Derrick Berger

Everyone is probably familiar with the ANSI 5010-formatting deadline, and we all thought we knew how it was going to impact our lives. Just in case, here is a brief history: The electronic transaction standard was going to be enforced on Jan. 1, 2012. On Nov. 17, 2011 CMS gave everyone a 90-day period of enforcement discretion. 

This created more confusion with providers and, I’m sure, carriers. 

For myself, I had to verify several times what they meant by “discretion.” Basically what I learned is that it meant you could convert if you wanted, but didn’t have to until April 1. I think this created more problems than just making a decision to convert or not.

So how did this situation happen? Here’s my perspective. First, the original information was poorly communicated. This is not surprising, as CMS never really does a good job of communicating …anything. In addition, the CMS website is difficult to navigate, let alone find anything “meaningful.” The enforcement decision was too close to the original deadline, which also created more problems.

The individual Medicare Administrative Contractors (MACs) aren’t any better at communicating. Anyway, I relied on my usual source, the AUA’s Practice Manager’s Network, which runs a listserve in which subscribers can participate (ask questions, answer questions, etc.)

No one posting on the listserve really knew what they should do next: Were there problems? Were the carriers having problems? Were the clearinghouses having problems?

I honestly wasn’t sure if we were in a testing phase or not. It took the impetus off testing for our practice, but I went ahead and pulled the trigger and switched all my carriers over to 5010 by the January 1 deadline.

I didn’t notice anything at first and just thought it was just normal “first of the year issues” (deductibles not met). January is usually one of the slowest months of the year for us in any case. About mid-January, I started looking into why clean claims from Medicare that are normally paid at 14 days had not yet paid.

I noticed our Medicare “bucket” for current claims was filling up more than normal. (Your MAC has to pay a clean claim in 28 days but not sooner than 14 days.)

I started worrying at day 21 and tried in vain to find a pattern:
• Some had been paid and others hadn’t. I couldn’t find the difference.
• I had our biller call on some claims that hadn’t paid. 
• They were “in process.” 
• I wasn’t receiving denials or exclusions, the first two things we normally are alerted to if there’s something wrong with a claim.

Finally, I heard from some other folks on the AUA Practice Manager’s Network who were experiencing the exact same thing we were with Medicare - delays with no patterns, no explanation. Some of them had it worse off than us. Ours were trickling in but some had had all of theirs rejected. Most of the ones I heard from had to use their line of credit since it created such a cash flow problem. We haven’t gone that far yet but if it doesn’t improve in the coming weeks, we will.

This entire time I have yet to hear any announcement from any carrier, clearinghouse, or CMS about the status of the conversion or what could be potential problems. This underscores the real problem in all this, communication.

In the end, I think it was the right thing to do but communication should have been better. And I think they should have announced their decision to wait earlier on; 45 days before go-live is unacceptable. My advice is to diligently watch your claims process. Make sure claims are at least in process, that the carrier has received them and they’re not in never-never land. Call the carrier and find out if you’re not sure. 

At least you’ll have an idea of what’s processing and what’s not. Good luck.

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The enforcement delay for 5010 may have been a relief to some, but has caused confusion for most.

Lack of Communication Leading to 5010 Conversion Confusion

When you are going to spend a lot of time with someone, you want to make sure they have the same goals and values as you, will grow with you, and will be pleasant to spend time with in good times or bad. I’m referring of course to your electronic health record (EHR) or practice management system.

Our search started over five years ago for our current system, when we launched our practice. I have an IT background so I knew somewhat what it was I looking for from a technology point of view. Since we were starting the practice from the ground-up, and moving to a new area to start the practice, we didn’t know anyone to ask - either professionally or nearby. So I really didn’t know where to start or what I was looking for.

I first used Google and Yahoo to narrow down the searches. I know that sounds naïve but I based it on rankings on these search engines. My method: I assumed if they had a sponsored link or were in the top five to 10 results, they were valid.

I used the Google and Yahoo results to build my short-list and settled on 10 vendors, and then looked for reviews of any type for each. This required me to search even further in the search results to see if anything would come up (good or bad).

I also used KLAS Research to make sure the vendors on the short-list were at least on their list of reviewed vendors. Capsite Research was somewhat helpful here too but I felt like KLAS had more relevant information in their reviews.

Next, I made a long list of questions that I would ask any vendor when purchasing software. These were mostly technology questions and some functional questions, which were difficult for me, since I didn’t have any clinical or work flow experience.

