Patient Relations: Tighter Ships, Smoother Rides

March 1, 2006

A well-run office requires policies on everything from billing to no-shows. Make sure your patients know what your rules are. And ensure they stick to them.


With an office overflowing with sick kids, crying babies, and nervous new parents, a pediatrics practice may not seem like the sort of medical group that can run a tight ship.

But don't tell that to Laurie Brady, manager of Renaissance Pediatrics, PC, in Chesapeake, Va. At her practice, in which four physicians, four nurse practitioners, and a physician's assistant see their young patients in 26 treatment rooms, you can bet on the majority of patients keeping their appointments, arriving on time, and paying their copayments.

Her secret? Brady works diligently to ensure that the practice's policies governing appointments, payments, and other matters are closely followed.

Brady reviews these policies regularly to see if they need to be modified, and she makes sure her staff enforces them. Staff inform patients of the practice's rules via multiple channels, as Brady believes patient communication is crucial to the practice's success.

"We are constantly looking for new and better ways to communicate with our patients," Brady says. "They want to know what we expect, and we want them to know what we expect. We try really hard to post our policies through any form of communication. It protects us and the parents."

START OFF RIGHT

Like Brady, use the first opportunity you have to inform your patients of your policies - even before patients are patients, if possible. It is common within some specialties, such as pediatrics and OB/GYN, for example, for potential patients to visit a practice before joining. Whenever a Renaissance Pediatrics staff member gives a tour to the parent or family member of a potential patient, she explains their office policies and distributes a new patient registration packet.

The packet, which can also be given at a patient's first visit, outlines the practice's hours of operation, policies for appointment cancellation, instruction for medication refills, and the patient's financial obligations.

But don't assume your patients read everything you hand them. Remember to take advantage of additional "teachable" moments to reinforce your policies, says Jack Valancy, a consultant in Cleveland Heights, Ohio. For example, remind patients when they call to make an appointment that they will be expected to make their payment when they arrive.

Practices with Web sites also commonly post policies and procedures electronically. Renaissance Pediatrics has a section on its Web site titled, "New Patients," which has links to a "New Patient Letter," "Financial Policy," and "New Patient Registration" (www.renaissancepeds.com/faq.htm).

Review your policies on a regular basis to ensure they address your practice's current problems, such as difficulties with no-shows or copayment collection.

"I caution practices to be careful not to make really harsh rules for everyone if only a few patients violate the rules," Valancy says. "You may end up offending the majority of your patients."

THE DELICATE SUBJECT OF PAYMENT

In the same vein, you may not want to disclose all details of each of your policies. At Prescott Valley Primary and Urgent Care Clinic in Arizona, for example, if patients are referred to a collection agency for nonpayment, the practice's policy states that they are also dropped from the practice.

That fact is not revealed in new patient materials on purpose, says Dieter Krantz, chief financial officer and administrator of the seven-physician clinic. "You don't want to say that right at the start of the physician-patient relationship. It sounds a little too harsh," he says.


In response to nonpayment, the office first sends three letters seeking reimbursement. The third letter indicates that the patient cannot return to the practice if the account is sent to collection, explains Krantz.

Indeed, payment policies can be a sticky subject within practices, and getting physician buy-in is important, notes Valancy.

"What I have found is the physicians often don't agree amongst themselves about payment of copayments and deductibles" in particular, he says. Attitudes range from, "We are here to provide healthcare" to, "Patients have to pay up!" adds Valancy.

With sensitive issues like payment, Valancy recommends trying to put a "positive spin" on such policies while also getting your message across. For example, if a patient does not pay when requested, a staff member could give the person a self-addressed envelope so payment can be mailed later.

"We also want to make sure we have a feedback mechanism to see how this is being received by patients, if they are objecting to it, or if it is really effective," Valancy adds.

Once physicians agree on their rules, "the next step is to make sure the staff understands the policies and procedures and are well-trained," Valancy says. This includes knowing what to do when a policy or procedure is violated.

EMPHASIZE TRAINING, ENFORCEMENT

The Prescott practice has trained its staff to articulate its policies to patients, but they also can refer to a binder containing all the office's rules, says Krantz. Specific policies are also echoed in signs around the office. Signs near the front desk and in patient rooms remind patients that copayments are due at the time of their appointment.

Staff know policies and enforce them, Krantz says. If a patient balks at payment, a manager is automatically called to speak to the patient. According to Krantz, this policy has translated into a 95 percent copayment collection rate for the practice.

Of course, there's no point in having policies if you don't enforce them. Conduct regular reviews with staff members to see if they are being effective in enforcing patient compliance, and then examine whether your problems are being resolved.

