George Conomikes

Last week, we share some reasons why you should evaluate a practice manager and first steps you could take in this process.  The following guidelines relate to performance goals for the practice manager that helps promote a well-run medical practice. One purpose of this review is to note areas where performance goals are being met. The second purpose is to address areas where performance goals are not being met. In this latter case, corrective actions should be sought and timetables established for meeting the stated goals.

The rating scale to be employed is: 1. Performance is better than goals; 2. Meeting goals; 3. Not meeting goals

Financial Management - Billing and Collections

1. Net collection percentage. Goal is 95+ percent. Based on quarterly or annualized data.

2. Accounts Receivable Aging Analysis. Accounts over 90 days should be no more than 25 percent of total A/R. Exclude anyone on payment plan, legal cases and OB care.

3. Accounts Receivable Ratio.
For primary-care practices - goal is 1.5 months. For specialty practices - goal is two month. Should be calculated minus credit balances

4. Denials and down-codes. Goal is to address within three business days. Are these being monitored to determine if staff is submitting "clean claims?"

5. Is the manger up-to-date on coding changes and also looking for atypical coding patterns among physicians?

6. Cost of Business analysis. Annual study of RVUs to determine practice break-even points

7. Accounts payable.
Checks written with controls. Pay only from invoices and restrict check-signing privileges. Ensures that credit balances are promptly paid to plans and/or patients

8. Maintain an effective and productive staff.

11. Recruit, select and train staff. Directs cross-training of staff to improve productivity.

12. Review and update job descriptions and job standards for each position.

14. Conduct performance reviews and salary reviews, with physician input.

15. Keeps physicians updated on personnel problems and needs. Recommends solutions.

16. Directs the development of practice marketing materials. Practice Information booklet.

17. Directs or conducts the promotion of practice with referring offices and local major employers.

18. Makes sure the practice facility is in top condition and a pleasant environment for both patients and staff.

19. Enrolls in management training programs

20. Networks with other local practice managers

21. Subscribes to management and practice management publications.

25. Is a good communicator with physicians

26. Maintains a professional appearance in manner and dress

27. Is punctual and viewed as hard working

29. Is well organized and carries out work systematically

Add Guidelines for the Larger Practice Administrator. 

The larger group practice administrator usually has a wider range of responsibilities. These would include the following skills that should be evaluated by the physician owners:

30. Budget-Annual projection for next 12 months. Helps in setting production and profit targets.

31. Profit planning-Annual exercise to help the physician(s) set profit goals (i.e. take-home income). This goal-setting allows you to set production or collections targets and keep track of them.

33. Investigate and make recommendations regarding new services, new equipment, new and expanded facilities and satellite offices.

35. Networking with practice administrators of same specialty.

36. Active involvement in specialty-society manager activities.

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Knowing how to evaluate a practice manager is vital to your success. Here are 36 specific guidelines that can be used. 

36 Guidelines to Evaluate a Practice Manager

Most practices conduct performance reviews with their employees. However, we have found that the great majority of physicians, whether solo or group practices, do not undertake a periodic and thorough review of the manager's job. This can result in the following problems that we encounter in our consulting assignments:

1. The manager does not have a clear definition of her criteria for performance. In these instances, the manager establishes the criteria that seem most suitable to the job at hand. The problem is there may be areas meriting managerial involvement that become neglected. We have been to practices where the manager regards the job as, almost exclusively, personnel management. This can result in a lack of oversight regarding billing and collections activities - the financial lifeblood of the practice.

2. The physician(s) does not have a clear definition of the manager's job. For example, we have witnessed recent cases of physicians looking into EHRs without manager involvement. The rationale: This is a clinical exercise best undertaken by the clinicians. Yet, when investigating EHR, the possible integration of these systems into the A/R system - perhaps even meriting a new A/R system - carries a high priority in EHR investigation. The practice manager definitely should be part of the study, if not heading it.  

And, in some settings the physician attitude is, that as long as the practice is performing well, the manager's job is assumed to be functioning properly. But when this is not the case, it is not unlikely that the physician(s) will put some of the blame on the manager. In a group practice, we often observe that different partners have differing interpretations -not only of the manager's job - but also regarding the manager's performance.

The evaluation form should not be taken as the final definition of your practice manager's performance criteria. In the smaller practice, some of the tasks listed may not be the responsibility of the manager. In these instances, the non-qualified tasks should be eliminated from the evaluation form. However, for the tasks that are part of the manager's job at your practice, the goals indicated are realistic and generally agreed upon by practice management consultants.

Both the manager and practice physician(s) should spend time reviewing the guidelines. Are all of the guidelines relevant to your practice's manager position? For example, in some smaller practices the manager does an annual budget. Yet it is listed here, not for the smaller practice, but for the larger group. Again, some smaller-practice managers are very much involved in negotiating with managed care plans. And a few practices have the accounts payable work being done by a part-time bookkeeper, even a practice owner's spouse. Therefore the guidelines should be modified, as seen fit for your practice

Practice managers will find the evaluation form very useful for their work. First, they can get a better picture of goals related to each of the many tasks in the manager's job. Second, they can use the guidelines for self-evaluation. Third, they can feel comfortable that their physician bosses will use the same criteria in evaluating the manager's performance.

Physician Involvement - Initial Study of Guidelines

Physicians should closely review and study the guidelines. Then, in conjunction with the practice manager, they should modify any of the guidelines for their practice. Once that agreement has been concluded, it would probably be feasible to consider an initial evaluation in three to four months. Subsequently it could be done annually.

