Is Your Office Safe for Patients?

 

I am amazed at how unsafe physicians’ offices can be for patients who are unsteady and using a wheelchair, walker, knee scooter, crutches or a cane.

 

It is difficult for them to enter the office, maneuver from the reception area to the exam rooms and get on or off an exam table.

 

Getting through a door, if you are in a wheelchair is practically impossible without an automatic door opener.  Often the button to activate the opener is difficult to reach or in a place where the door will hit the patient when it opens. 

 

The solutions are simple, comprised of common courtesy and compassion and will prevent an indefensible malpractice lawsuit.

 

If the main door to your office cannot safely open electronically, have a staff member greet the patient and open the door.

 

Leave space next to a regular chair in your reception area for a wheelchair.

 

Have some wide, large chairs with arms in your reception area for patients with a walker, crutches or a cane.  The patient can sit down or stand up balancing on the arms.  The crutches or cane can rest between the seat and the arm of the chair.  Otherwise they fall on the floor where the patient cannot reach them and other people cannot pass by without tripping.

 

If there is no space in front of your receptionist for a wheelchair or walker, have your receptionist come around to the patient and hand him or her or the caregiver the clipboard with the forms that need to be completed.  Better, having your nurse or medical assistant take the patient into an exam room and either fill in the form for the patient or ask the questions on the form and enter the information directly into the computer, can be an enormous timesaver.  This gets accurate information in the patient’s chart and bonds the patient and caregiver with your staff.

 

There should be space in your exam rooms for a wheelchair.

 

One of your staff should stay until the patient is safely on the exam table.  If your patient needs help undressing, your medical assistant should offer to do that and reassure the patient that he or she will aid the patient in getting dressed.

 

Having a member of your staff stay with these patients as they leave, facilitates making the next appointments easily and correctly.  It also gives the patients time to ask questions that may not have occurred to them when instructions or treatment plans were first discussed.  This obviates many phone calls to your office after the patient gets home.  It also allows the caregiver to get the car and bring it to the front door of the building.    

 

If your employee stays with your patient until he or she is safely in the car, it shows an understanding of the difficulty of the logistics.  Basically, it is polite.  Don’t you walk your able bodied guests to the door when they leave your home?

 

LESSON: Caring about your patients’ comfort and safety is as important as providing good medical care.  As well as protecting you from an indefensible malpractice lawsuit, patients are appreciative, more compliant and will refer others to you.

Appropriate Attire Augurs Respect

I was called into an office because patients weren’t paying their bills as agreed. And they were not following surgical instructions.

Something was wrong. The doctor and his employees couldn’t identify the problem.

All his employees were lovely, young blondes, dressed identically in skirts, blouses, sweaters, saddle shoes and socks. It looked like a high school campus.

I conducted a private interview with each staff member. The first was the office manager. I asked a few key questions regarding office procedures. Everything was done right. She said the patients did not take her seriously. They would not listen well to surgical instructions. I asked about her family. She was in her mid 40's and had two teenagers. I was shocked. I thought she was around 22 years old.

The next interview was with the biller. Her procedures were proper as well. She said the patients did not keep the payment arrangements they made with her, although they did pay eventually.

The same scenario repeated with every interview. Each pretty woman looked about 22, but was in her 40's, married with children. Each had worked there for more than 10 years. They were grown women dressed like girls.

I pointed out to the physician that the patients saw them as teenagers and treated them accordingly.

We all agreed that they could continue to be dressed alike because it was akin to wearing uniforms and made it easy to identify them as staff. But they should be dressed in jackets, blouses, skirts and flats, appropriate to their age and status.

Lesson: Dress your staff like adults if you want compliant patients. Demeanor is important, but first impressions are visual and set the tenor of the encounter.

Free Advice Can Cost You a Fortune

My client was starting a practice. We were leasing a space that had to be remodeled. The landlord was notorious for not completing construction on time. In the Letter of Intent I requested that the rent would not start until the construction was completed.

My client insisted that his cousin, a business attorney, review the lease. I asked if he had any experience with leases. My client replied, "Only in law school, but he is not charging me and my family insists." There was nothing for me to do but acquiesce.

Since I had written the Letter of Intent upon which it was based, he wanted to save money by not having to pay me to read the lengthy lease. My client would only allow his cousin to review the lease.

