Sprucing Up Practice Management

Joseph Goedert, News Editor
Health Data Management Magazine, October 2006

Six times a month, Susana Gummel used to stay late at the office, sometimes four hours late, running reports to assess business issues at Princeton (N.J.) Medical Group.

Now, a new module in the practice management system at the 22-physician, two-site practice automatically pulls data and compiles the reports while CFO Gummel is home. "I'm able to see my husband and kids again," she notes.

Further, a daily report previously done in the morning to identify returned claims that were missing information now runs in the evening, which means the practice management system is not being slowed down during business hours as the report is being churned out. Other time-intensive reports that now automatically run at night include a summary accounts-receivable-by-payer report and a breakdown of monthly revenue by physician and department.

Gummel and other staff view the new module-called the Background Business Processor and a free add-on to their practice management software from Horsham, Pa.-based NextGen Healthcare Information Systems-as a virtual employee.

In fact, the virtual employee has a name-Billy Bob. "It's like having an assistant-who I don't pay-running reports for me and making sure they're done," Gummel says. "Not everything in business can be automated, but where it can, it's so much faster to have the software do it, which gives me more time to work on other reports or processes that cannot be automated," such as a financial analysis of bringing a new specialty into the practice.

Practice management makeovers

Practice management systems, which automate administrative and financial processes at physician offices, have been around for decades.

But newer versions, or new modules, feature expanded functionality, making it easier for staff to do their jobs and bringing new conveniences and services to patients.

Practice management vendors, for instance, increasingly are offering Web-based portals enabling patients to request appointments and prescription refills online, or send secure messages to physicians or staff. Some vendors have introduced modules that can conduct an analysis of a practice's performance compared with its peers.

And some vendors are rolling out aggressive marketing campaigns. For example, one is allowing customers to use the technology for free until they reach a specific goal for increased revenue (see story, page 60).

Physician offices in growing numbers are buying combined, integrated practice management/electronic medical records systems. An integrated system brings several efficiencies to a practice. In particular, it speeds the coding of claims because diagnosis and treatment codes entered into the EMR automatically port over to the subsequent claim in the practice management system. That, in turn, results in a claim being completed quicker and submitted for payment quicker.

Today, two-thirds of practice management sales for San Francisco-based McKesson Corp. include other applications, particularly an EMR, integrated with the administrative and financial system, says Tom Leonard, vice president and general manager of ambulatory solutions.

Further, if a practice is just looking for an EMR, its request for proposals almost always require integration with the legacy practice management system, he adds. "The core functionality of practice management is evolutionary. But what's moving in the industry is improved connectivity."

Checking performance

One company offering new functionality is athenahealth Inc., Cambridge, Mass. It provides a free reporting service to its clients that enables them to measure certain business performance metrics in their office against those of other practices using the vendor's practice management system.

The company remotely hosts its practice management and electronic medical records software, so it has business data from its client practices in its data center.

Under the Live Benchmarking Program, practices now can run a daily report on three metrics: the average number of days between time of service and entry of charges into the system; the time period that claims wait in a staff member's "hold bucket" awaiting corrections before submission and the time period the claims then sit in an administrator's bucket awaiting approval; and the percentage of patient self-pay balances still unpaid after 90 days.

At Family Care Associates, a solo-physician practice in Wellesley, Mass., office manager Cora Schrader uses the service to gauge how the practice stacks up against others.

"As the practice grows, the service lets me see exactly the areas I need to work on," Schrader says. She's found that Family Care Associates, compared with more than 500 other practices, measures very well in having low charge entry and claims-holding lag times.

But there was room for improvement in its self-paid balance. New procedures have since been put in place, and such accounts with balances more than 90 days old have been cut in half. "Before, I wouldn't know if the practice was out of track because I didn't have anything to compare it with," Schrader adds. "This affords us the opportunity to identify any areas that need to be enhanced-areas that directly affect financial health."