Physician Involvement in the Manager's Review

In a group practice, each physician should be provided an evaluation form to review, study and complete. In a group, one physician should be the coordinator of these evaluations. Caution: do not calculate a composite "total score." The purpose of the review is not to provide a report card. Rather it is, first, to recognize those tasks that are "meeting goals" and "better than goals." These merit being acknowledged and commended to the manager. Second, and most important, special attention should be addressed to any tasks "not meeting goals." These need close study. The physician(s) should seek answers to help solve the low-performance tasks. For example:

A. Many managers are also involved in non-managerial tasks (billing, collections, medical assisting, etc.) as well as managing. Are the non-managerial tasks interfering with the manager's performance? If so, can some of the manager's non-managerial work be delegated to someone else? Example: Can payroll be done by a service?

B. Does the manager need to do a better job of planning the work? Perhaps the manager allows too many interruptions from co-workers. Or, is the manager micro-managing employees who are capable of working under less supervision? In a group, one physician should be delegated to conduct the manager's annual performance review.

The practice manager and physician can benefit from a thorough review of a practice manager's performance. Here are first steps you should take.

Guidelines for Reviewing the Practice Manager's Performance

Physician compensation is a key source of physician satisfaction or dissatisfaction. And it is the number one reason why physicians leave groups.

Medical groups need the stability that comes from close attention to each group's unique requirements.

The most common failing is that emphasis is placed on actual plan design. What is needed is a set of clear-cut strategies to build the foundation for good plan designs. 

The following strategies are tools for your practice.

1. The Primary Goal of Your Compensation Plan is the Preservation of the Group

Physician turnover has destroyed many practices. Studies have shown that it costs more to replace departed physicians than their salaries. Additionally, potential replacements see red flags when being recruited to replace physicians who have exited. And, worse, it is not uncommon for the departed physicians to remain in the community or nearby, thereby taking "their" patients with them. This means that the replacement physicians have to build new patient bases. The consequence: The replacement physicians may require two to three years to make any real contributions to the group's overhead.

Consider this, in a six-physician group, you may have five happy campers and only one doctor who is unhappy.  As consultants, we have found that these less-happy souls are usually the top producers and want the formulas changed. A pleased majority is not to be interpreted that the formula is working. For example: we worked with a six-physician pediatric group where the high producer wanted the long-standing, equal-share formula changed to provide more reward for production. The remaining five partners had resisted for some time, since changing the formula would result in less take-home for them. However, if he left, all of their overheads would quickly rise, resulting in much less take-home than if he stayed. We also pointed out that a replacement pediatrician would not be as productive for some time.  For these five, it was choosing a little less income versus a lot less income. They chose to allow him greater rewards, agreeing to a production-based formula.

It helps to anticipate changes. In too many cases the physician requesting changes has expressed an interest in change, but has not made these requests formally and clearly.  At a later stage, this requesting physician, still unhappy with the current plan may be seeking a quick decision, only to be stalled - and decide to exit. An annual review with each physician member of the group may help pick up "early warning" signs of dissatisfaction.

Surgery groups usually have different formulas than primary-care practices that are, in turn, different than medical specialists. Some multi-location groups have found that formulas that apply to one locality may not apply to others. One same-specialty practice could be hard-charging; another, more laid back. For example, one of our client internal medicine groups, valuing time off, opted for eight weeks of vacation per year and is willing to take home less. Others thrive on production, working more hours per week and per year.  This is where the annual review, the one-on-one discussions with each physician, the review of production data, can all be combined to arrive at improved formulas, when called for.

These guidelines may help you address a critical part of group success. Before defining compensation formulas, focus first on simple strategies: 

- Recognition that not everyone is pleased with current or new formulas;

- An annual review with all group members to let them know that their opinions matter;

- Different groups may require different rewards and different formulas.

Many physicians and administrators know they cannot impartially review their compensation plans.

They often determine that these sensitive issues are best left to outside experts - who are not involved with the physicians on a day-to-day basis. Instead, they have relied on their accountants or practice management consultants.

Here are four strategies to make sure that your physician compensation does not fail and you find yourself having to replace a departed doctor. 

Why Many Physician Compensation Plans Fail

The recent escalation of patient deductibles and copays has made it more difficult for the patient to be ready to pay for services at your practice. It is important for practices to educate and guide patients regarding their copays and deductibles.

The clue to improve your front-desk collections is preparation. If your front desk does not collect from the patient while at the practice then you will have less revenue, weaker cash flow, and more work.

 Review the accounts receivable with the names of scheduled patients. Patients with still-outstanding balances should be given a reminder call or email that includes a reminder on the outstanding balance. Those messages ask these patients to call, by name, a billing staff member to confirm their appointment. When these patients call, they are reminded of the outstanding balance. With larger balances due, and some starting to age, patients are often asked to deal with these accounts in order to keep their appointments. This is why these reminder emails/calls need to be clear about the name and number of the key contact person in your billing staff.

 You may prefer to couple this with Step 1. All accounts of those scheduled should be reviewed. Most of the following three activities can be assisted by your clearinghouse. For each established patient:

- Determine their eligibility. Check if they are still actively in the plan. If not, a billing staff call to the patient should get more current data. And patient data can be updated at that time.

- Determine if any deductible is due. If so, this should be noted in the appointment schedule.

- Determine the amount of the co-payment. This should be noted in the appointment schedule.

Many practices are unaware that their clearinghouse systems can provide data on patient eligibility, deductibles, and copays. The following leading clearinghouse companies provide the usual claims submission functions, but also provide the data being sought in Step 2. Their customary charges, including all these services, are usually in the range of $80 to $125 per physician, per month. Clearinghouse companies: RealMed; Gateway; Navicure; and ZirMed.

These preparatory steps will lessen pressures on your front desk staff and will result in much improved collections results.

There are two simple steps practices can take to improve front-desk collections from their staff in the age of the high deductible. 

Author | George Conomikes

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