, and supports employees by helping them to take action and improve.

Whether you conduct the coaching meetings, or you hire an outside coach, it's an employee benefit that bodes well for both productivity and profitability. It can also create a succession planning process that develops front-line staff into supervisors or managers.

5. How well is your "old growth" performing?

Not old by age, but old by tenure. It's common for medical offices to have long-term employees who remain in the same or similar job roles for what is often too many years. On the one hand, this can be perceived as loyalty. But in many cases, long-time employees get stuck in the "this is the way we've always done it" mentality and aren't motivated to learn new things, and rarely come to the manager or physicians with innovative ideas.

We recently guided a client to conclude that it was time to let go of a manager who didn't have the education, skills, initiative, or interpersonal abilities to be an effective administrator. The physician had realized it nearly three years before, but felt that firing her would have been "traitorous." So the practice hobbled along with high turnover, disempowered employees, and flat revenue as the physician became increasingly unhappy.

When the administrator was finally let go, it was like a shot in the arm for the employees, all of whom stepped up and began to blossom. Although there were a lot of pieces to put back together, the "thinning" was a huge relief for the physician as well, who said, "I should have done this a long time ago. Now I can move forward and build the kind of practice I've always wanted."

is a consultant and trainer with KarenZupko & Associates, Inc. She brings more than 20 years of consulting and executive and technology product management experience to her projects.

Higher performing practices look at their staff as dynamic individuals that need training, coaching, and mentoring to stay on top of their game.

Improving the Performance of Medical Practice Staff

If your practice expects new employees to get right to work after completing their HR paperwork and receiving keys and login credentials, it's missing a huge opportunity.Making new hires feel welcome and ready for their job role can speed the learning curve, improve the feeling of pride in the place they work, and set them up for greater success.Â Here are ten effective elements to include in your new employee orientation plan.Â 

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Sure your practice is busy, but don't neglect the chance to welcome new hires, and set them on the road to success.

Ten Elements of a New Employee Orientation Plan

It's no secret that patient financial responsibilities are higher than ever. So why wait until after the insurance company pays to collect a big balance from patients? By taking a few proactive steps, your team can offer payment plans that reduce patients' anxiety about what they owe, automate the collection process, and settle the patient's balance in six months or less.

Telling patients they'll owe a big chunk of cash 

 they have their surgery or office procedure is psychologically preferable to hitting them with an unexpected bill afterward. And as deductibles skyrocket, many patients now ask how much a surgery or procedure will cost, especially when it's elective or when patients are seeing your physicians out of network. From the patient's perspective, it's as important to have a plan for paying the bill, as it is to have a plan for treatment.

Integrate the conversation about money into your scheduling procedures or office visit processes. Provide a written estimate that shows the insurance plan allowables for procedures and services, minus the patient's unmet deductible, coinsurance, copay, and non-covered services. A clear understanding of what is owed can reduce patient anxiety and improve satisfaction.

These free, online tools are available directly from payers, or through a clearinghouse.. Enter CPT codes and the patient's identification data, and get instant access to contracted rates and unmet deductible and coinsurance amounts, as well as non-covered services.

If a cost estimator is not available for the patient's plan, or there is a question about whether cost estimator data is accurate (accuracy can be hit or miss with some payers, and in some regions), HealthcareArithmetic offers an iPhone app calculator ($1.99 in the iTunes store) that does the math, after your staff contacts the plan for the data points.

Just as they pay for Netflix or a gym membership, patients appreciate the option of automating payments on a credit card. But you can't expect staff to remember who-owes-what each month, and manually run everyone's credit card. Not only is it labor intensive, it's risky to leave patient credit card data lying around the billing office. Instead, use a Payment Card Industry Data Security Standard (PCI DSS) compliant, third-party vendor such as TransFirst, EasyPayCollect, or PayPal. These vendors automate the payment processing, properly store patient credit card data, and mitigate your financial risk.

When setting up recurring payment plans, strive for a three- to six-month pay off. Ask patients to pay a portion "down," then divide the remaining payments equally. For example, if the patient's unmet deductible for knee replacement surgery is $1,875, you might ask for $500 up front to secure a surgery date, then divide the remaining $1,375 and ask the patient to pay $343.75 per month for four months. If this presents a hardship, empower staff to negotiate the number of months until payoff, and come up with a plan that both the patient and the practice can live with.

Providing a written estimate and offering automated payment plans are effective solutions for most patients. But for those who need more time to pay, especially when a large balance is the result of an accident or an unexpected medical procedure, financing is a great way to avoid bad debt write-offs, long-term payment plans, and sending patients to collections.

Here's how it works: The practice is paid in full by the financing company in as little as two business days, getting the money into your bank account and off the books, with no fuss and no ongoing statements or staff intervention. The financing company takes a small service fee, which is nearly always less than the cost of staff managing the process, or the patient defaulting on payments. The financing company manages the entire collection management process, including following up with patients who don't pay. Depending on the company and the programs you choose to offer, 6-month and 12-month zero financing plans are common, with longer-term financing available as well.

Asking patients how they plan to pay off a $2,000 balance can make some staff squeamish. Ask your team to take turns "playing patient" so everyone practices having conversations about money.

Walk through the process of calculating the written estimates. Practice negotiating the number of months in the payment plan. Insist each person practices with eight to 10 "virtual patients" before they are turned loose on your real ones. Doing so will identify training needs and knowledge gaps, and build the confidence required for setting up payment plans with aplomb.

is a writer and content developer with KarenZupko & Associates, Inc. She brings 22 years of practice consulting and training, as well as healthcare technology product and executive management to her projects. She can be contacted at 