The landlord did not include that protective clause. The cousin missed the exclusion. The contractor ran way behind schedule because the landlord did not remove the debris in the suite in the time frame promised.

My client had to pay rent for three months on a unfinished, unusable suite. All this money came from the loan because he could not see patients. It greatly increased his debt.

The cousin may have been a good attorney in his field, but not in this area. His free services proved to be very costly.

Lesson: You must have experienced advisors, working together, act as your agents. You are counting on their expertise to keep you out of trouble.

Understanding Your Insurance Coverage Is Crucial

My client in Florida had suffered through two major storms in two years. She did not recover any damages from the first storm. I became her Consulting Administrator for the second claim.

After we solved the immediate problems of temporary relocation and patient contact, I asked if her insurance included business interruption coverage. She didn’t know. I asked her to send me the policy.

She had good coverage, but she didn’t know how good until I reviewed it. Not only did she have business interruption, she also had stretch coverage that included extra expense, equipment breakdown, hazardous substance, accounts receivable, computers and media, personal property of others, etc..

My fee was considered extra expense, so it was covered by her policy.

I guided her through gathering the data we needed to track lost income and increased expenses. We projected future expenses for records replacement including personnel costs. We determined how long to retain records for patients who would not return to the practice.

Her suppliers inspected the equipment for viability and provided the costs for replacement or repair. The moving costs were double, because everything had to be removed from the office while it was undergoing structural repair, then moved back into the office and set up.

Working together we created spreadsheets and reports. Her total recovery was $84,000, which she did not know she was entitled to receive.

Lesson: Let an expert inform you what to expect from your insurance policy and create supporting documents so you get what you paid for.

PROTECT YOUR PRACTICE IN CASE OF A DISASTER

Although it seems impossible to protect your office from a disaster as large as what happened Japan, there are immediate and monthly measures you can take to mitigate damage caused by nature such as a fire, flood, hurricane, tornado or earthquake.

I hope you never need to use them.

Three main categories to protect are people, records and the future of your practice.

People

Your patients and staff are most important.

Although it is unlikely that you will remain in the office following a disaster, it may be the safest place. Have emergency flash lights, hard wired and cell phones, bottled water and basic non-perishable food supplies on hand.

Have a plan to contact employees if a disaster strikes before or after office hours. Store employees’ (and their contact person’s) phone numbers in a cell phone as well as on a printed list.

Have an out of town or out of state contact person for everyone to call since local phone lines and cell phone towers most likely will be affected. Long distance phone lines are often functioning before local infrastructure is repaired. During the Northridge earthquake my friend in Virginia served this purpose. Although we could not call each other, all of us could call her and she could call each of us. She also told us the extent of the damage since she was watching the coverage on TV and we had no power.

If your voice mail is working, you can change the message to inform your patients of the status of your office, i.e., open, closed or seeing patients elsewhere. You can change this as often as you need.

You can also use your practice web page to inform patients you are open or where to find you until you reopen and post a temporary telephone number. You can update it frequently.

Records

If you have electronic medical records or a web based billing system, your records may be safe. to your providers about back up solutions and their disaster plans. For example, California businesses whose web servers were in those southern states were affected by Katrina.

Future of Your Practice

To safeguard the future of your practice, storing copies of your records off site is your best protection. Have a safe deposit box at least one hour away for flash drives, discs, tapes and photocopies of important papers.

Back up your computer daily. Video your entire office to show the major equipment, furnishings and wall decorations and their condition for insurance purposes.

Store the tape in the safe deposit box and mail a copy to a trusted friend or relative who lives far away.

There are other ways to retrieve lost records. Third party payors have some of your billing data.  The Internal Revenue Service, your banks, equipment leasing and insurance companies have your financial and equipment data.



PROTECTING DATA

Store in a safe deposit box one hour away -

copies of important papers; leases, licenses, managed care contracts, tax  returns, corporation documents, insurance policies

phone numbers and Email addresses of referring physicians, vendors, advisors

detailed aged accounts receivable year end back up

checking accounts year end back up

video or photos of office equipment, furnishings and decorations



Store in your home

one month advance printouts of appointment schedules

printout of employees’ phone numbers and contact person’s

printout of referring physicians’ phone numbers

aged accounts receivable daily back up

checking accounts daily back up

phone numbers and Email addresses for staff, hospital departments, doctors, vendors and advisors

YOU HAVE INDIRECT BACK UP

third party payors

hospitals

labs

surgery centers

IRS

banks

CPA

attorneys


If you follow all these steps, survival and recovery of your practice should be assured.



