Thursday, July 19, 2018

SMART Goal Setting 101 For Your Small Business

SMART goal setting is a popular technique for validating your goals. This is important because it helps you save time and energy by making the process of goal setting more efficient and productive. It helps you avoid spinning your wheels!

What is a SMART Goal?

There are several ways you can define the acronym SMART. It is the definition that is most appropriate for small business owners:

  • Specific - You have clearly defined what you want to accomplish.
  • Measurable - You have identified targets and milestones to track your progress.
  • Attainable - Your goal is realistic and manageable.
  • Relevant - You have identified a goal that fits with your business model.
  • Time-Based - You have identified a specific period of time for the goal.

SMART Goal Setting Tools

To determine if your goal is SMART once you have written it down, run through this SMART Goal Setting Worksheet and make sure each question is clearly answered.

It's also helpful to see what a SMART goal looks like before you get started. Here are a few SMART goal examples that further demonstrate the process.

When you're ready to start tracking your progress, be sure to review this list of Goal Setting and Tracking Software, too.

Five SMART Goal Setting Tips

Now that you know the basics about SMART goal setting, here are five tips that will help you maximize SMART goal setting in your business.

Think About the Big Picture
SMART goal setting is about breaking goals down into validated segments. At the beginning of the process, before you run your goal through the SMART criteria, it can be helpful to start at the end and work backward. When you have the big picture end goal in mind, it's often easier to stay focused through the process.

Get Down to the Nitty Gritty
After you have the big picture in mind, you need to take the opposite approach and focus on the details. When you begin to break your goal down into smaller actions to fulfill the "measurable" and "attainable" SMART criteria, include actions that are as small and as specific as possible. The smaller the steps you need to make, the easier it will be to make forward-moving progress and build momentum.

Use a Systemized Formula
SMART goal setting is about using a formula that, when completed successfully, will get you from point A to point B efficiently. The more structured you are in the process, the easier it will be to make progress. Use the SMART worksheets, examples, and tools I included above to get started. And resist the urge to set goals in your head! Write everything down, so you have a record of what you're aiming for and how you intend to achieve it.

Track Your Progress
When you are entrenched in your goal and so focused on the daily actions you need to take, it can be easy to forget where you are in the process. Plan regular goal check-ins to gauge your progress, review your next steps and celebrate your successes. It is not only a great way to make sure you're moving in the right direction, but it will also let you revel in your progress and stay motivated to keep moving.

Set an End Date
Open-ended goals are dangerous for a number of reasons, one of which is that there is no urgency or time pressure to encourage progress. No end date often means slower progress. That's why the "time-based" part of SMART goal setting is so important. Think through a timeline for your goal when you are first getting started and break it down into smaller targets so you can easily see your success at each milestone.

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Sunday, July 15, 2018

Understanding Global Billing in a Group Practice

Q: Our doctor ordered a diagnostic colonoscopy because the patient was 'due for 5-year repeat given adenoma of 6mm on last procedure in 2011.' The patient is being screened for colon cancer, but at an interval of five years instead of 10 because of the polyp. The patient's insurance covers screening colonoscopy. The patient would like the doctor to change the referral from diagnostic colonoscopy to screening. Thoughts?

A: What this comes down to is the patient wanting insurance to cover the procedure.

With a Z98.89, h/o colonoscopy with polypectomy submitted with the procedure and maybe even the pre-authorization, it becomes diagnostic. The larger view is that the 'screening' scope is a scope in the absence of a reason to suspect a problem — you have a reason to suspect a problem. So if you change it you are gaming the insurance to get them to pay (fraud/racketeering).

Q: We've been getting [recovery audit contractors] related to global billing. We are told that physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician; so if you see your partner's patient post-operatively, you cannot bill for that visit.

My lead physician says, "If I consult on a patient with for instance, pseudotumor cerebri, and send them to have surgery to protect vision in the right eye, I must still follow them for their vision in the other eye. This must not be absorbed into the global, as I am following them for the original condition, but not just in the surgerized eye. I assume this one can be appealed if they ask for their money back?