Examples of some functional questions: 
1. Can you batch patient statements to send them at once?
2. Is there a claims scrubber to pre-process claims before they are sent to clearinghouse?

Examples of technical questions are more like:
1. Is the PM/EHR a cloud-based or client-server based?
2. Are the PM and EHR single-sign-on (do they have separate logins or same login)?
3. What type of redundancy do you have a server level, data-center level, etc?
4. Who audits your security?

Showtime. I called the various vendors and spoke with the sales staff. Some took the time to respond to my questions and others wouldn’t answer until I saw their demo. This was another way for me to narrow down the list since this felt too much like a pressure tactic. I removed them from the list.

The Shorter List (or Short List of the Short List)


Now I had narrowed down the list to about three to four vendors. The next step is to ask the vendors for a reference, but I’m not a huge fan of this step. Typically the reference is someone who is very happy with the vendor.

I used the demo as the biggest single factor in selection. My reasoning here is because I wanted to make sure our choice was easy to use. Due to my lack of clinical workflow experience, I had to make sure it was easily adaptable and flexible to different workflows. In other words, I wanted something that wouldn’t require a lot of training but could grow with us if our needs change. It was mostly “fear of unknown” syndrome. I didn’t know what I didn’t know.

The vendor I ultimately chose answered the questions thoroughly, told me things I wasn’t even thinking about, and gave me a good feeling about the flexibility of the system.

Ask someone - even though I didn’t, I should have. Hopefully the reference you use will provide you with the good and the bad.

Get a list of questions and send them to your salesperson. This gives you really good insight into how comfortable they are with the product. It also forces them to ask other departments. More than likely they won’t know how to address security or many technology questions, and this process also allows you to see how the company works internally somewhat; i.e. Was the salesperson able to easily find this information from the IT department?

Take your time and do as much homework as you can. Ask people in your specialty, and even more specifically, someone the same size as you.

Why finding the perfect EHR or practice management system for your medical practice is like “The Dating Game.”

Choosing the Right Technology Match for Your Medical Practice

We use a large Internet host provider for domain registration, website hosting and email hosting. Although their reliability is great, I felt like our e-mail functionality wasn’t keeping up with our work flow. We had to use Microsoft Outlook as a standalone client or their e-mail client within a browser, a non-starter since it lacked even basic functionality like flagging, filters, e-mail address remembrance. With Outlook, if an employee changed computers during the day, their e-mail didn’t follow, and we couldn’t share calendars or have central calendars without installing Microsoft Exchange - which we’re too small for. Finally, Outlook is limited in how it syncs with the phone. It really doesn’t; it just pulls messages.

I started looking around for alternatives to see if possibly we could host Exchange offsite but it only solved some of my problems. I've used Google's G-mail for probably close to eight years now on a personal level and I have used it for another business I have for over a year.

With the other business, I use the Google Apps for Business product, which seemed like a logical choice for our practice. So I asked around and found out my daughters’ school just switched over from Outlook to Google Apps. So I decided that over the holiday break I would migrate our mail, calendar, and contacts.

I’m fairly technical so I didn’t have a problem doing the migration but I also always read the directions (toys, new cars, new toaster, etc.) I followed their directions and it was amazingly simple. You just have to follow the directions to the letter. They even tell you how to change your Internet provider’s settings.

I created the account and planned for some downtime while everyone was out of the office to do the migration. I moved the MX records over (these are e-mail records that tell your domain registrar where to route mail) in a matter of minutes. I then moved my e-mail over from my Outlook client to test some functionality before I committed anyone else’s e-mail.

I keep most of my e-mail, so the process for my account alone took 12 hours to move. I think their typical client has a much smaller file size. The smaller e-mail files in the office that I migrated took only a few couple of hours and went very smoothly. It moves over e-mail, folders, calendars and contacts, moving the latter two very well.

We’ve been using Google Apps pretty solidly for about three weeks since installation. I’ve had minimal complaints and most requests are just questions about how to do something differently.

The training was minimal since most people already have a G-mail account. We also use Google Talk to let the physicians know when a patient is ready, e.g. “DB is ready in 2.” They love it!

I’ll mention the cons first, since these are fewer and not very impactful:

1. The migration for the individual e-mail files was tedious but very doable.
2. Outlook still has the best and easiest to use client (but not the most powerful). And it’s what most people are used to.
3. Outlook has better word processing functionality. It’s basically Microsoft Word.