Moving to the Web

Another area where practice management vendors are boosting functionality is the Internet. Web portals can help improve communication between patients and physician offices and cut down on all those phone calls staff handle on a daily basis.

In April, The Family Doctors in Shreveport, La., enhanced its Web site with portal software from Misys Healthcare Systems, Raleigh, N.C.

The 11-physician practice's previous site was rather basic, offering such static information as driving directions, physician bios and a list of insurance plans the group accepted.

The new Web site, built on the vendor's PatientLink portal software, offers educational videos on demand as well as online appointment scheduling and registration. The portal also enables patients to print, complete and fax authorization forms for the release of their medical records, saving a trip to the office. Online payment is an additional function the practice expects to add this year, says Lisa Britt, practice administrator.

The Family Doctors also plans to add enhancements from Misys that will enable patients to request prescription refills and staff to send secure messages to patients to remind them of follow-up appointments or preventive treatment.

A small but growing number of patients are accessing the portal, Britt says. Doctors are using it mostly to educate patients, such as newly diagnosed diabetics, by giving them links to online content, she adds.

But Britt has a wish list of other functions she'd like to see added to the portal, which would increase office efficiency and patient acceptance. For instance, she'd like to see the portal enable online completion of all aspects of the release of information process. Interactive secure messaging between patients and staff or clinicians also is on that list because it reduces phone calls and unnecessary trips to the office.

Misys this year acquired Payerpath Inc., a Richmond, Va.-based claims clearinghouse. With that deal, the vendor was able to offer new functionality that has brought efficiencies to The Family Doctors.

The practice now can transmit batch claims via the Internet rather than through a dial-up modem. "We can transmit 600 claims in a few seconds compared with about 30 minutes with dial-up, if you could get a dial-up line because there are only so many access points," Britt says.

Through Payerpath, the practice also can get electronic remittance advice from four major payers that are responsible for about 35% of the practice's claims.

Vendors offering remotely hosted software via the application service provider computing model market the service as a cost-effective way for health care organizations to implement information technology. But the ASP model also can improve data protection because information is housed in secure vendor data centers.

Birmingham, Ala.-based Source Medical Solutions Inc. recently introduced an enhanced version of its combined SourceRad radiology information system/picture archiving and communication system. The software, offered via the ASP model, includes off-site archiving of all data from the radiology system, which is practice management software for imaging centers, and all images from the PACS.

Willamette Open MRI in Salem, Ore., went live with SourceRad when it opened for business in March. The five-radiologist imaging facility soon found value in having its data and images stored off-site.

When staff walked in on May 18, they realized burglars had been in the practice overnight. Gone were the desktop computers that accessed SourceRad, servers to transmit data and images to the vendor's data center, and virtual private network hardware for secure transmission.

No data loss

But the practice lost no patient data or images because that information didn't reside on the equipment that was stolen. Consequently, Willamette Open MRI did not have to report a data security breach and a subsequent violation of HIPAA privacy and security rules.

That was a huge relief for the practice, says Lisa Lewis, administrator. "When you're only open for two months and have to report to the federal government that patient information was compromised, that doesn't bode well for new business."

Staff discovered the theft at 7:30 a.m. on May 18. Two hours and a trip to the computer store later, much of the equipment was replaced and the new hardware up and running. But the practice could not immediately replace a laser printer that one radiologist relied on to print images, or the VPN hardware used to send data and images to off-site radiologists.

But with new desktop computers and connectivity servers up and running by 9:30 a.m, the practice could pull patient schedules from Source Medical's data center, call patients expected to come in that day and reschedule them.

As health insurers gradually have accepted HIPAA standard transactions beyond claims, practice management vendors in recent years have upgraded their software to support the transactions.

For example, LighthouseMD of Providence, R.I., early this year introduced a new version of its software that supports HIPAA eligibility verification and electronic remittance advice transactions.

