Money Your Practice May Be Throwing Away


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Money Your Practice May Be Throwing Away

  1. 1. How To Reclaim Money Your Practice May Be Throwing Away The Cost of Inadequate Documentation and Incorrect Coding
  2. 2. Basic Premises <ul><li>Most physicians </li></ul><ul><li>Are not practicing medicine “for the money!” </li></ul><ul><li>Are competent, compassionate doctors </li></ul><ul><li>Enjoy helping others </li></ul><ul><li>Work long, hard, often thankless hours </li></ul><ul><li>Deserve the money they earn! </li></ul>
  3. 3. Stressors Physicians Experience <ul><li>Rising clinic practice costs </li></ul><ul><ul><li>Generally 40-60% of a physician’s revenue </li></ul></ul><ul><ul><li>Practice costs expected to increase 20% in 2008 </li></ul></ul><ul><li>Decreased reimbursement from insurance companies </li></ul><ul><li>Increasingly complex medical field </li></ul><ul><li>Increased requirements and cost for maintaining licensure </li></ul><ul><li>Increased pressure to improve quality without compensation </li></ul><ul><li>Exorbitant, rising medical liability costs and jury awards </li></ul><ul><li>Increasing violence directed at healthcare workers </li></ul><ul><ul><li>28% of ED physicians are assaulted each year </li></ul></ul><ul><ul><ul><li>Annals of Emergency Medicine 2005 46(2):142-7 </li></ul></ul></ul>
  4. 4. Additional Stressors <ul><li>Unrealistic expectations from the general public, legislators, lawyers, and insurance companies </li></ul><ul><li>Idealistic, virtually perfect performance from physicians </li></ul><ul><ul><li>Quality is an unfunded mandate! </li></ul></ul><ul><li>Essentially free medical care is a “moral imperative” </li></ul><ul><ul><li>(Hillary Clinton’s, 2008 Presidential Candidate, address to George Washington University Medical News Today May 2007) </li></ul></ul><ul><li>Healthcare providers will bear the cost of public health </li></ul><ul><ul><li>Emergency departments must treat all people who walk through their doors regardless of ability to pay </li></ul></ul><ul><ul><li>Hospitals require that doctors be on call for the emergency department in order to have the privilege of working at that hospital </li></ul></ul><ul><ul><ul><li>Doctors must then see patients who cannot pay for their care </li></ul></ul></ul>
  5. 5. There is No Free Lunch <ul><li>Food, Shelter, Clothing and Healthcare </li></ul><ul><li>Should the government provide these for free? </li></ul><ul><li> Should businesses be required to provide these for free? </li></ul><ul><li>Why should doctors provide free healthcare? </li></ul>
  6. 6. What Physicians Already Do <ul><li>“ Physicians are an important source of healthcare for many uninsured and underinsured patients, as evidenced by the fact that a physician’s office is the usual source of care for about one third of uninsured persons, and physician uncompensated care costs were estimated as high as $11 billion in 1994” Managed Care and Physicians’ Provision of Charity Care JAMA 1999 281:1087-1092 </li></ul><ul><li>Physician Survey (American Medical News 2006) </li></ul><ul><li>76% of physicians provided free or low cost healthcare in 1996-97 </li></ul><ul><li>68% of physicians provided free or low cost healthcare in 2004-2005 </li></ul><ul><li>Physicians spent 10.6 hours/week providing uncompensated care! </li></ul><ul><li>“ A Growing Hole in the Safety Net: Physician Charity Care Declines Again” Center for Studying Health System Change 2006 </li></ul>
  7. 7. Impact of Physician Stressors <ul><li>Medical practices are BUSINESSES! </li></ul><ul><ul><li>A business is not sustainable unless income exceeds expenses </li></ul></ul><ul><ul><li>Unlike most businesses, medical practices (physicians) are legally restricted in setting fees for services </li></ul></ul><ul><li>Reimbursement for physician services are decreasing, therefore physicians must </li></ul><ul><ul><li>See more patients to sustain the medical practice </li></ul></ul><ul><ul><li>Spend less time with individual patients in order to see more patients </li></ul></ul><ul><li>The consequences of an increased workload can result in </li></ul><ul><ul><li>An increased likelihood of missing problems </li></ul></ul><ul><ul><li>Decreased patient satisfaction </li></ul></ul><ul><ul><li>A significant drop in physician job satisfaction </li></ul></ul><ul><ul><li>Hastened “burnout” </li></ul></ul>
  8. 8. To Err Is Human . . . But Don’t Err On Insurance Documentation! <ul><li>Incorrect billing for the documentation provided </li></ul><ul><li>Regardless of the complexity, lack of clarity, and unending changes made to the system IS ASSUMED TO BE FRAUD! </li></ul><ul><li>And can turn a doctor </li></ul><ul><li>into a criminal! </li></ul>In less time than it takes to receive payment from the Centers for Medicare and Medicaid!
