8 Strategies to Offset Falling Reimbursements
Any size practice can bring more to the bottom line.
BY JERRY HELZNER, SENIOR EDITOR
As ophthalmology practices deal with an accelerating trend of reduced or stagnant reimbursement rates, practice administrators and physicians are increasingly challenged to find ways to lower costs and increase revenue. Unfortunately, many of the efficiencies that have been advocated apply only to larger practices. It’s relatively easy to find cost savings in cataract surgery when you have two operating rooms, several surgeons and a large staff. But what about the solo ophthalmologist who does about 10 cataract surgeries a week in a community hospital?
This article offers eight relatively simple concepts that can increase financial returns for a practice of any size without scrimping on patient care or diminishing staff morale. In fact, the opposite is true. These recommendations are designed to create a more positive patient experience and make for a more productive workplace. It has been said that working hard is a wonderful trait but that “working smart” is what creates success in business. These ideas are intended to help any practice work smart.
1 Attack the No-show Problem
Unless your patient base is made up entirely of saintly individuals who possess none of the flaws of ordinary humans, you are dealing with a significant number of no-shows and same-day appointment cancellations in your practice. Steven Silverstein, MD, who writes the “Efficient Ophthalmologist” column for this publication, estimates that no-shows and same-day cancellations typically account for 13% to 15% of all appointments scheduled by his practice, accounting for approximately $100,000 a year in lost revenue per physician.
Dr. Silverstein and his staff have used a number of approaches to address this issue, from robot reminder calls to live calls the day or evening before the appointment, to follow-up calls to offenders to find out why they missed their appointments. He has even considered imposing a penalty fee for missed appointments or same-day cancellations. Some of these approaches have worked better than others — a phone call from a staff member the evening before the appointment had good results — but he still continues to fight what he considers a major problem.
“There is new thinking now that, with this multi-media generation, a practice might look into hiring an outside company that uses phone, e-mail and text, beginning about a week before the appointment, to both remind the patient of the appointment and give them a chance to reschedule,” says Dr. Silverstein. “If they want to reschedule, the practice still has time to refill that slot.”
While it is impossible to offer a total solution to the no-show/same-day cancellation issue, you should attempt to quantify the extent of the problem in your own practice and take steps to reduce the losses. The multi-media approach might be the best answer if it can be done in a way that does not offend the patient.
2 Consider a Physician Assistant
UPS has a slogan: “What Can Brown Do for You?” You should ask yourself this question: “What can a physician assistant (PA) do for our practice?”
Although only a small, but growing, percentage of ophthalmology practices employ PAs, the practices that do so find them to be welcome additions. Practices such as St. Luke’s Cataract and Eye Center in Tampa, Barnet Dulaney Perkins in Arizona and Cleveland Retina have all reported excellent experiences in employing PAs.
Physician assistants have become even more valuable in recent years, as, unlike optometrists, they can perform the patient histories and physicals that Medicare has mandated since 2009 for all surgical procedures. In addition, as so-called “physician extenders,” PAs can perform some surgical tasks, such as opening and closing in cataract surgery, under the supervision of an ophthalmologist.
From a cost-effectiveness standpoint, the American Academy of Physician Assistants reports the average salary of a PA at $90,000 a year, far less than the average OD.
3 Eliminate Errors
Salim Butrus, MD, in private solo practice at the Eye Center on Capitol Hill in Washington, D.C., notes errors are a triple danger. They cost money and time, and can hurt a practice’s reputation.
Dr. Butrus and his staff pay the strictest attention to the preoperative evaluation of all surgical patients, especially in laser and cataract refractive surgery cases where more variables are in play.
“Doctors need to rule out dry eyes, atypical keratoconus and epiretinal membrane before even thinking of implanting a premium IOL,” says Dr. Butrus, who recommends bilateral OCT to check for epiretinal membrane.
“For all cataract patients, before putting in any drops, I advise being extra cautious and doing manual Ks and bilateral topography,” he says. “For all male cataract patients, I need to know if the patient has ever taken Flomax (tamsulosin) for an enlarged prostate. I have found that not all patients will volunteer that information. With patients who have taken Flomax, you need to prepare for possible floppy iris syndrome, which can be a major complication if you are not ready to deal with it.”
4 Avoid Cloned Claims
Copying information from previous claims not only can result in rejected claims; it can also raise red flags that lead to time-consuming and aggravating government audits.
With some of today’s EHR systems, legitimate patient encounters can result in information duplicated from previous claims templates through so-called “default documentation” that can overlook significant new findings. Medicare wants to see individual notes for each patient encounter. Some developers of electronic systems can provide individualized patient templates that reduce the potential for cloned claims. That is a good question to ask a vendor if you already have electronic records or are considering purchasing of such a system.
Payers consider cloned claims misrepresentations of the medical necessity requirement, and Medicare administrative contractors (MACs) warn you will have to return any payments you have already received.
Passing on patient compliments to the staff leads to better morale and greater staff productivity.
