Laurie Hyland Robertson

A couple of years ago, my own physician sent me a hand-scrawled note along with some lab results that had turned out normal: “Hope you’re feeling better!” No provider before or since has made such a gesture - I’d call it alternative practice, in fact - and it’s one that really stuck with me.

But the majority of allopathic physicians would draw a Sharpie-thick line between my doctor’s action and “alternative care.” Why is this so? And does it really make sense for today’s healthcare needs? Consider that nearly three-quarters of Americans have sought “alternative” medical treatment at some point in their lives. Odds are, most of those folks are also the patients of allopathic physicians - they’re your patients. Clearly, they’re seeking something they’re not getting in more mainstream practices.

I see some providers automatically characterize the distinction between these care philosophies as “evidence-based medicine” versus “complementary and alternative medicine.” Is a clear division even helpful in treating today’s hyper-consumers (some of whom may, regardless of how misguided the notion, feel that they themselves have nearly as much expertise as their physicians)?

Maybe it’s time to consider a new way of looking at these boundaries.

A few more questions to ponder: Given the standard painkiller-plus-muscle-relaxant prescription for back pain, is simple, supervised exercise an alternative treatment for a bad back? It’s a cheap (and relatively effective) one, to be sure. But because it’s alternative, in the sense of “not done very often by traditional physicians,” does that make it suspect?

Physician rants against alternative medicine - as it’s more typically defined - are pretty common on the message boards and online communities I have regularly trawled for 

. Much of the vitriol falls into the category of opinion, and frankly, not a lot of the comments could be considered “evidence-based” under even the loosest definition of that term. As plenty of physician writers have noted, what constitutes evidence for one group - say, a young, male university student who is Caucasian taking part in a trial - isn’t necessarily relevant to members of any other group, but the “evidence” is often applied as if it is. And a lack of such “evidence” is used frequently to condemn with broad strokes.

Granted, the pool of available patient dollars seems to dry up a little more each year. But wouldn’t expanding the list of provider types to whom you refer benefit your patients? Are we really talking about a zero-sum game?

Maybe it’s time to think about eliminating the bitter undertone of competition from discussions of patients’ health choices.

Sure, the alternative medicine world has its quacks and charlatans. (As does allopathic medicine - consider the reproductive specialists who must’ve been involved in the infamous octuplet case.) So naturally, a heaping helping of due diligence is in order. As is undertaking your own education on available treatment options. Your patients will see other providers either way, so wouldn’t you rather be in that loop, ensuring that the care they receive is legitimate? 

It only makes sense to help patients get the most out of the time and money they’re inclined to spend this way anyhow. A nonjudgmental attitude from you will also make them more likely to tell you when they’re trying a new diet tea that could interact with the heart medication you so carefully prescribed.

Maybe it’s time to stop resisting and start considering how alternative medicine can play a part alongside what you do.

She speaks nationally on practice management issues, and is also co-owner and manager of Whole Chiropractic Healthcare, in Odenton, Md. She can be reached via 

Articles

Reconsidering Alternative Medicine


At the busy group we’ll call Rural Internal Medicine,* there’s a lot going well. Satisfaction and loyalty run high among patients, staff, and physicians alike. Revenues and cash flow are steady. Their EMR is up and running, with nary a stray scrap of paper in sight at this three-physician Maryland-based practice. Really, everything’s hunky-dory, with just one exception: Payers who continually change their already-inscrutable rules. 

“The administrative part is just unbelievable,” says practice administrator Jean Ellis.* “I’m not nasty by nature [but] you really feel as if nothing will get done if you don’t adopt a split personality.” The practice gets it done, but Ellis increasingly wonders whether the time devoted to certain relationships is worthwhile, and she and her billers bemoan the fact that they’re often forced to play hardball - not to mention a constant game of “Mother May I” - with payers. 

Although Ellis’ staff seems to be doing just about everything that can be done to make payer interactions as painless as possible, a check-up is sure to uncover additional opportunities to improve. To effectively address these issues, Rural Internal Medicine - and other practices that may not be so adept at playing the payer game - will ultimately need to break them into specific problem areas, looking perhaps at slow payers, eligibility and authorization questions, poor reimbursement, and simply pinning down shape-shifting policies. Here is an overview to get things rolling. 


