After-hours blind spots: Assessing and improving reliable access

For many health care organizations, after-hours strategies are often synonymous with having coverage for incoming calls. Health care leaders turn to a call center service or develop a schedule for on-call professionals, checking the box for 24/7 needs and equipping teams with guidance for appropriate escalation paths.

Yet variables exist at every juncture that impact the efficacy of an after-hours strategy. Imagine a regional health system that rolls its phones to an answering service at 5 p.m. One night, this call center is effective in routing a concerned parent to the on-call pediatrician. But the next night, issues mount: One call gets routed to the wrong provider. In another instance, the answering service pages an appropriate physician, but the contact number is out-of-date. When hiccups occur, the likelihood that patients will become anxious and simply head to the emergency department (ED) increases.

Breakdowns in after-hours access rarely show up as performance metrics, but they do impact clinical outcomes and the bottom line through inappropriate ED utilization, unnecessary readmissions and patient leakage. A better approach is "reliable access," where a consistent operating model exists that is measured, manageable and transparent.

Foundationally, after-hours access is one area where a nurse-first triage strategy can markedly improve consistency across the enterprise and improve the outlook on physician burnout. American Medical Association data suggests a 43.2% burnout rate with high stress among emergency medicine, family medicine and OB-GYN physicians, where heavy on-call workload environments exist. A nurse-first model ensures patients promptly reach trained clinicians who use evidence-based protocols to assess acuity and provide guidance.

Reliable access: A deeper look

More comprehensive than coverage, reliable after-hours access means patients consistently reach clinical support every time. In contrast, coverage means someone is scheduled to receive phone calls.

Reliability breaks down when health care leaders treat after-hours coverage as a staffing exercise instead of a system performance strategy. In many organizations, ownership of this area is fragmented, and there is no clear line of accountability. Without system-wide oversight, small behaviors that can impact reliability go unnoticed and unchanged.

For example, it would be easy for executives of a large multispecialty group to believe their after-hours model is working because they rarely receive complaints. What leaders might be missing is the variance between clinics once the doors close. In one primary care office, calls may roll to an answering service that texts the on-call physician directly. In another, calls are held in a queue until enough accumulate to justify paging the provider.

With the latter, patients may have already waited more than 30 minutes before the messages are sent to the physician. This model isn't designed to deliver timely clinical triage. It is instead designed to collect messages. Without oversight into routing times, escalation intervals and callback performance, patients can quickly learn that after-hours means "go to the ED."

With nurse triage, patients have timely access to a licensed professional who can listen and direct them to the appropriate level of care, whether that's home management, next-day follow-up, urgent care or the ED. Notably, up to 60% of all ED visits remain non-urgent and potentially unnecessary.
Seven steps assessing after-hours reliability

Understanding after-hours blind spots starts with a thorough analysis. Health leaders can start the process by evaluating seven areas of after-hours access to determine how reliable systems are across the enterprise.

1. System level ownership Who is in charge of after-hours strategies? Is access governed centrally for visibility and accountability, or is it a collection of departmental decisions?
2. Consistency under variability Change is the only constant in health care. The real test of reliability is consistency — whether the patient experience remains predictable regardless of changes in demand, acuity or staffing. How does an after-hours access model respond to variability?
3. Continuity of care In time-sensitive situations, delayed guidance can increase clinical risk. Can patients reliably reach timely clinical guidance after hours, or are decisions pushed into the ED or deferred until morning?
4. Consistency of documentation quality Accurate documentation is critical to optimal next steps with a patient. Are after-hours interactions documented consistently, visible to the appropriate teams and reinforced by closed-loop escalation and clear follow-up accountability?
5. Downstream operational impact When gaps exist in after-hours access, pressures are compounded during the day. This can look like increased ED traffic, additional follow-up work and care coordination delays. Where are after-hours access gaps showing up operationally?
6. Clinician strain Increased work becomes a driver of burnout and retention risk. Is after-hours on-call work placing undue strain on providers when issues could be resolved without a provider callback?
7. Executive visibility Does leadership know if after-hours access is unreliable and the downstream impact it is producing?

A more reliable way forward

Going forward, it is important for health care leaders to devise after-hours access strategies that go beyond the concept of staffing coverage. Many organizations reinforce reliability with a nurse-first triage model that connects patients to a licensed clinician for timely clinical guidance and appropriate escalation. With clear standards and follow-through, this approach reduces delayed callbacks and protects provider capacity. The real question isn't whether someone is on call; it's whether performance is consistent, measurable and manageable across the enterprise.