Basic Disaster Preparedness Kit

Flash lights with fresh batteries

Spare bulbs for flashlights

Portable radio with fresh batteries (and hand cranked back up)

Packs of fresh batteries

Basic First Aid Kit

Bottled water sufficient for you, your staff and patients for at least 24 hours

Packaged foods (crackers, pretzels, nuts, dried fruits, hard candies)

Canned foods (tuna, salmon, fruits, cheese spreads)

Can openers, hand operated

Candles

Matches

Kleenex

Toilet paper

Paper towels

Baby wipes

Packets of eye glasses cleaning wipes (can be used as an antiseptic)

Blankets

Extra pair of glasses

Basic toiletries (bars of soap, wash cloths, toothpaste, tooth brushes)

Phone numbers for each staff member stored in a cell phone and on a print out

A print out of phone numbers for your and each of your staff’s family members and neighbors

Phone number of out of town contact person in cell phone and on print out

Cash



Note: The American Red Cross web page has more detailed lists.

How Much Does it Cost You to See a Patient?


Are you paying to see patients without knowing it? A medical practice is a business which is supposed to make money, not lose money. Do you know how much it costs you to see a patient?

Before the incursion of managed care, this figure was irrelevant. However, it is of prime importance now. The managed care organizations and insurance carriers know their profit per patient. That is how they determine capitation rates. You will be a more savvy businessperson if you know where your profit begins. It will help you to determine which contracts to sign, which to add and which to drop. Knowing your cost per patient may cause you to disenroll from all the contracts in which you participate.

How You Determine Your Cost Per Patient

To determine the cost of seeing a patient in your office, you need your true overhead. Therefore, do not include depreciation, contributions to your pension plan, or your bonus at the end of the year. Once you determine your monthly overhead, divide that total by the number of days your office is open each month. That is your overhead per day. Divide that by the number of hours in a day you or your staff sees patients. That is your cost of seeing 1 patient per hour in your office.

Because you generate income, sometimes the largest amount, in other facilities; hospitals,surgery centers, nursing homes, etc. Your cost of seeing those patients is minor. It is mostly staff time, i.e. scheduling, billing, collecting. So factor in 1 hour which is attributable to services you render outside the office. Divide that by the number of patients you actually see in one hour. Now you know what it costs you to see a patient.

For example, if your overhead is $14,000 per month, your daily overhead is $700.00 ($14,000 divided by 20). Your overhead per hour is $87.50 ($700 divided by 8 hours per day). Now divide by the number of patients you see in an hour, let's say 4, your cost per patient is $21.88. You can round this up to $22.00 for easy figuring. If you want to perform a retroactive reality check without going through these alculations,divide your total monthly expenses by the total number of patient visits that month to determine your cost per patient. Because expenses fluctuate, you will need to do this for several consecutive months to obtain a true number.

How to Use This Number

If a managed care contract pays you $5.00 per member per month, calculate how many of your patients come from that contract, how often you see a typical patient from that plan in a month, and how long the visit takes of your s and your staff's hands-on time. This should be quite a revelation!

Third Party Payors Will Still Pay You

Remember third party payors, except capitated contracts, will pay you even if you are not a participating provider. They pay you less than their participating providers, but your fee is not limited by a contract. Your patient will pay the difference between your fee and the amount of the insurance payment. Medicare and some other insurers will send the payment directly to the patient and the patient will pay you.

If you disenroll from a plan, you can protect your physician-patient relationship by notifying your patients of the reason for of your decision. Some will remain with you and pay your full fee. Others cannot afford to go out of plan and will seek another physician. At first you are going to lose patients, but you might lose more money by seeing them! You can replace contracted patients with paying patients by promoting your practice to other groups. Then you will make more money by seeing fewer patients. I have numerous clients all over the country who are doing just that. Their overhead is lower. Their patients are happier. And their profit is considerable.

Lesson: My most successful clients do not participate in managed care contracts and are non participating providers. This is the time for physicians to take back the lead in health care payment before any legislative changes can take effect.