Ellis’ billers track insurer hassle factors by running regular queries from the practice management system, graphically analyzing, for example, response to level 4 and 5 submissions by payer group to detect denial patterns. As a result, the practice now strictly requires that patients sign advanced beneficiary notices, and they’ve made a decision to always “bill what they’re doing,” regardless of the expected payer response. A small sign on the front desk alerts patients that a number of payers are on the practice’s watch list; patients with these plans are advised to seek guidance from their HR departments or insurance brokers to determine whether they might be able to switch to an alternative company. 

As insurance company “customer service” becomes an ever more egregious misnomer, patients increasingly look to the practice for information about their coverage. This forces the staff into developing considerable expertise on a myriad of payers’ plans and policies. There’s a tipping point to all this learning, where holding onto certain payers may no longer make sense. Payers that represent a relatively small proportion of patients or those that set up roadblocks to providing good care should go on the watch list, or even be cut. Limit participation only to those plans offering the most juice for the squeeze, so to speak. 

For denied claims, focus efforts on the most damaging types. According to revenue cycle management firm athenahealth, coverage-related problems result in particularly long cycle times. Expect to wait up to 40 percent longer to get paid for those claims than for claims denied for other reasons. Clearly, the before-visit, new-patient process merits extra attention. Perform whatever verification activities you can in advance. This is your chance to find out what copay or deductible the patient might be required to pay - and to communicate that information, as well as reiterate your billing policies in no uncertain terms before she arrives at your reception desk, grinning sheepishly and saying, “I’m so sorry - I must’ve left my checkbook at home today!” 

Information on patient copays, deductibles, and coinsurance amounts is increasingly available from payers, so make use of it. Many consultants say that online is the most reliable way to obtain eligibility data, and Rural Internal Medicine’s experiences bear this out. Particularly problematic payers, however, may necessitate a multimedia approach - for some, the automated phone system is the most up to date, whereas others’ reps are the prime source for reliable information. Add this to the list of payer quirks to know and track. Unless a payer has full-on real-time adjudication - which precious few currently do - online systems may prove best for general checks of eligibility rather than determining coverage for specific tests or procedures. 

Athena and others, such as the consulting firm The Verden Group (through which you can sign up for payer policy change alerts), also maintain databases of evolving payer rules, informed by the claims they process for their clients, so that practices using their services don’t have to expend the energy to keep up. Even the smallest practices are starting to outsource billing and collections in response to the type of difficulties Rural Internal Medicine is facing. As payer rules become more complex, automating billing functions through a revenue cycle management company is becoming more attractive to avoid the tedium - and, let’s face it, the increasing impossibility - of keeping track manually. 

Another tactic to make things easier in the long term is maintaining a master file of verification forms for each carrier and group. Take time to update the forms annually (or more often, if coverage changes) and cross-reference them with your denial reports, but you’ll have a single go-to spot for basics, such as copay amounts, along with the payer’s contact information. Organizing the billing and collections teams by payer also makes administration a little easier, as each biller only has to remember the rules of a handful of payers rather than all of them. 

Ellis should also selectively approach payers about their rules. For example, if a payer requires preauthorizations but then approves them 95 percent of the time, present that data. Perhaps preauths aren’t really necessary for “routine” care? 

More burden-reduction strategies that lie outside the practice itself include a scanning lockbox, which would have the bank receiving and processing EOBs, and remote capture for checks - both simple means of increasing efficiency in the face of rising payer demands on Rural Internal Medicine’s time. 

In addition to carefully prioritizing which payer quirks most urgently require staff attention, Rural Internal Medicine should also give top billing to the larger issue of streamlining its approach to payers’ administrative requirements. Perhaps while payer concerns remain initiative Number One, the practice would continue to verify every patient’s eligibility, even though that may not be the best ongoing use of staff effort. 

It’s OK to shift your primary management focus, and to create task forces to address particular problem areas. You’ll avoid staff fatigue and the problem of being blinded to an issue, which can happen in the presence of a constant low-level background drone from a host of smaller problems. True, there’s no silver bullet to fix the problem of burdensome payer rules, but resolving the above little things is at least a start toward a larger solution.