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When to bill CHI, PIN or CCM: A practical framework for independent practices

When CMS introduced Chronic Care Management codes in 2015, primary care practices spent years figuring out how to operationalize them. A decade later, many practices that did the work are still running care coordination programs under that same CCM-only mental model, even though the reimbursement landscape has shifted.

In January 2024, CMS introduced two new sets of codes under the Physician Fee Schedule: Community Health Integration (CHI), using HCPCS codes G0019 and G0022, and Principal Illness Navigation (PIN), using G0023, G0024, G0140 and G0146. Both expand what Medicare reimburses for between-visit coordination. Both have specific qualifying conditions and documentation requirements. And both are currently uncaptured in most independent practices I encounter.

The gap is rarely about willingness. It is about decision-making. When a practice manager is asked which code to bill for a given patient, the honest answer is often “I don’t know,” and so they default to billing nothing, billing CCM for everyone or running an informal coordination program off the books. None of those serve the patient or the practice.

A simple decision framework can clarify the choice.

Question 1: Does the patient have two or more chronic conditions expected to last at least 12 months?

If yes, CCM is in play. The patient qualifies for ongoing chronic care management: care coordination, medication management and between-visit support. The practice can bill the corresponding CCM codes for the time spent. CCM is the workhorse. Most patients with multiple chronic conditions in a primary care panel qualify, and most practices have at least started billing it.

Question 2: Does the patient have unmet health-related social needs that affect their care?

If yes, Community Health Integration enters the picture. CHI was designed to reimburse for the coordination work that addresses social drivers of health: transportation barriers, food insecurity, housing instability and social isolation, when those barriers are documented as affecting the patient's clinical condition. G0019 covers the first 60 minutes per calendar month; G0022 covers each additional 30 minutes.

CHI is not a replacement for CCM. A patient may qualify for both, with the practice billing each for distinct services on different days. The key is documentation. The social need must be identified, the intervention must be tied to a clinical concern, and the time must be tracked under the appropriate code.

Question 3: Does the patient have a serious, high-risk illness requiring active navigation?

If yes, Principal Illness Navigation may be the right code. PIN was created for patients with serious, high-risk conditions expected to last at least three months, including cancer, COPD, congestive heart failure, dementia, HIV/AIDS, severe mental illness and substance use disorder, where the patient is at risk of hospitalization, nursing home placement, acute exacerbation or functional decline. PIN reimburses for the navigation work that helps these patients move through the health care system, manage symptom burden and execute their treatment plan. G0023 covers the first 60 minutes per calendar month; G0024 covers each additional 30 minutes.

PIN doesn't apply to every patient with a chronic condition. It's specifically for serious illness with high navigation need. But for the patients it does fit, the reimbursement is meaningful and the clinical benefit is real.

Putting the framework into practice

The framework above is simple in concept and harder in execution. Capturing the right code for the right patient requires three things working together: clear identification of which patients qualify for which programs, documentation that meets each code's specific requirements and time-tracking that holds up under audit.

That infrastructure is where most practices stall. The codes exist. The patients exist. What's missing is the operational layer that connects them: the workflows, the documentation templates, the staff time and the EHR integration to make sure that what's clinically happening is also what's getting billed.

Related content from Medical Economics: New Medicare codes could transform how physicians serve their most vulnerable patients: here's how to use them

Bottom line

The codes have been live since January 2024, with federal reimbursement authorized. The patients these codes were designed for are sitting in independent primary care panels right now, often receiving the coordination work informally and unbilled. Practices that operationalize CHI and PIN now will be ahead of the value-based care curve. Practices that don't will keep leaving Medicare revenue uncaptured and, more importantly, will keep leaving their most complex patients without the coordinated care those codes were designed to fund.

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Hidden costs, unmanaged denials drain practice revenue

Medical practices are losing money in places most administrators never think to look, from aging shredding contracts to appeals that never get filed, and the gap between what practices spend and what they collect is only widening.

Shawntea Gordon, MBA, FACMPE, CEO of Atlas & Perpetua Healthcare, said the pressure on practices has intensified in recent years as technology costs, staffing shortages and stagnant reimbursement converge. She works with practices across the country to identify revenue leakage and build sustainable cost-management frameworks.