A Word of Caution:  Although your primary goal is to take care of your patients, you must have an office in which to do so. You have to be sure each patient is not costing you money, but is generating a profit so you can keep your doors open.

Indecision is Expensive.




Changing your mind constantly creates costly contracts and chaos.

A physician’s office was in terrible turmoil. His administrator of 13 years had finally gotten on his last nerve. The doctor called me in to solve the problems.

The administrator gave mismanagement a new meaning. After many weeks of unfruitful meetings, the physician took my advice and we terminated the administrator.

The doctor asked me to become the temporary administrator, straighten out the office, get it running efficiently and then hire a permanent administrator.

I kept discovering expensive long term or noncancellable contracts for such things as the copier, postage machine, FAX, telephone and internet monthly usage, telephone equipment, telephone book advertising, even the water cooler. I renegotiated or canceled as many as I could. I saved the doctor $200,000 per annum.

After several months as the Consulting Administrator, I began to see that my client would change his mind about every issue several times, often within the space of an hour or two.

Then I realized why the administrator locked the doctor into these contracts. It was so hard to get him to stick to a decision, that as soon as he said yes to anything for more than three hours, the administrator sealed the deal. Once the document was signed, there was no need to discuss that again for years. What a relief for the administrator. What a disaster for the bottom line of the practice.

Lesson: Allow time for careful consideration and use your diagnostic skills to make profitable practice management decisions.


Word of Caution: Physicians’ offices are facing additional turmoil because of the recent passage of Health Care Reform legislation. Pay attention. Mind your business. It’s your practice.

Do You Have a Practice Plan?

My most successful clients call me in several times during their careers, particularly when they are planning major changes.


These visionary physicians engage me for a three or four day consultation. We spend the majority of our time discussing their philosophical plan for the future of their practice and the practical steps to keep them on course to realize their dream.

Primarily we discuss the growth of the practice. Should he or she hire an associate to become a partner? Should they take add more partners? What is the upper limit to the number of partners? Should they expand the office? Should they buy a building? Do they have a buy-in formula? Does it match the buy out?

We also consider other issues. How many years does my client want to actively treat patients? When will he or she stop performing surgery and /or procedures? How will that affect the practice and its value? Who will take over the practice when he or she retires? Will the founding physician always receive an income from the practice? What benefits will continue after retirement?

Who will take over the administration of the practice? We plan the succession as best we can by considering the short term and long term cost/benefit ratio of each scenario. All of this leads us to an informed decision.

Lesson: You spend many years building a practice that treats patients well. If you have a business plan that parallels your patient treatment plans, your rewards can perpetuate and be multiple.

Word of Caution: Knowing what you want in the near future is particularly important now because of the uncertainty of health care insurance reform legislation.

Are you covered for all the disastrous situations that can affect your practice?

Treat your practice as well as you do your patients.. You take care of other people’s medical emergencies every day. Be prepared for your own. Unfortunately, physicians are not immune to illness.

One of my clients suffered a sudden, unexpected, medical episode rendering him unable to practice for several months. He thought the office overhead would be paid because he had business interruption insurance. Not so. Business interruption coverage is for fire, flood and damage caused by external sources. Business overhead insurance covers your practice if you are disabled. This is separate from your personal disability insurance. He had a personal disability policy. He did not have business overhead insurance. What he considered to be redundant coverage was not.

His colleagues were very generous and covered his solo practice while he was hospitalized. The one thing we didn’t have to worry about was care for his patients.

We had to scramble to pay the bills and prevent the employees from fleeing. His receivables would only flow in for a month or two. His business bank account balance was low. His personal disability policy had a 90 day waiting period. For an accidental injury, such as a broken leg, the receivables would have carried him through to recovery. But his prognosis was poor. We could not borrow from his personal account. It was the perfect storm. One insurance policy would have been his lifeboat.

Lesson - Meet with your insurance agent annually to discuss your entire package of policies. Make sure it is complete. Then, if you ever find yourself in an intensive care unit, all you will have to worry about is your physical recovery.


Word of Caution: The saying,“don’t be penny wise and pound foolish”, is too true to be trite.

Don’t Be An Air Talker

anana

My client is a very successful and busy physician. He thinks quickly and is able to see many patients in a day. He has a large staff to help him care for all his patients.