This article originally appeared in the March 2009 issue of Physicians Practice.

A busy internal medical practice learns to push back at payers’ administrative requirements.

The Great Practice Makeover: Undue Burden


Bill Sinclaire, MD,* has a tough decision to make. The payer that covers 40 percent of his patients reimburses at levels that verge on scandalously low - below Medicare, below Medicaid, and below every other payer in his area. As a result, he and the other psychiatrists in the Southern practice where he’s medical director are seriously considering dropping this payer. Still they’re justifiably worried about the hit revenues will take, and about what will happen to their patients who can’t afford increased out-of-pocket expenses. 

Sinclaire brought in a consultant to work with this payer’s reps to try to improve rates, but the consultant hit a brick wall. “I think she was sort of led on for a couple of months,” he says. “They talked with her as if they were open to negotiation. She got together claims data to submit to them, and after talking to them over about a period of two months, [the payer] came back and said that they weren’t willing to negotiate, and in fact the rates were set across the state.” 

Even more maddening, Sinclaire knows of several other specialists who have had success in negotiations with this particular payer. But that’s actually good news: It means Sinclaire shouldn’t give up. 


Aside from knowing that this payer can be negotiated with, Sinclaire has a few more tools at his disposal for dismantling this intractable payer’s brick wall. 

He definitely needs to push back on the assertion of a set rate across the state. With the exception of certain aid programs, it’s unlikely that a truly mandated rate exists. A national rep from this particular payer tells Physicians Practice that the company absolutely does not have a ban on negotiating with psychiatrists, so, frustrating though it may be, at least one more salvo is in order. 

Sinclaire needs to conduct a detailed review of the terms of each contract - not just the ones he feels are especially onerous. Although he has a fairly good handle on his various payers’ allowables, a closer look wouldn’t hurt. Too many solo docs unwittingly end up employing an overly simple heuristic as a substitute for thoroughly analyzing the true patterns occurring in their practices. Too many also assume they’re actually getting paid the contracted rate, and plenty more aren’t attempting to objectively classify each payer’s “hassle factor.” 

Try a simple ranking method that accounts for the volume of procedures, automatically assigning greater weight to the reimbursements attached to the services you provide most frequently: Over a period of six months to a year, calculate average total dollars received per visit. Take the total amount collected for each contract or government program, and divide it by the number of patient visits over the same period. The resulting values will help you more accurately compare your payers. 

In addition to objective fee schedule criteria, consider more subjective measures such as physician and staff time to collect on claims, and the time and effort involved in resolving administrative issues such as credentialing or trying to recover disputed claims. Look, too, at average number of appeals required and time spent on preauthorizations for each payer’s patients. 

Sinclaire might also consider contracting with additional plans in the area, or at least approaching them, so he’ll have more information with which to “prove” the going market rate to the poor payer. Colorado-based consultant Marcia Brauchler often helps clients negotiate with managed care companies, and she recommends compiling a list of your state’s insurers, along with how many covered lives each one represents, to target your efforts to the players that matter in your market. (The state insurance commissioner should be able to provide this info.) 

Creating your own carve-outs also can be an especially effective strategy for specialists, too: “Mr. Insurer, how about you pay me 120 percent of Medicare’s rate for codes X and Y” - codes that constitute a sizable proportion of your business, of course - “and I’ll make you a deal! I’ll accept just 85 percent of Medicare for every other code I bill!” 

Before you take the step of dropping a poor payer, tell them about your plans. Pointedly. Take the matter as high up the food chain as you possibly can, and enter the discussion armed with data. For Sinclaire, that would include his perpetual two-month waitlist for initial consultations and a limited number of colleagues to whom he can refer the overflow. Patient satisfaction data and any compelling outcomes stats would come in handy as well. 

Also ask patients or their caregivers to contact the insurer - and their employers’ benefits offices - on your behalf. It’s like politicians getting pressure from their constituents, and payers do listen. 

Finally, says Brauchler, find out if your state has on the books a statute or regulation requiring that managed care companies maintain sufficient providers to ensure “network adequacy.” Indeed, Sinclaire’s state has such a rule, which may mean that the payer must reimburse providers in a given specialty - the non-contracted folks, anyway - their billed charges (not just the payer’s allowable) if the ratio of patients to providers is too low. 