“The disparity between the costs we’re putting out and the reimbursement we’re getting in has gotten so much larger,” Gordon said. “I think the tech stacks with our organizations have gone from maybe two or three main software systems to upwards of 15.”

That assessment tracks with data from MGMA, which has documented steady increases in operating costs per physician even as collections have remained relatively flat for many specialties. The AMA’s Physician Practice Benchmark Survey has similarly flagged rising administrative overhead as a top financial stressor for independent practices.

Gordon said the most common source of revenue loss she encounters is unmanaged denials, followed by charges sitting untouched in accounts receivable. But she said leakage often starts much earlier in the revenue cycle, with front desk data entry errors that miss coordination of benefits or patient responsibilities, undocumented in-office services and down coded claims that go unchallenged.

“We have denials that aren’t appealed. We have down coding happening. There’s kind of a ton of places where I find leakage typically,” she said.

For administrators who have never formally benchmarked their expenses, Gordon’s advice is to start with historical data before making any changes.

“If you are not starting from an evidence-based perspective, you’re at a high risk of going off in the wrong direction,” she said. “Go dig into your own historical data.”

She recommends using established associations, including MGMA, HFMA and relevant medical specialty societies, as benchmarking references rather than newer online tools that may lack the historical depth to produce meaningful comparisons. She also cautioned that practices must be honest about their own characteristics, including size, location, community type and payer mix, before concluding they are over- or understaffed.

“A lot of groups that I come into say staffing is the highest cost, we need to get rid of staffing,” Gordon said. “Then we do an analysis and find out they’re already vastly understaffed, and the reason they don’t have more revenue is because the staff is burnt out.”

Beyond the expected line items of supplies and technology, Gordon flagged one cost that often goes unnoticed: outdated shredding service contracts.

“So many people kept their shredding services on the same rotation” after transitioning from paper to electronic records, she said. “If you weren’t paying by weight, or you’re paying like a monthly minimum fee, and you’re not really dumping a lot into the shredder bin anymore because you’re putting everything online, that’s one place that I see people just have these monthly contracts that they’ve had since ’92.”

She acknowledged shredding costs are relatively small individually but said they illustrate a broader pattern of practices paying for services that no longer match their operational reality.

Before making any significant change, Gordon said leaders should run through a standard set of questions: Will this create a compliance risk? Will it hurt the patient experience? Will it affect revenue collection? She described a case in which a practice switched medical supply vendors to cut costs, only to discover the new vendor had a history of back-ordering a critical surgical item.

“You have to dig into those things ahead of time,” she said. “Really make sure you’re looking holistically and not just making a decision based on your gut.”

For the longer term, Gordon recommends building a structured improvement cycle rather than conducting one-time audits. That means doing a full organizational review, building a 90-day improvement plan and then converting that review cadence into a standing monthly process.

“This is something you look at every single month,” she said. “How can we do better than we did last month? How can we improve, even if it’s just by 1% every single month?”

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Improve Patient Collection with 9 Easy Steps

Understanding and then running the patient collection process can indeed be a challenge. To assist with collection issues, we present 9 practical steps outlined below.

1. Collect Payments Upfront

One strategy involves increasing transactions at the point of service (POS) collection. Utilizing the moment when the patient is physically present is ideal. The front desk or check-in staff should actively communicate any outstanding balances and previous collection attempts to the patient.
This approach ensures that patient balances are addressed quickly, allowing billing departments to boost revenue from collections. Moreover, it minimizes the need for prolonged efforts in pursuing unpaid bills and issuing statements.

2. Collect Payments through Patient Portals

Simplify the payment process for your patients by encouraging online payments through a dedicated patient portal. This user-friendly approach enables them to make payments securely from the convenience of their homes. Opting for online payments enhances patient comfort and simplifies the collection process, saving valuable time and resources. Without the hassle of dealing with physical paperwork, you can expedite the collection of payments efficiently.

3. Developing Well-designed Statements

Clarity is important when it comes to patient bills. Craft easily understandable statements, ensuring patients fully understand their charges, services rendered and any adjustments. Include essential contact details like phone number, contact person, and email address to facilitate inquiries about statements. This transparent communication aids in promoting a smoother patient collection process.

4. Provide Multiple Plans for Payment

For patients eager to pay but unable to settle the entire bill simultaneously, offering flexible payment plans provides confidence in meeting essential treatment costs. Customize these plans, especially for patients facing higher bills, ensuring their financial limitations do not hinder necessary healthcare. Verify that these payment plans align with state and federal regulations, maintaining compliance for both parties.