He would come out of an exam room, face the front office area where there are five women working and tell them what he wanted for the patient he had just seen. Then he was into the next exam room with the next patient in the blink of an eye.

There was only one problem. He never noticed that each of his employees was either talking on the phone or helping a patient. They all were busy. Many did not hear or see him. The ones who did, didn’t know to whom he was talking. So often no one did what he asked.

The level of care was disintegrating as fast as his risk for malpractice was increasing.

He couldn’t understand what was wrong.

I told him either to address a staff member by name or to catch her eye before barking out orders and disappearing. Better yet, hand some one the patient’s chart containing a written order.

I also alerted each employee to watch for him when he came into their area. If he didn’t tell one of them specifically to order the test, set up an appointment with another physician or call the hospital, they could determine who would do it.

Lesson: Make sure your staff knows who is responsible to carry out your orders or no one will.

Word of Caution: Review your charts daily. Every time there is an omission or your staff makes a mistake, it is your license on the line.

She Disappeared in Plain View

She is a lovely woman, a very good physician and terribly shy. She had been in practice for severalyears. Every day, when she walked across the bridge from the medical office building to the doctors’ parking lot,she smiled back and said hello to many colleagues.

Then she got pregnant. She cut her hair. She got contacts. She rushed home to lie down after a busy day.

After the baby was born, she lost her weight very quickly. Now, being a nursing mother, she was even more distracted when she walked to her car. She barely noticed or spoke to anyone. And no one spoke to her.

Her practice began to slow down. Her referrals were dropping off. She called me.

It seemed that her appearance had changed so much; new hairstyle, no glasses, different weights, that no one recognized her. And her natural shyness was exacerbated by her increasing haste to get home.

We decided to have a party to let the doctors who knew her, and those who didn’t, that she was still in practice. I understand that physicians do not usually like to attend social events, particularly where they don’t know anyone. So I included a personal note in the invitations to the doctors on staff whom I knew, but she didn’t, saying she was my client, that I would be there and to please stop by because I would love to see them.

Everyone attended the party, if only for a moment to say hello. She met many physicians. And those she knew were pleased to have some time to chat. Her practice boomed

Lesson: Social interaction with other physicians can be as important to keeping your practice vital as maintaining your medical skills.

Cautionary Word:  Be certain to tell physicians you  meet and those you know, what you do, particularly if it is something new.

Pricing a Practice For Sale

A physician hired me to help him buy the practice of the physician who had inspired him, since his childhood, to become a doctor. My client was honored to be offered the practice.


I knew the seller slightly. We had met at several conferences. He was an officer in the state medical association and highly respected. It was a little intimidating, but a thrill for me to be included.


My client and I met at the seller’s office. It was very cordial until the seller presented us with the asking price, $250,000. The equipment was minimal and old, the office lease wasn’t assumable, the receivables weren’t included and the profit never reached $250,000 in any year. The practice didn’t warrant that amount. We were aghast, but rather than refuse him straight off, we decided to meet again in a few days.


My rules regarding the price of a practice are, the floor is what it would cost to set up a similar office and the ceiling is the current year’s net.


My client and I were discussing our strategy and trying to figure out where the number came from. Suddenly I realized that the seller must have taken a huge loss in the stock market and needed that money to replace his entire retirement fund.


Sure enough, the next time we all met, the seller confessed. That is exactly what happened. I gently explained, no matter how much my client respected the seller, he could not make a living if he bought the practice at that price. We declined the deal.


The older physician still has not sold his practice.


Lesson: The price of a practice can’t be based only on the seller’s needs.

A Word of Caution:   No matter how much you respect a physician’s medical skills, when entering a business deal, always get sound, formal financial documents and rely mostly on them.

The Washcloth Syndrome

thththt


My client was asked by a slightly older physician if she wanted to buy her practice. The seller was pregnant again, this time with twins. She knew she could not continue in practice as the mother of four.


The negotiations went well and then became progressively difficult. The seller was resistant to every purchase price we offered, every plan we devised. We couldn’t understand it.


Then it hit me. When I was ten, I had a sore throat just before I was to leave for summer camp. The doctor came to the house, examined me and said I couldn’t go to camp. He told my parents to wrap my throat in a warm wet washcloth several times a day. When they tried to put it on my throat I wouldn’t let them near me. They couldn’t understand why I didn’t want the washcloth. I didn’t care about the washcloth, I wanted to go to camp, but it was right in front of me and the only thing I could fight.