  9. 9. The Injustice <ul><li>Demands from insurance companies are increasing </li></ul><ul><li>-more paperwork, denial hassles, phone calls, audits, etc. </li></ul><ul><li>Meanwhile </li></ul><ul><li>Physician practice costs have </li></ul><ul><li>increased by 20% since 2001 (AMA) </li></ul><ul><li>Health insurance costs have nearly doubled </li></ul><ul><li>Yet insurance companies are reducing reimbursement to physicians! </li></ul><ul><ul><li>By 2013 it is predicted that Medicare reimbursement will be 50% of the reimbursement seen in 1991! (Vital Signs March 2005) </li></ul></ul><ul><ul><li>2008 Medicare cuts will average 9.9% (AMA) </li></ul></ul><ul><ul><li>5% cuts are planned for 2009 (AMA News, Aug 2007) </li></ul></ul>
  10. 10. How Can Physicians Afford To Work? <ul><li>Give up coveted independence in favor of employed positions?! </li></ul><ul><li>Stop seeing Medicare and Medicaid patients?! (MMWR 56(10);230) </li></ul><ul><ul><li>In 2004 20% of physicians no longer accepted Medicare patients </li></ul></ul><ul><ul><li>9.3% no longer accepted Medicaid </li></ul></ul><ul><ul><li>60% of physicians interviewed in 2007 by the AMA state that they will limit the number of new Medicare patients as a result of aggressive, proposed cuts to physician reimbursement (AMA) </li></ul></ul><ul><li>Surviving requires understanding AND playing the insurance game! </li></ul><ul><li>Maximize reimbursement through </li></ul><ul><ul><li>Adequate and thorough documentation </li></ul></ul><ul><ul><li>Appropriate Coding </li></ul></ul><ul><ul><li>Get Paid For The Work You Do! </li></ul></ul>
  11. 11. Many Physicians Under Code! <ul><li>Most physicians do more work than their documentation supports! </li></ul><ul><ul><li>And, as the saying goes, </li></ul></ul><ul><ul><li>if it isn’t documented, it didn’t happen! </li></ul></ul><ul><li>Fear of fines and loss of licensure have forced physicians into under-coding! </li></ul>
  12. 12. How Much Is At Stake? <ul><li>33-52% of patient encounters are under coded </li></ul><ul><ul><li>(JABFP 2001;14:184-92 and FPM October 2003 “How to get all the 99214s you deserve”) </li></ul></ul><ul><li>Assumptions </li></ul><ul><ul><li>$30 difference in reimbursement (99213 to a 99214) </li></ul></ul><ul><ul><li>30 patients per day </li></ul></ul><ul><ul><li>= lose ~$300 per day! </li></ul></ul><ul><ul><li>[33%(30 patients/day) x $30/patient = $300/day] </li></ul></ul><ul><li>For a physician working 5 days/week for 50 weeks, that is $75,000 annually per physician!!! </li></ul><ul><ul><li>That’s no small chunk of change! </li></ul></ul>
  13. 13. What Is The Gain? <ul><li>Decreasing billing and coding errors by just 50% could mean an increase of nearly $40,000 per year in practice revenues! </li></ul><ul><ul><ul><li>The equivalent of seeing an additional 690 (99213) patients/year </li></ul></ul></ul><ul><ul><ul><li>Or, an extra 3 patients/day! </li></ul></ul></ul><ul><ul><ul><li>WITHOUT THE EXTRA WORK! </li></ul></ul></ul><ul><ul><ul><li>$40,000 per year / $58 per patient = 690 patients per year </li></ul></ul></ul><ul><ul><ul><li>690 patients per year / 250 work days per year ~ 3 patients per day </li></ul></ul></ul><ul><li>Put another way . . . </li></ul><ul><li>Losing $300 per day is like seeing nearly 3 new patients per day for free! </li></ul><ul><li>($90 per each 99203 new patient) </li></ul><ul><li>This won’t make physicians rich! </li></ul><ul><li>This merely decreases the impact of ongoing losses </li></ul><ul><li>due to decreasing reimbursement and shifting healthcare costs! </li></ul>