5. Identify Outstanding Balances

Before or during providing care, ensure that coverage is verified with payers and that payer rules are understood. This approach helps pinpoint changes in the patient collection process, outlines coverage for expected treatment charges, and clarifies patient payment responsibilities.

6. Allow a Variety of Payment Options

To enhance financial well-being, medical practices can optimize collections from patients by expanding payment options. Refocus your patient collection process where patients bear more medical expenses. Increase convenience for patients by accepting various payment modes such as credit cards, debit cards, electronic fund transfers (EFTs), checks, and cash. This flexibility accommodates diverse patient preferences and simplifies the payment process for improved collections.

7. Streamline Your Payment Posting Process

Optimizing payment posting enhances patient collection efficiency. Implement these strategies:

Real-time Posting
Aim for real-time posting of payments to maintain up-to-date financial records. Use electronic systems for instant payment verification and accurate documentation.

Automated Tools
Invest in automated payment posting tools to reduce manual errors and simplify reconciliation. These tools integrate with your billing system, saving time and minimizing discrepancies.

Detailed Documentation
Ensure comprehensive documentation of each payment received, including payment method, date, and services covered. This record-keeping aids in transparency and resolving any inconsistencies.

Reconciliation Checks
Regularly reconcile posted payments with your bank statements to identify and address differences. This approach helps maintain financial accuracy.

Staff Training
Provide adequate training to your billing staff on efficient payment posting practices. Familiarize them with the latest tools and technologies to maximize effectiveness.
Implementing these measures will expedite the payment posting process and contribute to a more efficient and error-free patient collection workflow in your healthcare practice.

8. Follow Up on Overdue Collections

Ensuring a robust cash flow calls for constant follow-ups on overdue patient collections. Consider the following strategies for managing delinquent patient collections in healthcare:

Make a Phone Call
Initiate a personalized phone call to connect with patients regarding overdue accounts. Clearly explain the outstanding balance and inquire about any reasons for payment delays. If necessary, discuss feasible payment plans during the conversation.

Send a Written Reminder
In addition to the phone calls, dispatch a well-crafted written reminder to the patient’s home or email address. Ensure the communication is transparent and empathetic and includes complete information on available payment methods.

Persistence and empathy are key during follow-ups, particularly when patients encounter financial difficulties. Collaborate with patients to find mutually beneficial solutions, effectively creating a positive approach to resolving overdue patient collections.

9. Outsource Your Patient Collections

Consider outsourcing to enhance the efficiency of your medical billing collection process. Outsourcing third-party billing providers brings expertise to implement effective strategies, ensuring a steady cash flow and quick collection. They specialize in patient follow-ups for overdue accounts and assist with denied claims. The advantages of outsourcing patient collections include:

• Improved cash flow
• Increasing patient satisfaction
• Reduction in administrative burden

The Era of Contactless Payments in Healthcare

Patients are now seeking convenient ways to settle bills without visiting hospitals. Virtual payment portals offer the comfort of debt clearance from home. By 2025, market reports showed that contactless transactions had firmly crossed the tipping point, with over 60% of all global in-store transactions utilizing tap-to-pay methods.

Today, customers can effortlessly tap credit or debit cards onto POS devices for payments. Setting transaction limits adds an extra layer of security against unauthorized withdrawals.The younger demographic, aged 26–35, prefers online wallets like Google Pay, Apple Pay, and PayPal, as highlighted in the U.S. Bank Healthcare Payment Insight report, with 28% favoring mobile app payments.

Enhance patient payment accessibility by including QR codes on statements. The QR Codes Forecast and Trends 2022 report by Insider Intelligence predicts a surge in U.S. smartphone users scanning QR codes—from 83.4 million in 2022 to 99.5 million in 2025.

Implementing self-pay collection practices reduces accounts receivable days and overall improvement in the collection process.

Conclusion– Sharing Your Load with Billing Experts

Managing the patient collection process can be overwhelming, especially with a higher number of patients. Engaging the services of medical billing experts can relieve this burden. Billing professionals specialize in translating medical services into accurate codes and assisting in determining correct patient charges. Operating a healthcare practice without billing experts is risky. Errors in billing and inaccuracies can lead to patient lawsuits and federal fines. To avoid such consequences, healthcare professionals wisely choose certified billing experts. Including these professionals in your practice ensures billing accuracy and minimizes legal risks, ultimately contributing to a smoother patient collection process.