The same is true if I diagnose a pituitary tumor. When I see them after surgery, I am seeing them to attend to a whole different organ system (the eyes/vision) than the pituitary gland. I'm not in the global am I?

A: The 'what you are told' part is verbatim CMS guidance and is correct per their guidelines. These appear to be somewhat hypothetical questions, but there are some nuances within them that can change the answer.

As regards the first case, the pseudotumor cerebri, where the patient is sent to 'have surgery' to protect the right eye — who was the surgeon doing the surgery? If that surgeon is in the same group and of the exact same specialty (neuro-ophthalmology), any follow up that Dr. A does on that surgerized eye is included in the global. This is the only permutation of these circumstances where the global period applies to Dr. A.

We need to know the exact specialty of that surgeon. As to case one, the surgical period does not apply if:

- The other surgeon is not a neuro-ophthalmologist

- Dr. A is following up on the other eye

You might also make also make a case that even if Dr. A were following up on the original condition of the surgerized eye, he is doing a medical evaluation of the original condition and not the normal follow up care for therapeutic surgical procedures. The definition of the latter is, 'follow up care for therapeutic surgical procedures includes only that care that is usually part of the surgical service'. His follow up is not of the surgical service, but of the medical condition.

That is likely moot as conditions one and two above most likely apply.

In the example of the pituitary tumor, the likelihood is even higher that Dr. A's services are distinct from the global period. Here a neurosurgeon most likely removes the tumor, and the global period applies to that service alone. They are separated by specialty and the problems that each addresses.

Every specific case or set of actual events will have a right or a wrong answer regarding the applicability of the global.

Q: There is a current debate in our office regarding infusion pump disconnect billing. The nurses want to bill 96521, however billing staff disagree we believe the disconnection of the pump should be a 99211. The office is flushing and disconnecting the pump. Since 96521 states refilling and maintenance, we did not feel it was appropriate as they were not performing a refill.

Here is the body of the note completed by the nurse:

'The patient presented with the mediport accessed and the home infusion pump in place. The port was flushed and the home pump was dc'd. A CBC and a CMP was drawn for the pt to seen on Monday.'

A: You are right that the language does not seem to match. I'd be uncomfortable using the refill/maintenance code for unplugging it, but it's always possible that a given payer would allow this in their definition of maintenance.

In looking into the CPT Assistants there is no specific guidance there. In looking up a policy for the actual infusion code 96416 to see if the policy stated if the disconnect was included, there is no language to that effect. A non-authoritative Q & A article found online refers to a Medicare policy — but I can't locate that policy.

"Question: Can we bill when the patient comes in to have the pump disconnected?

Answer: According to Medicare policy, if the patient comes in to the office for the sole purpose of having a pump unhooked by a nurse, a level-one office visit (99211) may be billed."

Since you are clearly not refilling the pump, you are not entitled to the whole value of the code. The Medicare fee schedule (MFS) amount for the 96521 is in the neighborhood of $120.00. The MFS for a 99211 is about $20.00.

Since there is no code that exactly describes what you are doing, CPT would have you bill either an unlisted code, or use a modifier if appropriate. A modifier 52 for reduced services would be appropriate here. Then you will know exactly how much the payer values this service. It may end up being close to the 99211. This is a judgment call, but as above – you do not meet the definition of the whole code.

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Wednesday, July 11, 2018

The true value of medical missions

Guest Post By  Stephen H. Hanson, PA-C 

I have been blogging for Physicians Practice since 2011. I write about a wide variety of interests (I hope) to the physician profession. My favorite topics are EHRs and, of course, physician assistant practice and what physicians should know about PAs and their role on the healthcare team.

This past week, I have been as far removed from the U.S. healthcare system as one can get in the world. I am with the HELPS International Bakersfield surgical team in Cobán, Guatemala. This is my third annual mission with HELPS, and the second trip to Cobán. We completed hundreds of surgeries and procedures and saw thousands of clinical patients onsite and in outreach to remote villages.

