February 2000 Bulletin

Path to success ‘Better-performing’ groups tell what they did

By Sandra Lee Breisch

All orthopaedic groups want greater revenues, good outcomes and ways to become a superior medical performer.

And The West End Orthopaedic Clinic Inc. in Richmond, Va., has done that in the accounts receivable and collections area by optimizing reimbursements for their 26 orthopaedists.

Their success story is cited in last December’s Medical Group Management Association (MGMA) published Performance and Practices of Successful Medical Groups: 1999 Report Based on 1998 Data. The 88-page report is based on 270 "better-performing" practices; 38 are orthopaedic practices that shared data related to profitability and cost management success stories and responded to MGMA’s Cost Survey and its supplemental Practices and Procedures Survey Questionnaire.

"Best practices are defined as a proven service, function or process that has been shown to produce superior results in benchmarks that meet or set a new standard," says Daniel A. Jaynes, MGMA’s project manager of the report.

The "better performing" practices were selected as superior performers in four areas: profitability and management costs; production, capacity and staffing; accounts receivable and collections; and managed care operations. Only a few orthopaedic success stories are cited in the report.

At West End, their administrator, James Perkins, was instrumental in helping the group achieve such status from the MGMA in the accounts receivable and collections area.

He did so by first creating "a keen awareness" of reimbursement levels among physicians. "A surgeon should know exactly what they’re being paid by every insurance company," says Perkins.

To achieve such awareness, Perkins created a six-member orthopaedic contract committee and hired a paid chairman to oversee bimonthly meetings. Perkins also attends these meetings. "The intent of the committee is to get physicians more closely involved in contract negotiations, monitor reimbursement performance and promote accountability among physicians for accounts receivable and collections," says Perkins.

The committee also oversees the group’s billing technology to improve collection procedures. Contractual fees agreed upon with third parties are all inputted into their computer. "This allows us to compare the fee we’ve received versus what’s been charged with the contracted amount," says Perkins.

Yearly benchmarking helps the group measure historical trends to see how the accounts receivable has improved and if it is growing.

To improve their collection policy, the group implemented various procedures. "We improved our billing procedures by having a write-off policy where physicians tell us what they want to do with an account over 90-days old," says Perkins. "For instance, the physicians determine if the bill should be send to a collection attorney, is considered a bad debt or uncollectable or if we should pursue an appeals mechanism such as sending it back to the insurance company or medical director for resubmission."

To measure the group’s collection progress, Perkins says they look at historical trends. "We look at what our reimbursement by relative value unit (RVU) by insurance company was a year ago and how this number changes in the aggregate," he says.

By relying on the reimbursement per RVU value, Perkins says it creates "ease" of contract negotiations. "All of our contracts are converted to reimbursement per RVU data, as well as collection rate," he says. "This means you divide the amount of money that you received by CPT code RVU units to determine what we’re paid by carrier. Therefore, the computer system must track the RVUs by CPT code and many practices don’t track this volume weighted information."

West End participates in MGMA’s annual survey and analyzes other groups’ aggregate numbers by specialty for comparison. The goal is to see how the practice can improve. "When the physicians see a practice that has numbers that are better than the norm, they want to find out what other practices are doing and learn from them," says Perkins.

Another group that earned "better-performer" status is the Eastern Oklahoma Orthopedic Center, Inc. Their success story is one of not only accounts receivable, but also profitability and cost management.

The group’s administrator, Roger J. Bourne, says their eight orthopaedic surgeons and two family practice sports medicine physicians played a strong role in making determinations in collection procedures. "Our success was tied to a slow, painful process of trying different methods of reducing the accounts receivable," he says.

To ensure physicians were paid for their services and fewer write-offs, the group established a relationship with a financial institution that provides loans to patients. "Should patients have credit problems or not have any insurance or money, we have them fill out a credit application with the financial company," says Bourne.

Several account representatives are assigned to specific insurance groups so there’s a cohesive relationship with insurers. The group also has a certified surgical coder who assists and educates physicians with coding, Evaluation and Management documentation guidelines and works with the medical director in creating a comprehensive compliance program.

The practice has one surgery schedule coordinator who juggles physicians’ schedules at various medical facilities and maintains the physicians’ on-call schedules, too.

To increase profitability and cost management, Bourne says he knew the physicians’ "productivity levels" needed to improve. The group hired their own certified surgical technician team of three, including a registered nurse supervisor. The team members were
selected by the orthopaedists and not the hospital staff. "Our own surgical team provides quality, efficiency and they know the physicians’ protocols and equipment in the operating room," says Bourne. "The operating room turnover time is greatly enhanced and we see more patients get in and out of surgery."

At the office, two family practice sports medicine physicians serve as "feeders" to the orthopaedists so the orthopaedists can handle 30 to 40 patients a day.