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Denial rates are rising, here’s how to fight back

Claim denials are getting worse. Data from Kodiak Solutions shows payers initially denied 11.8% of claims in 2024, up 15.7% from 2020, and the Medical Group Management Association’s 2024 benchmarking report on denials and appeals found more than half of U.S. health care organizations now report denial rates exceeding 10%.

Kem Tolliver, CEO of Medical Revenue Cycle Specialists and co-author of “Advanced Strategy for Medical Practice Leaders: Financial Management Edition” (MGMA), told Physicians Practice that the practices getting ahead of this problem share one habit: they show up to payer disputes with data, not grievances.

“When you approach a payer, data is what really matters to them,” Tolliver said. “If we provide them with data, give them examples, show them why something should have been paid, give them justification, that’s what is going to break through and lead to a correction on a claim. Frustration is not a strategy for a solution.”

She recommends documenting every payer interaction with reference numbers, dates, and the name of each representative. Teams should also resist the habit of working the easiest accounts first.

“What we really want to encourage our teams to do is look at denial drivers, identify root causes, and dig into the complex accounts too,” she said.

Finding the root cause

When denials spike, Tolliver starts by sorting them into four buckets: front-end intake, documentation and coding, payer communications, and practice management system data. From there, she pulls denial reason codes from X12.org, groups them by root cause, and builds correction and training plans from what the data shows.

CPT coding is one of the most common and preventable denial drivers she encounters. Her fix: document payer-specific reimbursement guidelines internally, covering coding, modifiers, authorizations, and referrals. Industry data backs up the priority: roughly 50% of all denials trace back to front-end errors, with eligibility issues alone accounting for about 22% of preventable denials.

Metrics that matter, and ones that mislead

Tolliver said practices often take false comfort in the gross collection rate and total charges, neither of which captures the full picture. The metrics she trusts are aging accounts receivable, time-of-service collections, clean claims rate, and denial rates by dollar amount.

“If patients have out-of-pocket balances of $5,000 for the day and you’re only collecting 60% or less of that, those are dollars that could be collected with no expense to the practice,” she said. “No statement, no collections agency, just a person asking for the money.”

The stakes are real: Kodiak Solutions data shows the patient collection rate from commercially insured patients fell to 34.5% in 2024, down from 37.6% the prior year.

Stop the leakage before it becomes routine

Tolliver’s sharpest warning is about revenue leakage: the slow, quiet losses that never feel urgent enough to fix. Under-coding, writing off collectible balances, accepting virtual credit card payments without negotiating, and failing to renegotiate fee schedules are the forms she sees most often.

“Revenue leakage is something that is often hidden,” she said. “It gets masked under other things and doesn’t feel as urgent. But I think it is a serious threat to financial stability, because it has a way of becoming routine.”

A January 2026 MGMA Stat poll found denials and appeals account for 48% of the biggest revenue cycle leaks practices report. Industry analyses put the total cost of leakage at 4% to 5% of revenue, as much as $800,000 to $1 million annually for a $20 million practice.

“These are not emergencies today, but they add up,” Tolliver said. “Stop letting it slide.”

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Targeted marketing to maintain existing patients and attract new ones

Of course, it is nice to attract new patients to your practice, but it is easier to keep the patients you already have. The estimated cost of attracting a new patient is $200 for primary care and $600 for plastic surgery. However, the cost and energy required to keep existing patients are modest. Most practices have dozens, if not hundreds, of patients that need follow-up and haven’t been seen in months or years. They may have fallen through the cracks. This article will discuss how to return existing patients to your practice and suggestions for attracting additional patients.

Target existing patients for appropriate services by reviewing your patients’ medical records. Just pull a few patients’ charts a day (electronic or paper) and review them for services that would be appropriate to recommend. For example, if you are a primary care physician, look for females in the 50+ years-or-older category who haven’t visited your practice in the past two years. Contact them and suggest that it may be time for a physical.

Another example is a urology practice that has patients with a diagnosis of bladder cancer. These patients need regular follow-up cystoscopy. An electronic health record review of requests can be accomplished in seconds by creating a report based on pre-defined parameters – as opposed to months of effort if you used paper charts.

Determine whom you want to target, and check with your EHR vendor to determine if the necessary patient data can be easily generated and downloaded in a convenient format. Integrate targeted marketing into your daily patient flow by identifying recommended services to guide patient care as they present. This could range from missing immunizations to cosmetic services that could benefit the patient. During the pre-visit chart review, ask employees to identify patients who may be candidates for the recommended services.