Surgical Associates of New Haven (Conn.) soon found the eligibility transaction to be useful, but not a necessity for the three-physician practice. Most patients are referred from primary care physicians, so confirmation of insurance "is generally established by the time they get to us," explains Lisa Edwards, administrator.

Electronic remittance advice, on the other hand, has been a big time-saver, Edwards says.

Remittance advice for about two-thirds of the practice's claims is now received electronically. "Explanation of benefits on paper are upwards of 10 pages long with more line items than I care to estimate," she adds.

The paper remittances from each payer could take up to three hours to post to patient accounts. In contrast, it takes about 15 minutes to check that electronic remittance automatically posted to patient accounts was done accurately.

Further, the job previously was done by a full-time employee who wanted to cut back on hours. That employee now works part-time from home checking the postings. "The real bang for the buck for us is electronic remittance," Edwards says.

Standardizing standards

The fact that HIPAA standard transactions are not truly standard has hindered industry implementation and use of the transactions and reduced the efficiencies that the law envisioned.

Now, a small number of practice management vendors have committed to be early adopters of new "operating rules" to standardize the HIPAA transactions.

The vendors-including Emdeon Corp. and athenahealth-join a handful of vendors serving health insurers and several clearinghouses in committing to be certified in compliance with the operating rules by next March.

The other vendors include The TriZetto Group Inc. and Quovadx Inc., and clearinghouses Availity LLC, GHN-Online Inc., MedData and Passport Health Communications.

CAQH, a payer advocacy group, leads the transactions standardization initiative, called the Committee on Operating Rules for Information Exchange, or CORE. The goal is to standardize the transactions to the point that they can be conducted as easily as an ATM transaction.

CORE's first task was to develop a first phase of rules for the eligibility verification and benefits determination transaction, and the vendors will seek certification that they support the standard transaction.

Washington-based CAQH recently selected Edifecs Inc., Bellevue, Wash., as one of the certifying agents. Selection of another certifier is expected this month.

Through the phases

The first phase operating rule for the eligibility/benefit transaction is very basic, telling providers, for instance, that a patient is covered and has a $500 deductible. CORE now is working on a second-phase rule for that transaction that will give more information. For instance, future payer replies to an eligibility/benefit transaction could tell providers how much of the deductible has been satisfied.

The rules also will standardize methods to show more information on patient copays. The first phase rule, for example, covers copays on high-volume services, such as radiology. The second phase will add lower volume services, such as the copay for smoking cessation consultation or treatment.

After CORE has completed operating rules for the eligibility/benefit determination transaction, members then will work to develop rules for the electronic remittance advice and claims status transactions.

CORE members, representing multiple stakeholders in the industry, hope the eligibility/benefit determination operating rules accelerate adoption of the concept of standardizing HIPAA transactions, says Gwendolyn Lohse, project director.

"As we move forward and the concept is sold, it will be easier to adopt more phases because people will realize this is the way they want to do business."

Sidebar

Vendor pitch: Install now, confirm benefits, then pay

On Nov. 7, 2005, Comprehensive Urology in Los Angeles went live on an integrated practice management/electronic medical records system. In early August, the two-physician practice received its first bill from the vendor, Alteer Corp. of Irvine, Calif.

The vendor last fall started testing a new marketing strategy of not charging for its products until clients have reached an agreed-upon goal for increased revenue.

For Comprehensive Urology, the goal was to increase revenue by 15% above a base monthly amount of $176,000, says Pat Koch, office manager. Once the goal was met, Alteer would receive any revenue above the target of about $202,400.

In February, the goal was met for the first time, and monthly revenue by mid-summer averaged more than $220,000. The first bill from Alteer represented the vendor’s cut of increased revenue from February through June.

The practice’s increased revenue stems from efficiencies gained by using both the practice management and EMR modules, Koch says. A major efficiency is the electronic capture of charges in the EMR that automatically post to the practice management system. “Charge slips aren’t sitting around for two or three days and then the doctor doesn’t remember what he did for the patient,” she explains.