  14. 14. Tools to Improve Documentation <ul><li>Electronic Medical Records (EMRs) </li></ul><ul><ul><li>Electronic medical records are available, but are often cost-prohibitive </li></ul></ul><ul><li>Standardized forms </li></ul><ul><ul><li>Proven to improve documentation </li></ul></ul><ul><ul><li>Less expensive </li></ul></ul><ul><ul><li>Most are designed to be completed by hand and kept in a paper chart </li></ul></ul><ul><ul><li>Many are specific for particular complaints </li></ul></ul><ul><ul><ul><li>such as cough, sore throat, etc., </li></ul></ul></ul><ul><ul><ul><li>yet lack the scope needed to address multiple comorbidities </li></ul></ul></ul><ul><ul><li>Few contain reminders </li></ul></ul><ul><ul><ul><li>Physician Quality Reporting Initiatives </li></ul></ul></ul><ul><ul><ul><li>Risk of excessive alcohol intake </li></ul></ul></ul><ul><ul><ul><li>Severity index scoring, etc. </li></ul></ul></ul>
  15. 15. Electronic Medical Records <ul><li>In 2004 President Bush created the Office of the National Coordinator for Health Information Technology whose mission is to </li></ul><ul><ul><li>“ Implement an interoperable health information technology infrastructure nationwide” </li></ul></ul><ul><li>System costs </li></ul><ul><ul><li>Software, hardware, training, implementation, ongoing maintenance and support </li></ul></ul><ul><li>Induced costs </li></ul><ul><ul><li>Costs involved in the transition to an electronic medical record, such as the temporary decrease of productivity </li></ul></ul><ul><ul><li>A Cost Benefit Analysis of Electronic Medical Records in Primary Care The American Journal of Medicine 2003 114(5):397-403 </li></ul></ul><ul><ul><li>E-Health 101:Electronic Medical Records Reduce costs, Improve care, and Save lives American Electronics Association 2006 </li></ul></ul>
  16. 16. Electronic Medical Records Capabilities May Include* <ul><li>Viewing </li></ul><ul><ul><li>Medical notes, labs, reports, formularies </li></ul></ul><ul><li>Documenting </li></ul><ul><ul><li>Medical notes, labs, reports </li></ul></ul><ul><li>Ordering </li></ul><ul><ul><li>Prescriptions, labs, tests, consults, durable medical equipment </li></ul></ul><ul><li>Messaging </li></ul><ul><ul><li>Physician-Staff; Physician-Physician; Physician-Patient and vice versa </li></ul></ul><ul><li>Care Management/Follow up </li></ul><ul><li>Analysis and Reporting </li></ul><ul><ul><li>Adverse drug reactions, drug-drug reactions, chronic disease reminders, preventive care reminders, statistical analysis </li></ul></ul><ul><li>Patient-directed </li></ul><ul><li>Billing and Scheduling </li></ul><ul><li>* All capabilities are not available for all EMR systems </li></ul>
  17. 17. Who Uses Electronic Medical Records? <ul><li>~ 25% of office-based physicians used some form of EMR in 2005 </li></ul>National Center for Health Statistics National Ambulatory Medical Care Survey
  18. 18. Implementing Electronic Medical Records <ul><li>$2,500 - $44,000 initial start-up cost/provider </li></ul><ul><ul><li>Software </li></ul></ul><ul><ul><ul><li>50-200% of initial costs </li></ul></ul></ul><ul><ul><li>Hardware </li></ul></ul><ul><ul><ul><li>$5,000-10,000/provider </li></ul></ul></ul><ul><ul><li>Implementation </li></ul></ul><ul><ul><ul><li>$3400/provider </li></ul></ul></ul><ul><ul><li>Additional maintenance costs </li></ul></ul><ul><ul><ul><li>$700-1500/provider per month </li></ul></ul></ul><ul><ul><ul><li>Providers include MD, NP, RN, LPN, PA, MA, receptionist </li></ul></ul></ul><ul><li>Lost productivity estimated at >$10,000 in the first year </li></ul><ul><li>Average time to return on investment is 2.5 years </li></ul><ul><ul><li>This makes electronic medical records unobtainable by most medical practices </li></ul></ul>The Value of Electronic Health Records in Solo or Small Group Practices Health Affairs 2005 24(5):1127-1137 A Cost Benefit Analysis of Electronic Medical Records in Primary Care The American Journal of Medicine 2003 114(5):397-403 Electronic Medical Records Systems Cost Effective, Study Shows Medical News Today 2007