Some quick searching turned up more potential ammunition for Sinclaire’s negotiations: The county where he practices is a federally described Health Professional Shortage Area, a designation made by Health Resources and Services Administration of the Department of Health and Human Services. The bottom line: Don’t give in too easily, as help is available. 


Still, if the brick walls won’t budge, Sinclaire may eventually be forced to drop this payer. 

A loss of the magnitude the practice would likely suffer will be tough to weather. But exactly how big would it be? And how long could Sinclaire survive on that reduced revenue? Here again, base your projections on actual data from your practice. 

“What we’ve thought about doing is staging a withdrawal,” says Sinclaire. “We’d have one person drop off [the payer’s panel] and build their practice back up, and then have another drop off … .” This would be a time-consuming undertaking given the approximately 20 providers in Sinclaire’s practice, potentially stretching on for years, but it may be the best way to avoid crippling the practice’s cash flow and ensuring that the physicians feel comfortable with their patients’ continuity of care. 

They’ll have to be careful, of course, not to simply have all of Dr. A’s patients transfer to Dr. B when A drops the payer. And at the very least, assuming your contracts allow this, don’t accept any new patients under the plans you’ve determined aren’t worth dealing with. (Another reason you’ll have to be intimately familiar with each of your contracts.) Continue the patient education campaign, too, making sure staff have clear answers to pass along when that payer’s patients come calling. 

Plan ahead, ideally giving patients at least six months’ notice that you’ll no longer be accepting their insurance. Although there’s no need to delve into specifics, tell them why. Just keep it simple and non-accusatory (no whining!), and offer a list of the plans you will continue to accept (or otherwise explain how they’ll be able to pay you if you’re going completely cash-only). Try to post patient notices about changes in your practice’s contracting during early fall, as that coincides with most employers’ open enrollment periods - loyal patients may be able to switch plans to one you’re still accepting. 

Scan contracts for an “evergreen clause,” which means that your contract will automatically renew unless you give advance notification that you want out. The clause may stipulate that you submit notification a certain number of months in advance, or you may only be able to terminate during a certain period each year. You may also be obliged to continue accepting that payer’s patients, both new and established, for up to 12 months after terminating a contract with them. 

Terminating a payer contract may not be as easy as you’d think, but in the end that step may not be necessary anyway. 

This article originally appeared in the February 2009 issue of Physicians Practice.

An in-demand psychiatrist needs help leveraging his popularity for a more appropriate fee schedule.

The Great Practice Makeover: He Wants More Money. But He’s Worth It.


Kristin Murphy*, administrator of an anesthesia group, has a common complaint: “I’m having trouble recruiting intelligent people who can work independently for part-time work,” she says. “And when I finally get them trained, they leave as soon as a full-time position is offered to them. How do you find quality individuals who just want part-time work?” 

A familiar conundrum, but one that’s potentially devastating to a practice’s productivity, particularly when the staff in question handle your billing. Murphy has been filling the gaps with college students, whom she praises as fast learners, as well as with previous employees willing to work a few hours here and there. But the college kids are usually onto the next thing after a semester or two, and former employees are not reliable long-term, which is not too surprising. They had their reasons, after all, for leaving in the first place. 

All of this leaves Murphy spending precious time and energy training an endless string of new hires - and the practice’s cash flow on shaky ground - as everyone focuses only on meeting the next deadline. “It’s starting to burn out myself and the other gal who has been here a long time, having to constantly train people,” says Murphy. “It puts you behind on your own work.” 

She says the practice can’t afford to hire a full-time biller, and indeed, it doesn’t currently have enough work for another one anyway. But making the search for admin help even more challenging is the fact that even part-time candidates increasingly want benefits, too, such as health insurance coverage - essentially impossible to offer for this practice. “Since we are a very small company, our benefit costs are astronomical,” says Murphy. “We have dropped group healthcare coverage and put employees on individual plans.” 

Murphy feels she’s done her due diligence in terms of staffing analysis - she’s convinced that what she needs is part-time help - and maintains that her “current employees are working their patooties off!” Still, she wonders whether she’s overlooking anything that would help her retain quality part-timers, which is certainly possible. How to find out? 