Enhanced reporting functions in the new software also alert staff to copays and outstanding balances while the patient is in the office.

The staff can run a report late in the day to identify copays and outstanding balances that should be received from scheduled patients the next day. When a patient comes in and staff enter a name into the practice management system, an alert section of the screen highlights the copay and any outstanding balance.

The alert feature also gives reasons for any denied claims for previous treatment, such as the need to get a new address or insurance card from the patient.

Having such information automatically available to staff—and the process requiring that certain data fields be filled—has made them more efficient, Koch says. “They can’t slack, they can’t just enter the patient name and phone number,” she adds. “They have to do their job; the system requires it.”

The two physicians also have increasingly become more efficient, relying less and less on paper-based patient information. “They still want the last progress note,” Koch notes. “They can’t seem to get away from that last piece of paper, but over time, that will go away.”

Sidebar

Common Mistakes Imperil I.T. Changes

Vendors and consultants that routinely replace practice management systems say physician offices commonly have expectations that are off the mark.

"They universally will underestimate the money and resources it takes to switch out a system," contends Ken Hufford, a practice director at Minneapolis-based Healthia Consulting.

Further, physicians tend to overestimate the impact of new information technology on increasing revenue and underestimate the effect of workflow and practice pattern changes, says Ken Carr, vice president of consulting at Per-Se Technologies Inc., Alpharetta, Ga. The company sells physician and hospital revenue cycle management software and outsourced billing services.

Consequently, practices don't provide the resources to make an I.T. changeover smooth. Carr recalls recent conversations with a mid-size practice that wanted to implement a combined practice management/electronic medical records system. "The docs didn't want to hear it would take supplementary resources," he says. "They didn't care that the office manager would work 60 hours a week for months."

Workflow the bulk of the work

Many physicians and administrators view practice management systems as a basic I.T. application and don't realize that a different system brings different workflows and ways of doing business.

As a result, they don't initially plan for a comprehensive workflow analysis to understand the roles and functions of all the employees who will touch the new system. "Workflow design takes up the bulk of the work and what gets compressed at the end of the project is education and training," Hufford says.

Insufficient training could negate efficiencies expected from the new system. "Are charges getting into the new system?" Carr asks. "If they are, great. But are charges then getting to the payers?"

Further, practices often shortchange the amount of time after go-live that it takes employees to really get comfortable with the system. That's why a second and possibly third round of refresher training is needed to enable staff to retain more information, Hufford says.

The problem is, physicians and administrators may not want to pull staff off the floor and have downtime for refresher training, fearing it will adversely affect daily operations.

But a low comfort level with the technology ultimately backs up patients and affects the revenue stream, Hufford says. "There's a direct correlation between how comfortable people are on the system and how deep the dip in the revenue stream will be."

When installing new practice management software-or any I.T.-a practice should have a formal project plan headed by an individual who is ultimately responsible and accountable for success of the plan, Carr says. Too often, a physician is put in charge who is not trained in project management and is trying to carry a normal patient load during the implementation phase, Carr says.

Other advice consultants offer includes:

* Test functionality of the new system comprehensively before go-live with up to 10 of the practice's most important payers and its clearinghouse.

* If outsourcing the business office at the same time as replacing the practice management system, try to place some affected staff in other positions and offer a generous severance package to those who will be leaving. This keeps the practice from turning into a hostile workplace during a time of considerable change.

* Don't recreate the wheel, trying to make the new system function like the old one. If the old system met the practice's needs, why is it being replaced? Accept that routine tasks will be done a new way.

* A physical move of the practice may seem like a good time to replace a practice management system, but it's not. "It gets overwhelming and dilutes everyone's focus because there is so much going on," Hufford says.

For more information on related topics, visit the following channels:

• Group Practices
• Hospitals