Keep in mind that we have no diagnostics aside from mainly ultrasounds and MRI / CT scans that patients bring with them. There is no blood bank. The only resources and supplies that we have at our disposal are the ones that we bring with us. The “heavy” equipment (OR tables, anesthesia machines, monitors, kitchen equipment, furniture, racks, etc.) reside permanently in Guatemala City, and is brought to the site and set up by the HELPS advance team.

The team itself brings the consumables (gowns, gloves, medications, sutures, etc.) in scores of “dive bags” that have to be checked by the team as extra luggage. Every member of the team pays their own way to live in a barracks situation, eat cafeteria food (which was great by the way), and endure plumbing that can only be described as “interesting.”

We travel all day Saturday and Sunday, and then furiously unpack and set up onsite Sunday night, to begin screening surgical patients late Sunday to begin major surgery and minor procedures first thing Monday morning. By Monday morning, we have created a fully functional field hospital with pre-op, five ORs (which this year and last were all in the same room, and adjacent procedure room (That I staffed most of time when not doing main OR procedures and first assist), a post-anesthesia care unit, and a small observation unit for overnight stays.

One advancement this year is that Stryker donated a laparoscopic set up, and we were able to do all of the cholecystectomies laparoscopically, eliminating the need for overnight observation. This was a huge positive shift in our operation.

For me as a PA, and for the NPs, it is great to work in an environment where I am not judged by my license, or constrained by state regulation, but by my training, experience, and knowledge. I have worked in plastics and reconstructive surgery for nine years. It is the highlight of my year each time I am on mission to practice at the very top of my training, experience, and scope of practice, and be respected by all the members of the surgical team beyond my status as a PA. This is what Optimal Team Practice (OTP) looks like, and it works.

The people of Guatemala are simply amazing. They come by the thousands to a mission site, with hope in their eyes and prayers in their hearts that we somehow, someway will be able to help their physical conditions, and alleviate their suffering. All too often, we have to turn away people that have problems just too complex to help due to the limitations of the team.

That said, we helped hundreds. We changed lives. And, many times, the lives that we changed the most were our own. No one can go away to a place like Cobán, or Tejutla in Guatemala and not come away changed forever in a way that you will never forget. In our great United States of America, we take for granted that which the majority of the world has never experienced. Great healthcare, clean water, education, public health infrastructure, community infrastructure, etc.

So, today, we are packing, decompressing, and taking stock of the things that went well, and the things that didn’t, so that we can improve of operation for next year. There are always key long-term volunteers that mentor and guide the many rookies who are part of every team.

One thing always remains a constant, and that is each member of the team is a selfless, sacrificing individual who is here for the right reasons and considers being a member of the team a privilege. Every American should go on mission once in their lives to the third world.

Mark Twain said it best:

“Travel is fatal to prejudice, bigotry, and narrow-mindedness, and many of our people need it sorely on these accounts. Broad, wholesome, charitable views of men and things cannot be acquired by vegetating in one little corner of the earth all one's lifetime.”

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Monday, July 9, 2018

How To Analyze Your Medical Practice Data to Optimize Profits

These days it can be difficult to keep a medical practice in the black. You may have little control of many of the factors that determine how much money your practice makes, with payer’s fee schedules and unfunded mandates having many practices feeling boxed in. However, by analyzing your practice data, you may find areas where you are leaving money on the table.

Don’t Lose Your Patients

Many of the ways money slips through the cracks aren’t even known to the physicians losing the cash. One great example of this is call abandonment. Not answering the phone when it rings can cost you a bundle. Elizabeth Woodcock, president of Woodcock and Associates, an Atlanta-based physician practice consulting firm, says the call abandonment rate is as high as 28 percent in many practices.