When you’re faced with a situation as seemingly intractable as Murphy’s, start by questioning your underlying assumptions. In this case, that might mean determining whether the workload really doesn’t merit an additional FTE, and whether the folks you already have are working efficiently and at full capacity. Conversely, in light of the current complexities inherent in the reimbursement environment, it’s also worth analyzing whether a college student, no matter how bright, could actually be costing more than he saves. A top-notch billing pro could potentially bring more dollars in the door, which would cover that person’s salary and then some. 

Bringing in an additional FTE really might be justified if this new billing person proactively corrects issues on the front end. For Murphy that could even mean working with the facilities where her docs have privileges to improve, over time, the information coming into the practice. After all, says Murphy, “The part-timers are not there to fix their [own] mistakes,” and they don’t necessarily have a sufficient personal investment in the practice to consider their work a career. If she ends up correcting the same errors over and over - a snowballing time-waster if ever there was one - even the quickest short-termer becomes a liability. 

Possibly, the next step could be to entertain ways to take on 

 work to better justify an additional FTE (and then more realistically be able to offer the benefits in the first place). The physicians at this southwestern U.S. practice tell Murphy they’ve never enjoyed such profitability as they now have with her leading the administration. “We have a fabulous collection rate because we appeal so many denials,” she says. And, she says, the docs are thrilled with the staff’s ability to keep current with changing carrier rules. Idea: Perhaps it’s time to bring that expertise to a wider audience and seek economies of scale by taking on billing or other services for outside physicians. 

Or go polar opposite and outsource your billing. Consider a revenue cycle management vendor that would provide regular reporting. If you don’t like the idea of forking over a flat fee, consider an RCM company that charges using a percentage scale - if they don’t perform, you don’t pay. 

Offloading non-revenue-producing administrative work to a professional employer organization is another possibility. PEOs undertake a host of HR functions, usually for larger practices, but the value for Murphy could come primarily in the form of access to benefit programs. Expect to pay a fee or a proportion equaling about 4 percent of payroll for these services. Although it would mean giving up at least some control of staffing, that cost could be worth it to a practice like Murphy’s, which can’t find affordable health coverage for its employees and has trouble locating worthy job candidates. 

Providing an attractive work environment certainly helps draw candidates. This practice offers perks such as flexible hours and dress for those in clerical positions. And, she points out, plenty of the previous part-timers 

 end up wanting to come back at some point, even if only for short periods or, say, around holiday spending season. 

Perhaps Murphy could establish a more formal coverage network comprising these alums, a sort of extended job-sharing arrangement that would provide them a bit of increased financial stability. In exchange for being more regularly available, these folks might receive a slightly higher hourly rate, reflective of Murphy’s reduced training burden. 

Murphy plans to expand her applicant pool to more specifically include older folks as well. “We’ve advertised at the schools, Mother’s day out, churches, daycares as well,” she says. But the practice is located in an affluent area where women in their child-raising/parent-caretaking years - the group you might typically look to for such roles - tend to pursue either charity work or leisure activities to fill their spare time. “My applicants come from farther away, and as such really want full-time in order to make it worth the trip.” 

The specialty of anesthesiology presents some unique challenges. Obviously, one is the inability to capitalize on an often-fruitful recruiting avenue - the practice’s own patients. 

On the other hand, relocating the office to a neighborhood with a larger applicant pool (and lower overhead?) could be an option, as patient-facing activities all take place in off-site facilities anyway. 

Certainly, traditional advertising isn’t out of the question to find well-qualified folks, although word of mouth may ultimately prove most productive. For starters, ask local IM practices to keep their eyes peeled. Murphy might also look to retail and other service businesses in her immediate vicinity. And think creatively - even store greeters might have a lead for you. Approach one who’s on the ball and impresses you, and say you’re looking for someone with a personality like hers. Perhaps you can offer the attraction of a better work environment … Upon hearing this suggestion, Murphy’s understandably a little skeptical: “Oh, don’t tell me my next biller is going to come from Wal-Mart!” But you never know, do you? 

where we’re talking about how you find reliable part-time employees. 

This article originally appeared in the January 2009 issue of Physicians Practice. 


It’s a common problem: How do you find competent administrative staff willing to work part time? We help one practice solve this conundrum.