Additional training may be necessary to improve staff compliance. Although Brady's office requires patients to submit their copayments at the time of service, there was a time when patients weren't paying.

"I think before it was rather lax, and we didn't really have any accountability. If someone was giving [employees] a hard time and not paying, they would just let them go," says Brady. "We had too many copayments that were not being paid, and we realized we needed to do something about it."

Brady noticed that some staff were too timid about collecting payments; they were asking for payments as if they were optional, rather than making it clear that payment was required.

So Brady spent an hour one morning before the office opened teaching staff members customer service skills and providing tips on being more forceful when requesting payment for services.

Now, says Brady, "We are collecting 82 percent of all copays" at the time of patients' appointments. "This is a 27 percent increase over last year."


Brady made additional changes to achieve better patient compliance with her practice's payment policies. Seventy percent of her patients have commercial insurance, 26 percent receive Medicaid, and the balance are self-pay patients or hold no insurance. The office conducts insurance eligibility checks on all potential patients using its payers' Web sites. These checks were originally performed one day in advance of a patient's appointment, but that gave the staff little time to investigate potential problems.

Now staff conduct such checks two days prior to each appointment. Patients are consequently questioned about lapsed insurance, enabling the office to more efficiently collect information on copayment amounts and other individual benefit policies.

ENFORCE YOUR APPOINTMENT POLICY

Similarly, staff call all Renaissance patients (or their parents) to confirm upcoming appointments; this also was previously done just one day in advance, and staff were permitted to simply leave voicemail messages. But the practice's no-show rate was steadily increasing, and Brady decided to refine this policy.

Staff now make appointment confirmation calls to all patients two days in advance. If a patient is new and the staff does not reach a person directly, they leave a message saying the patient's parent must call within 24 hours to confirm the appointment, or it will be cancelled. Parents with newborns are exempt from this policy. The office now has an 11 percent no-show rate, an improvement of nearly 60 percent over years past, Brady says.

To further ensure the office remains on schedule, the practice has adopted a strict policy concerning late arrivals for appointments that it has also posted on its Web site. Written to clarify this policy as much as possible, it reads, "In an effort to provide expedient services to all patients, we ask that patients reschedule if they arrive 15 or more minutes beyond their scheduled appointment time. We want to reduce the wait time for all patients ... Please be on time for your child's visit."

In addition, staff now give patients an appointment time that is 10 minutes earlier than their "real" scheduled appointment. If they show up more than 20 minutes after they were told to arrive for a well-child visit, their appointment is officially cancelled and rescheduled.

If the parent is there for a "sick" appointment, a staffer will phone the clinical area and ask whether the patient can still be seen then; if the answer is no, she is given the next available appointment for later that day. "Renaissance Pediatrics will never turn a sick child away," Brady explains, adding that the practice sees patients on schedule 90 percent of the time. This policy concerning late arrivals is communicated in the practice's new-patient packet and is also posted on the practice's Web site.

Brady says the policy has resulted in a minimal number of late arrivals. "Once this happens to a parent, they don't do it again, I can tell you that," she affirms.

FOLLOW UP

Brady's practice pays attention to more than patient adherence to administrative policies and procedures. Office staff also track whether patients follow their doctors' orders, such as keeping appointments with referred specialists.

A day after a specialist visit is scheduled to occur, a member of the staff phones the patient's parent to ask for a brief report. The practice's electronic medical record system alerts staff when such visits are scheduled so no oversights occur.

The practice instituted this policy of checking to see if an appointment was kept rather than waiting for a specialist's report (or realizing one was not forthcoming due to a missed appointment) after an unfortunate experience.

"We had a patient who was sent to an orthopedist for possible scoliosis. The mom was non-compliant and did not keep the appointment. A year later she brought the child back and she had severe scoliosis. We did not want that to happen again. We want every child to get the care they need," explains Brady.

Parents who continually violate office policies and don't keep specialist appointments can be dismissed from the practice, but that is ultimately up to the patient's physician. Brady shares this information with him or her and then asks for a final decision.


Asking a patient to leave a practice is obviously a last resort. Unless the parent is "just blatantly disrespectful" of the office's policies, "we will try to work with them," says Brady.

Adds Krantz, "People are people, and some are easier to deal with than others. We believe that most people really want to take care of their responsibilities."

Theresa Defino, an editor for Physicians Practice with more than 15 years experience covering economic, legislative, and clinical aspects of healthcare, can be reached at tdefino@physicianspractice.com.

This article originally appeared in the March 2006 issue of Physicians Practice.