As odd as it sounds, it’s easy to see how this happens. Some practices are so busy that no one has a chance to grab the phone before the caller gives up. A patient trying to make an appointment might go to the hospital or to urgent care or just call another physician. Online scheduling or scheduling through the portal can help with this. But if your patient base isn’t comfortable with those methods, you need to make sure someone answers the phone. “Most telecom systems offer an abandonment rate as a standard feature,” says Woodcock. Take a look at yours and see if you can recoup some lost income by addressing this problem.

Another way business is lost and doctors don’t even know it is when referrals “leak” out of the practice. Doctors in a multi-specialty practice usually refer patients to each other. A primary-care physician who wants a patient to see a cardiologist will naturally refer that patient to a cardiologist in the same group. However, if the receiving physician doesn’t follow up on the referral, the patient is lost to another practice. “We often see that practices are not following up on referrals,” says Woodcock. “If the staff in charge of calling patients to schedule appointments doesn’t make those calls in a timely manner, the business is lost, and the doctor will never even know.” Analyzing in-practice referrals to see if they are resulting in appointments could highlight a big leak you didn’t know you had. If your staff doesn’t have time to take care of this, “the solution,” says Woodcock, “is not hiring more people. You need to invest in a self-scheduling system.”

Check Your Fees

You may be billing for less than you’re entitled to. A careful analysis of fee schedules could earn you a raise. “Analyze your fee schedules and make sure your practice fees cover the allowable fees from your highest payer,” advises Tammie Olson of Management Resource Group, an Ocean Springs, Miss., a firm offering financial management and support services for the healthcare community. “For example, if you accept Aetna but set your fee schedule with the Blue Cross Blue Shield allowable amount, you may be leaving money on the table if Aetna reimburses more.” Olson also recommends taking a look at your payers’ fee schedules to make sure their reimbursements aren’t too low. “If you have a payer whose fees are too low, you might want to renegotiate your contract. If they won’t allow you to renegotiate, then you may want to consider dropping this payer.”

In most cases finding and fixing these problems takes little time and little or no expense. Ignoring them is like walking away from money.

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Thursday, July 5, 2018

The secret to successfully negotiating with health plans

Negotiating with health plans is not about who you are or what you do. As a healthcare provider, it is about receiving fair compensation for what you deliver. As a health plan, it is about controlling liabilities, and, in the rare occasion when one arises, supporting assets.

Assets represent value. Effective value-based providers can be valuable assets. Yet many doctors refer to being paid for performance as “ghost money,” believing value-based programs to be just another clever scheme by health plans to cheat them when it is rarely the health plan at all. It is the program. That could be a hospital or hospital system not wanting to cannibalize its revenues to share the shortfall with others or “clinically integrated networks,” Accountable Care Organizations, or Independent Practice Associations naively not requiring change as a requirement for participation.

Large physician practices, including hospital owned practices, make the promises of higher salaries, which they afford through higher fee reimbursement gained by aggressive consolidation and negotiation. While effective in the past, now it moves them from marginally valuable partners to voracious behemoths creating ever increasing liability, which will be controlled – or eliminated.

The refusal to make the cultural, behavioral, and organizational changes needed to transform from a liability to an asset is a liability to everyone – patients, practices, physicians, and payers. Anyone telling you differently is lying.

If you don’t think that is true, consider the overwhelming rules, conditions, and regulation, from pre-authorization controls to scope of practice limitations imposed by commercial and public payers. Payers are controlling liabilities and mitigating exposure.

Physicians, particularly primary care physicians, in their view, must work long and hard to scratch out mediocre success, underpaid for performing tasks requiring expert skills. That is true, but repetitive tasks, however skilled, are incorrectly confused as providing value.

Treating people episodically for conditions related to treated chronic conditions is often viewed by payers as a failure to properly treat an underlying chronic condition. For anyone paying the tab, that is a liability. For health plans, it is a double liability. Their customer (the premium payer) is damaged, and they must pay for someone to try to fix it.

Hence, more limitations, restrictions, and controls.