  19. 19. Benefits of Electronic Medical Records <ul><li>Improved documentation </li></ul><ul><li>Reduce paper chart pulls </li></ul><ul><ul><li>Estimated to cost $5/chart </li></ul></ul><ul><li>Decrease costs for transcription </li></ul><ul><li>Reduce redundant labs and tests ordered </li></ul><ul><li>Some provide prompters </li></ul><ul><ul><li>Preventive care </li></ul></ul><ul><ul><li>Medication options </li></ul></ul><ul><ul><li>Adverse drug interactions </li></ul></ul>A Cost Benefit Analysis of Electronic Medical Records in Primary Care The American Journal of Medicine 2003 114(5):397-403
  20. 20. Financial Benefits of EMRs <ul><li>5-year net BENEFIT of a “full EMR” </li></ul><ul><ul><li>$86,000/provider </li></ul></ul><ul><ul><li>Full EMR includes electronic prescriptions, chronic disease reminders, drug interactions, and preventive care prompters </li></ul></ul><ul><li>5-year net COST of a “light EMR” </li></ul><ul><ul><li>$18,000/provider </li></ul></ul><ul><ul><li>used only to reduce paper chart pulls and transcription costs </li></ul></ul>A Cost Benefit Analysis of Electronic Medical Records in Primary Care The American Journal of Medicine 2003 114(5):397-403
  21. 21. MedicalTemplates <ul><li>Standardized patient encounter forms </li></ul><ul><li>Adobe PDF Technology </li></ul><ul><ul><li>Use as a paper form OR </li></ul></ul><ul><ul><li>Use as an electronic form </li></ul></ul>
  22. 22. MedicalTemplates Features <ul><li>Documentation prompters </li></ul><ul><ul><li>HCFA 1997 documentation guidelines </li></ul></ul><ul><li>Quality reminders </li></ul><ul><ul><li>Medicare PQRI </li></ul></ul><ul><li>Checkboxes </li></ul><ul><ul><li>Save time </li></ul></ul><ul><ul><li>Save energy </li></ul></ul><ul><ul><li>Time is Money </li></ul></ul>
  23. 23. Implementing MedicalTemplates <ul><li>Required Hardware and Software </li></ul><ul><ul><li>Free Adobe Reader from </li></ul></ul><ul><ul><li>Basic computer ($350 or less) </li></ul></ul><ul><ul><ul><li>Intel Pentium III or better for Windows </li></ul></ul></ul><ul><ul><ul><li>PowerPC G3 or better for MacOS </li></ul></ul></ul><ul><ul><li>One or more MedicalTemplates </li></ul></ul><ul><ul><ul><li>$150 per template </li></ul></ul></ul>
  24. 24. MedicalTemplate Benefits <ul><li>Inexpensive implementation </li></ul><ul><li>Minimal learning curve </li></ul><ul><li>Improved documentation </li></ul><ul><li>Reduce paper chart pulls (if using electronic format) </li></ul><ul><ul><li>Estimated to cost $5/chart </li></ul></ul><ul><li>Decrease costs for transcription </li></ul><ul><li>Prompters/Reminders improve </li></ul><ul><ul><li>Preventive care </li></ul></ul><ul><ul><li>Quality of care </li></ul></ul><ul><ul><li>Treatment options </li></ul></ul><ul><ul><li>Evaluation options </li></ul></ul>
  25. 25. MedicalTemplates ROI Assumptions <ul><li>Template cost $150 per practitioner </li></ul><ul><li>Computer cost $350 (most offices already have >1 computer) </li></ul><ul><li>Baseline under coding rate 30% ($300 lost revenue/day) </li></ul><ul><li>Reduction in under coding 50% </li></ul><ul><ul><li>If 33% of 30 patients seen in one day are under coded </li></ul></ul><ul><ul><ul><li>10 patients are under coded by $30 apiece = $300/day </li></ul></ul></ul><ul><ul><ul><li>A 50% reduction = Only 5 patients are under coded </li></ul></ul></ul><ul><ul><ul><li>Increased revenue = $30 x 5 patients now coded correctly = $150 </li></ul></ul></ul><ul><li>Increased revenue of $150/day equates to a savings of </li></ul><ul><ul><li>$750/week $3000/month >$36,000/year! </li></ul></ul>At $150 per template, the template pays itself off in 1 day!