This is a harsh price to pay. Your practice must be aware of the cloned claims issue and be sure to avoid submitting any documentation that has the appearance of being cloned.
5 Save Time in Surgery
Even if your practice performs only a small number of surgical procedures, you can save time and increase productivity with just a couple of simple steps. Surgeons and surgical coordinators have suggested these ideas:
■ Use a mini-block for sedation in routine cataract surgery with healthy patients. This smaller injection allows the patient to recover faster and go home sooner. You do not want to have postoperative patients lingering in your facility longer than necessary.
■ Use sublingual Versed (midazolam) instead of IV in routine cases where possible. This idea comes from Bradley Black, MD, of Indianapolis. “It eliminates the need to start an IV, which saves time, aggravation and money,” he says. “Obviously, there are instances where an IV is preferable and quick access important. However a majority of healthy, not overly anxious patients do very well with this method.”
Dr. Black has used Versed for years, although he notes there has been a recent shortage of IV Versed that he gives in a sublingual manner. He does not like the oral form, which he says is not as consistently absorbed.
“It has a very bitter taste and we have them hold it under their tongue for 30 seconds before swallowing or spitting it out,” he notes. “It has a very fast 10 to 15 minute onset and is out of their system within the hour, though we do not let them drive home. We use it alone the great majority of the time. There are concerns that insurances will look at the anesthesia component and not cover anything if IV is not started. The main issue with Versed is, it is difficult to supplement if more is needed, which is why we start IVs on especially nervous folks.
■ Let surgical patients wear their own clothes instead of dressing gowns. Surgeons report that just doing this greatly increases the comfort level of patients and saves time and money.
■ Cross-train your surgical team. This will allow patient flow to move smoothly even when staff members are absent due to vacations or illness.
■ Review cataract surgery lists a week in advance. This will help ensure that all the appropriate IOLs will be on hand for these patients.
■ Schedule more complex cases later in the day. That way, you can keep to the schedule and tackle the longer cases at a time when you don’t have other patients waiting.
■ Standardize the OR turnover procedure. This will ensure that the OR is quickly ready for the next case. Inefficient turnover procedures account for lost time that directly affect surgeon productivity.
6 A Happy Staff is More Productive
Amir Arbisser, MD, founder of Eye Surgeons Associates, Bettendorf, Iowa, says he carries a digital recorder in his pocket and immediately relays any compliment from a patient about a staff member to the staff member’s supervisor, so that the compliment can be recorded in the employee’s personal file.
“During the exam, the patient may say to me that one of our staffers patiently answered all of her questions and relieved her anxiety over the upcoming cataract surgery,” Dr. Arbisser says. “I will immediately stop and convey that message to the supervisor so that the staffer can be given a pat on the back.”
Dr. Arbisser says that immediate personal recognition of good work aids practice productivity and creates a positive atmosphere throughout the entire staff.
“I used to forget to pass on these remarks,” he says. “Now, there is a dictated note in the employee’s file, which the director can use as part of the employee’s annual review.”
7 Delighted Patients Create Referrals
Dr. Arbisser offers another simple tip that takes almost no effort but makes a great impression on postoperative patients. The surgical staff programs in the phone numbers of all that day’s surgical patients on the cataract surgeon’s cell phone so that the surgeon can make a quick personal call to each one to make sure that things are going well in the hours after surgery.
“It’s a brief call that doesn’t even extend the workday. The cataract surgeon can make the call on her way home from the surgery center,” says Dr. Arbisser. “It’s very useful because sometimes the post-op instructions can be misunderstood and the surgeon can answer questions and correct any misconceptions about the instructions.”
Another idea to please patients: Provide transportation for your surgical cases. It will also widen the practice’s geographic service area, especially to patients who may not have considered your practice without it.
Finally, given the diversity of society today, you may be in an area in which people of various ethnicities and nationalities make up your patient base. If you have a number of Hispanics as patients, for example, it would be a wise idea to have one or more bilingual staff members fluent in Spanish.
8. Have Paperwork in Early
Maria Tietjen, practice administrator for American Surgisite, which operates a number of ophthalmic ASCs in the Northeast, wants to see all the relevant paperwork in the file well before the day of surgery. That includes the history and physical findings along with preoperative patient information. Having the paperwork in early helps ensure smooth patient flow.
“Patients can be held up on the day of surgery if the paperwork has not been received from the office,” she says.
Ms. Tietjen also suggests making an advanced notation of a complex or difficult surgical case so the schedule can be adjusted for these more time-consuming procedures.
One more bit of advice on paperwork: It’s wise to give patients their post-op instructions before the day of surgery because they are more likely to understand and follow the instructions if they can go over them in advance. Giving these instructions to a patient just out of surgery can cause a possibly stressed patient to become confused.
Real Revenue for Little Outlay
The beauty of these ideas is that all of them can be implemented fairly quickly with little or no cost. The financial payoff comes from a combination of a direct increase in revenue, greater practice productivity, more referrals from satisfied patients, and by eliminating the time lost to inefficiencies and recovering from errors. OM