In fact, I’m actually composing this blog in Word and then I will copy and paste into G-mail. But for almost everything else I can use the G-mail just fine.

There are a lot of pros to migrating to Google Apps:

1. Administration. You can administer everything from a central location, including passwords, file sharing, calendars, etc. Also you can control a lot of communication functions (“no instant messaging with outside users, no file sharing with outside users, etc)
2. No more backups of .PST files (a.k.a mail files).
3. Users can check e-mail anywhere, at anytime.
4. You can force an HTTPS (secure) connection for all users.
5. 25GB of storage / user (that’s a lot of storage space).
6. Cost: $50/user/year. (Outlook costs ~$200 /user anytime you install it).
7. Centralized dashboard which allows me to see: who is logged in, when they last logged in, for how long they were logged in, and where they logged in from. The dashboard also allows me to create calendars, install new app’s for the users in my organization, log support cases, etc. In other words, I can do anything I need to in my organization in this dashboard.
8. Phone sync works really well. It syncs both ways for calendar, contacts and mail. It is compatible with iPhones, Androids, and Blackberry devices (we have each of these in our office).
9. Centralized office calendar was HUGE for us. We can now see when everyone else is off, lunch plans, holidays, etc. It works very well!
10. Google Talk and limiting it to users inside your organization (this is what Google calls your company).
11. Very powerful email filtering, labeling and marking messages for follow-up.

Overall, the integration of Google Apps is a big win for us and it works very well in our work flow. I’m now looking at some different apps to see if they are applicable to us and I’ve been inspired to move our documents (patient input templates, patient handouts) to Google Docs. With Google Apps, I feel like it’s more secure knowing we are not using .PSTs or having to login to an unsecure site. I feel now we’re even 

My only regret? Not having done it years ago.

Moving communication to Google Apps at our medical practice has boosted our communication and work flow.

Moving our Medical Practice Further into the ‘Cloud’

We don’t often give raises. Believe it or not, our employees actually prefer this.

Instead we give an annual performance review “bonus” which is tied directly to our employees’ performance. Most employees, most years, are within the 90th percentile of their possible performance, and we award, for example 95 percent of their target bonus if they score a 95 percent. I keep the review spreadsheet form simple, just enough information to make sure we are on the same page and can discuss it if we are not. This simplicity was important for me; I’ve done performance reviews and appraisals at other companies and they can be very complicated and confusing. My feeling is that it’s not always beneficial for the employee to have an overly-detailed, convoluted review. Our process provides a chance for feedback for the employees and gives us a chance to discuss anything that comes up in the review process.

When we do the annual review, the physician has to sign off on it before I review with the employee. At a little more than two weeks pay, the money is about the same, but they get a lump sum and at that pay range, they appreciate it more. If we gave raises, we’d be tied to that pay for rest of their employment, and it also doesn’t make sense to give COLA raises. All our employees understand that physicians don’t receive COLA raises, so they can’t be passed on.

Holiday bonuses are given between Thanksgiving and Christmas. The amount employees get depends on how long they have been at our practice. Even if you’ve only been on the team for a month, you get something. We split this bonus up over two paychecks to minimize the impact on our cash flow. In this way, we can give the bonuses before Christmas.

Regarding a holiday party, we live in a small town about an hour south of Houston. Basically this means no upscale restaurants in our area. Chili’s is it, and because we go there every week we decided to do something else instead.

We rent a “bus” and take everyone and their spouses to dinner in Houston. We have a great time and everyone seems to really enjoy it. We get to meet each other’s spouses and get to know each other outside of work.

It might sound cliché but it’s a great bonding experience for us. We all have spouses, kids, etc., so our lives outside are typically too busy to socialize outside of work. We all work hard during the year and this is a great reward. 

Each year I ask if they would like to opt out of the dinner and just get a larger bonus. The answer is a resounding “No!” They all want dinner. 



We don’t often give raises. Believe it or not, the employees at our medical practice actually prefer this.

At Our Medical Practice, It’s Relationships over Bigger Raises

With Medicare cuts looming next month, I’m looking for where we can cut costs in our practice. I’m not much of a gambler - I even consider myself risk averse - but I’m willing to bet my equipment won’t break. Earlier this year we looked at equipment warranties as fair game for cost savings. I think this might be a place others might look too. 