  26. 26. MedicalTemplate ROI Calculation Including Computer Costs <ul><li>In just 1 month, </li></ul><ul><li>the Return On Investment (ROI) could be: </li></ul><ul><li>Average improvement in reimbursement in 1 month </li></ul><ul><li>X 100 = ROI </li></ul><ul><li>Cost of Template + Cost of Computer </li></ul><ul><li>$3000 </li></ul><ul><li>X 100 = 600% </li></ul><ul><li>$150 + $350 </li></ul>
  27. 27. MedicalTemplate ROI Calculation Without Computer Costs <ul><li>In just 1 month, </li></ul><ul><li>the Return On Investment (ROI) could be: </li></ul><ul><li>Average improvement in reimbursement in 1 month </li></ul><ul><li>X 100 = ROI </li></ul><ul><li>Cost of Template </li></ul><ul><li>$3000 </li></ul><ul><li>X 100 = 2,000% </li></ul><ul><li>$150 </li></ul>
  28. 28. Time to Recover Cost of MedicalTemplate <ul><li>MedicalTemplate + Computer ($500) </li></ul><ul><ul><li>$500/$150 ~ 3 days </li></ul></ul><ul><li>MedicalTemplate without Computer ($150) </li></ul><ul><ul><li>$150/$150 = 1 Day! </li></ul></ul>
  29. 29. Savings Not included in ROI Estimates <ul><li>Reductions in down coding </li></ul><ul><li>Reductions in claim denials </li></ul><ul><li>Reduced time spent on documentation </li></ul><ul><li>Reduced time pulling charts </li></ul>
  30. 30. MedicalTemplates <ul><li>General forms </li></ul><ul><li>Clinic H&P </li></ul><ul><li>Clinic Follow Up Note </li></ul><ul><li>Hospital H&P </li></ul><ul><li>Hospital Follow Up </li></ul><ul><li>Pulmonary/Critical Care H&P </li></ul><ul><li>Pulmonary/Critical Care Follow Up </li></ul><ul><li>Pulmonary Clinic H&P </li></ul><ul><li>Problem specific forms </li></ul><ul><li>Asthma </li></ul><ul><li>COPD </li></ul><ul><li>Pneumonia </li></ul><ul><li>Pleural Effusion </li></ul><ul><li>Lung Mass </li></ul><ul><li>Interstitial Lung Disease </li></ul><ul><li>Chest Pain </li></ul><ul><li>Pulmonary Hypertension </li></ul>
  31. 31. MedicalTemplates <ul><li>MedicalTemplates has created multiple medical templates appropriate for evaluating patients in the clinic or hospital setting. </li></ul><ul><ul><li>MedicalTemplates are fillable PDF forms that allow the physician to type historical information directly into the form. </li></ul></ul><ul><ul><li>They can be saved electronically for later reference. </li></ul></ul><ul><ul><li>Documentation time is decreased </li></ul></ul><ul><ul><ul><li>Most components of the history and physical exam can be completed by checking the appropriate box. </li></ul></ul></ul><ul><li>Reducing documentation time by 5-10 minutes per patient could save the physician >2 hours per day! </li></ul><ul><ul><li>30 patients / day x 5 minute decrease / patient = 2.5 hours / day SAVED! </li></ul></ul>