The resistance of the seller was not the price or the details of the deal. She did not want to give up the solo private practice she had worked so long and hard to create. Once I realized that, we discussed it. My client and I assured the seller that we understood that selling was not her choice, but her only option. The seller relaxed. Her objections disappeared. And the sale went smoothly.


Lesson: Discover the real problem and you can solve it. Just as in diagnosing a difficult patient, the skills of a specialist are valuable tools. An empathetic, experienced, expert third party can make the deal.



A Word of Caution: The advice of a colleague who has done it once or heard about someone who did it once, can create the worst case scenario and be a deal breaker.

You Must Be Proactive to Survive In This Economy



In this unprecedented economic environment, you have to make critical decisions and changes to keep your practice healthy.

Your patients will always need you. Can you be there for them?

How can you continue to provide services at your level of care?

It is almost impossible to understand the economic news. Where do you start to cope with this?

This is what I am doing with my clients. First, decide what you can control. How can you reduce your costs without damaging your practice? Second, determine what you can influence. How can you retain and increase your income?

What You Can Control
Examine your expenses. Determine which costs to eliminate, reduce or leave untouched.

Review your insurance coverage. Is it too much, too little or redundant? Are you covered for what you think you are?

How about your employees? Review their duties, hours, benefits and number. Are you overstaffed?

Do you use outside services? Should you keep them? Or should you discontinue them? Should you increase them and reduce your staff?

Do you have service contracts? Are they protective? Should you cancel them? Should you reduce them? Or is it best to continue them unchanged?

Should you convert to electronic medical records?

What You Can Influence

Evaluate your income. Decide how to retain and build referral sources. Reinforce your long term and best referrers. Reestablish relationships with people who have stopped referring to you. Seek new referrers.

Are your managed care contracts profitable? Should you disenroll, renegotiate or limit the number you participate in? Consider becoming a non participating provider for all third party payors. All of my clients who are now non participating wished they had done it sooner. Physicians provide the highest level of medical care. You are irreplaceable.



Lesson: When facing uncharted waters, don’t plot your course alone. Get expert advice to define the basics of what you need to do to reach your goal. Decide, then row, row, row.

A Word of Caution: Don’t make irrevocable or long term decisions. What Congress does or does not do about Health Care Payment Reform will affect you.

 

Ms. Fox is available to present the following talk to your group:

How to Cut Expenses Without Killing Your Practice

You Can Smell Embezzlement

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Several years ago, my client and I started his practice. He became very successful. He was beginning to understand the practice management portion of his office. It didn't smell right to him.

He thought one of his employees, Peg, was stealing. Before she left on maternity leave, Peg trained the new receptionist, who was inexperienced, sweet, though not too bright. When Peg was gone, the theft seemed to stop. When Peg returned, it returned. Now they were working together and the front office was not running properly.

He called me in to verify his suspicions.  The staff was told I was evaluating the efficiency of the practice. Peg was very resistant to my questions and did not like me observing her. I asked each employee to fill out a form listing all their duties. Peg was the only one who did not do it.

Over the weekend, the doctor and I were alone in the office. We went through drawers and files in the front office. We found white out in Peg's drawer, something he had forbidden months before. We also found an entire file of referred patients without appointments, a problem he thought he had corrected with Peg before she went on maternity leave.

We didn't think the new receptionist was part of the theft, since she didn't handle the money. But she was not making those appointments, probably following Peg's instructions.

Embezzlers are often insubordinate. Peg trained the new receptionist not to make the appointments which decreased the physician's income. So the amount Peg was embezzling was not as evident.

On Monday, when Peg saw what we removed from her drawer, she was smart enough to know we were on to her. She quit before we could fire her.

Lesson: A swindler plus a sweet and simple employee are a calamitous combination.


A Word of Caution:   Embezzlers make messes in other areas of the office to cover their tracks. This could be more detrimental than the amount embezzled.

Ms. Fox is available to give the following talk to your group

Protect Your Practice
How to Recognize and Prevent Embezzlement

(for Physicians only)

how employees embezzle

procedures to prevent embezzlement

what to do if you find an embezzler