An interesting question came up on the Practice Managers’ Network for the American Urological Association about purchasing extended warranties for expensive equipment, specifically ultrasound. Our practice uses ultrasound on a daily basis. Ultrasound probes are fragile and can cost $5,000 to $10,000 to replace and/or repair. Warranties/replacement plans/maintenance agreements average about $4,000 to 5,000 per year per device for this particular machine. Ours is currently 4 ½ years old and we have not had any problems (fingers crossed).

We have a smaller bladder scanner that costs about $10,000 to replace. It’s used a lot (almost 20 times a day). The warranty runs about $2,000 on it but this includes a calibration.

I very rarely buy extended warranties, replacement plans, or maintenance agreements on any piece of equipment. I feel like you’re gambling either way but the odds are in your favor if you don’t buy. The math is simple: If I bought the ultrasound warranty every year for the past year (first year “included”), I would have spent well over $15,000 without having to ever replace anything.

This has also been my policy on the personal side as well (TV’s, wireless routers, cell phones, etc). Cell phones call it insurance and it adds up to about $75 per year. I’ve only ever lost one cell phone in almost 15 years. My guess is that these are probably huge profit centers for these companies, medical or otherwise.

There is an exception, however. Last year I bought a printer for our front office to use. The printer was on sale for $450 from $550 at one of the larger office supply chains. When I went to check-out the clerk offered a replacement plan for three years for $39.95. That’s less than 10 percent of the purchase price and spread over three years. It also covered accidental spills, breakage, and or lightning strikes. I couldn’t say no. If ultrasound manufacturers and/or other larger expensive manufacturers provided a warranty/maintenance agreement with terms like this, I would gladly do it. My ultrasound probe that costs $7,000 new could have a $700 replacement plan over three years. I understand why they don’t do it since they know most people probably purchase their expensive warranty programs. I hope they understand as well when I kindly refuse year after year.

I can’t cut these costs but others might look to when renewing. I do have funds available should we need to purchase a probe, etc. There are plenty of companies in the U.S. that will do the repair for less than the manufacturer and which will provide a loaner.

The physicians and staff are all very well aware of how much these items cost. We roll the dice but I’d like to believe the dice are weighted in our favor.

We looked at equipment warranties as fair game for cost savings. I think this might be a place others might look too.

Are Medical Equipment Warrantees Worth the Investment?

Most every staff member in our practice knows how to do more than one job. When you have just two physicians and five supporting employees, only one absentee means your support staff takes a 20 percent hit, so each staff member and their knowledge and competencies are an investment for us. We cross-train by default and try to train before we are “forced to” but sometimes that happens, and in those cases it hasn’t been a bad way to learn.

Our practice management system / electronic health record (EHR) software is an important consideration in our training. Luckily our combined system is pretty easy to use; in fact we spend more time showing a new employee around the office than training them on the technology. We just need to give them a login and password to start, and they typically pick it up quickly. At the most, we may show them the basics, but very briefly, which is just as well because I am not the world’s best teacher.

For anything about the system that isn’t easy to grasp, the technology has multiple training videos that show how to complete any tasks step-by-step. These videos are available for all levels, and I definitely rely on them when a new feature comes out or during beta testing. Another underrated resource is the help file, which I find myself using quite often.

We’re also fortunate that our system supports cross-functionality. In other words, the back office has access to the same things our front office does. This means that the two nurses in the back office and the three in the front office don’t have to pass paper charts around, as we would have to do if we were a paper-based office.

This cross-functionality also helps when we do need to learn each other’s jobs. Because we don’t have a lot of room for employees to be promoted, trying out different jobs is a small benefit. Even though people are creatures of habit, change can be a good thing. Employees like the challenges of something new and the ability to change it up and do something else once in a while. In this case, we also get a strong appreciation for each other’s work, which you can only get by sitting in someone else’s seat for a day or two.

Besides our built-in training system with our practice management system and EHR, we offer other materials for employees, buying materials like books, video training, continuing medical education (CME) as needed, and offering the opportunity to take specific college courses applicable to the job.

Even though our training isn’t completely structured, it still exists and is used and appreciated. To be successful, we’ve found that you need to make sure people understand why they are learning what they are learning. And you have to look at it as an investment - which is exactly what it is.

From EHR use to simply knowing a colleague’s job, ongoing training at your medical practice is a worthy investment.