"The feeders do a lot of conservative care for the sports medicine injury patients," says Bourne. "This way we haven’t wasted our surgeon’s time on procedures that the sports medicine physicians can handle and everyone’s time is being used more efficiency. And this allows us to get more patients in."

The practice also has an orthopaedist on "day call," to take walk-ins and emergency referrals and an orthopaedist on "night call," to handle emergencies.

"The group is able to increase profits because we have all of these components in place," says Bourne. "If one is out of place, it might hurt productivity. And a lot of productivity is tied to the attitude of physicians, their work ethics—if they’re willing to work hard, give more, then they can do more."

According to MGMA’s Jaynes, one reason revenue is greater at the better-performing practices is physician productivity. "During interviews with groups, one constant was that administrators credited the group’s success to the quality of care and strong work ethic of the physicians—highly qualified, hard-working, patient-oriented physicians," Jaynes says.

Bourne says the group also uses MGMA data to benchmark. "We don’t live or die by that data, but we massage the data and it still gives us a pretty good snapshot of how we compare with others," says Bourne.

He adds that working with the BONES Society, the national organization of orthopaedic practice administrators, also has been an asset to the group’s success.

Here are some suggestions to improve a patient’s perception of the time spent with a physician, the physician’s interest level in his/her problem and the explanation of the illness and treatment.

1. Know patient’s reason for visit before you enter room.
2. State patient’s name when you introduce yourself.
3. Touch patient, either on shoulder or handshake. Decline handshake for patients with upper extremity problems.
4. Patients do not like to hear other patients or see other’s treatment.
5. Be very careful of times you leave the room. Have a signal from nurse to get you out of room, i.e., two knocks is a physician call back.
6. Don’t look at your watch. If this is a habit, remove it.
7. Show patient his/her X-ray, even if it is normal.
8. Write down what your treatment plan is. Use anatomical education sheets.
9. Have someone call the patient day after discharge. Schedule follow-up at that time.
10. Always sit down in room. If possible, sit lower than the patient. Perception is that you spent twice as long a time with patient.
11. Never reprimand staff or a patient in front of others.
12. Patients don’t need to hear technical terms. This may be an emotionally charged visit for the patient that will increase anxiety and decrease listening. Even educated patients can have their anxiety skyrocket with technical terms and not understanding makes them feel dumb and ill at ease. Write everything down for the patient.
13. Remember that the patient has already chosen you as their physician. You do not need to impress them with your credentials. In fact, the more you can relate to them on a personal level, the more at ease they will be. Patients who want specifics, like how many of this particular surgery have you done and what was the outcome, will usually ask. Talking more does not necessarily increase patient understanding. Talking less technical and giving the patient a picture of what is wrong with them may increase their understanding.
14. Ask the patient, especially the quiet one, if he or she has any questions. Remember that the "service" you provide is to tell the patient what is wrong with them and what can be done about it, even if it is nothing. If they leave and don’t understand this, they will feel dissatisfied with the overall care.
15. Try to know what your patient expects. You may need to educate them about realistic expectations. Remember, "expectations unmet, increase anxiety and dissatisfaction."

Here are some suggestions for staff that can improve service and meet patient expectations:

1. Remember that patients hear and see everything. Personal conversations should be kept out of the front desk area.
2. Patients will think you’re great when you handle a difficult patient well and will comment negatively if you get angry with any patient.
3. Greet every patient as you would when opening your own front door. No one should walk through the front door without hearing a greeting.
4. Somehow, always acknowledge the patient’s presence. If you’re on the phone, make eye contact and hold up a finger to let them know you’ll be with them in a minute. Your "priority" is the person standing in front of you, not the phone.
5. Assist handicapped patients with paperwork.
6. Patient recognition is very important. If you know the patient’s name, use it to address them. Always error on the side of formality, use Ms., Mr. or Dr. instead of first names unless addressing a child or the patient corrects you. Don’t use "honey" or "sweetie." If there is a preferred name, type it in on the chart, i.e., "Colonel Smith."
7. Eye contact and smiles are great. They put people at ease.
8. Example for first time patients: "Hi. Welcome to our clinic. We have a coffee machine in the waiting room. If you’ll please complete this paper work and return it to me, your doctor would appreciate it and be with you shortly. Thank you."
9. Know if the doctor is running behind; inform the patient when he comes in. If the wait is longer than 30 minutes or if the patient seems upset by the wait, offer to reschedule the appointment.
10. Remember, many patients do not show their anxiety. Anything you can do that personalizes their visit will be greatly appreciated by them and those watching.

Source: Elizabeth Stringer, MSN, Medical Research and Outcome Consultants, Inc., Colorado Spring, Colo.