Conversely, cognitive activities, such as managing health and preventing, slowing, stopping, or reversing the progression of chronic disease, which is three of every four dollars of healthcare spending pre-Medicare and 96 of 100 dollars post Medicare, is an asset. Assets are supported. Assets are rewarded. Assets are protected.

But, learning from experience, payers are cautious.

Value based reimbursement, which mitigates payer risk, generously rewards those who successfully make the transition from task-based service providers to clinical managers – and deliver results.

If you just think about that for a moment, payers mitigating liabilities makes all of the sense in the world. Managing price and some overutilization through regulations and controls are their two most effective tools – pretty much their only tools to reduce premiums.

Why would payers want to reduce premiums? Because it makes them more competitive and allows them to grow, particularly when they are competing for self-insured employers, who represent most of a health plan’s business.

How can providers do better? They can control spending, lower relative risk on a population scale (an advantage because lower risk to lower rates is a year’s lag), and improve patient experience. The combination gives payers a competitive advantage. Competitive advantages are assets as are those who deliver them.

The secret to success is fundamental, and, for many, uncomfortable, because it requires abandoning victimhood, the quiet comfort of managing a fiefdom, and adopting fundamental change in collaboration with others who have had success in transforming liabilities into assets.

The present system is a familiar nest that many are not ready to leave, which is why accountable care organizations, clinically integrated networks and the like don’t require any meaningful change in order to grow and increase care coordination fee income. It is a liability that will be controlled, and, eventually, starved.

Our parents told us all that you can never get something for nothing. The cost of an entitlement mentality is to be forever controlled. The cost of being a lone wolf sticking to the old ways is to be caged until you are no longer of any use at all.

I, for one, would rather be productive.

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Wednesday, July 4, 2018

Developing A Financial Plan For Your Small Business

Your financial plan is last, but it may very well be the most important of these three plans. Without the funds to launch and maintain your business, it will very likely sputter and die when it runs out of financial fuel. Keep in mind that it takes most new businesses months or even years to begin to make a profit. This is why you have to make sure you have your financial bases covered until you're able to create a healthy cash flow.

Start your financial plan by figuring out how much capital you'll require to start your business and where that capital will come from. Create a spreadsheet of all of the expenses you anticipate in launching your business. Some items on your list may include:
  • Equipment
  • Furniture
  • Software
  • Office space/store location
  • Remodeling work
  • Starting inventory
  • Public utility deposits
  • Legal and other professional fees
  • Licenses and permits
  • Insurance
  • Employee training
  • Website and other digital properties
  • Marketing collateral 
  • Grand opening event
  • Advertising for grand opening

Include the cost — or estimated cost — of each expense and total them to get an idea of the initial capital you'll need to get your doors opened.

Now do the same exercise focusing on anticipated ongoing monthly expenses. Your list may include some of the following:
  • Your salary
  • Staff salaries
  • Rent
  • Utilities
  • Advertising and promotion
  • Shipping and handling
  • Supplies
  • Telephone
  • High-speed Internet
  • Website maintenance
  • IT services
  • Bookkeeping or accounting services
  • Insurance
  • Taxes

Total up the estimated cost of each of these items to get an idea of your monthly expenses. Multiply that number by 12 to get an estimate of what it will cost to keep your business afloat for one year.

The last piece of your financial plan is estimating what your business will bring in, immediately and as it grows. You can't see into the future so you won't know with 100-percent certainty how successful your business will be or how long it will take before it generates income. Be conservative in this step. Use the information on your projected income from your business plan as a starting point, then add in more details to fine tune your estimates.

With your completed spreadsheet, you should have a very clear idea of how much you'll need to start your business. You can begin exploring small business funding options.

You may realize you need to do some additional research to gather information about the market as you begin working on your three plans. You may need more information to develop pricing strategies or reach cost projections. Take the time to get all the information you'll need so your plans are comprehensive and accurate. If you get stuck, consider enlisting the help of an expert — a business consultant, marketing expert or accountant — to help you through. You can also reach out to your local SCORE chapter to get free business advice and mentoring.

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