Other ways to attract patients include:

• Writing a blog. Pen an article or a posting for your own website – alternatively, provide the article to interested parties such as your local media. The easiest blog service to use is WordPress.com
• Tweeting messages or posting on Facebook. Write timely comments about issues that are relevant to patients – and pertinent to your practice, such as the pollen count if you are an allergist, or a new robotic surgery available to treat prostate cancer if you are a urologist.
• Contacting schools, senior citizens centers, religious institutions, childcare centers, and other potential sources of new patients. Ask if they will include an article by you in a future newsletter or allow you speak at an upcoming function. Or offer to perform on-site screenings to make appropriate recommendations for follow-up care.
• Volunteering for community activities. Not only is volunteering good for your community, but it also makes your name visible.
• Getting to know those in your community who routinely meet new arrivals to the area; the benefits officers of local employers and real estate agents are two places to start.
• Thanking established patients, referring physicians, and staff who refer patients to you. Show your appreciation to referral sources, but avoid lavish gifts, especially to referring physicians, because they may be construed as payment for referrals. You can make a lasting impression just by sending a note of thanks for a referral.
• Honing customer service skills throughout your practice. Patients who are impressed by the service they receive at your practice will spread the word.
• Developing an online presence. Keep your website, Facebook business page, LinkedIn profile, and other pages up to date; use an attractive design; post patient education information and profiles of you and your staff; and, if applicable, keep the navigation simple.
• Doing lunch. Have a meal with your colleagues in the medical staff lunchroom at your local hospital or offer to bring lunch to a referring physician’s office. These social interactions and networking can lead to establishing strong collegiality.
• Giving a lecture. Volunteer as a guest speaker for hospital grand rounds, hold your own conference for referring physicians, or distribute a link to a recorded copy of your lecture online. Serving as a lecturer increases your profile as an expert and offers your colleagues insight into the services you offer.
• Communicating. When caring for a patient referred by a physician, provide that physician with frequent written updates, ideally through an automated referring physician communication process.

Marketing efforts don’t require a tremendous investment. A quick response (QR) code, for example, is a smartphone-readable barcode that can store website addresses, plain text, phone numbers, email addresses, and nearly any other alphanumeric data. Develop a QR code to link to your practice’s website or online patient portal: it costs nothing to create a QR code, and it can be done in a few seconds. Use it to link to your website, phone number, and/or address. Or develop special QR codes for promotional items or events.

Marketing activities

Develop a fact sheet for your practice that can also serve as a direct-mail piece to promote it. Distribute it to potential patients using contact lists you obtain for the markets you wish to target. While a billboard, radio, and newspaper ad will get traction, consider advertising in other venues, such as movie theaters, grocery stores, and other venues in the markets you are targeting. And don’t forget about opportunities at schools (such as the student health center at a nearby university), local sports leagues, and community events. While not heavily viewed, community cable television stations can create visibility for your practice at no cost to you. Cable stations often broadcast health segments and value good content. Local broadcasters, especially those with news and public affairs programming, can be affordably targeted by sending the station a letter at least once a quarter explaining your expertise in your specialty. It may take a year – or even two – but eventually you can break through when their staff needs to interview a physician about an issue relevant to your specialty and area of expertise.

Charity auctions and similar events are another local-cost marketing opportunity: consider offering your services as part of an auction for a school or local charity. For example, I have offered a no-scalpel, no-needle vasectomy at a school auction. The title in the auction book is “School Tuition Getting You Down? A No-Scalpel, No-Needles Vasectomy May Be the Solution”. This offer was seen by dozens of parents who learned about the procedure. If they didn’t have the highest bid to receive the donation or weren't ready to have the procedure at that time, they went to my website for more information. Eventually, several parents (mostly the female parents!) called my office to make an appointment for the procedure. The cost was negligible, as was the time invested to create the offer.

If you are in a community where English is a second language, consider offering materials in other languages as well. Google Translate is an excellent (and free) option for materials placed on your website. Community-based online platforms or newspapers and radio stations can serve as links to ethnic groups that might be underserved in your market. Depending on how many patients in your practice use English as their second language, consider hiring a bilingual receptionist or nurse. Offer to give talks at community centers. It is also worthwhile to learn a few words in their language, such as ‘thank you,’ ‘nice to meet you,’ and ‘goodbye.’

If you don’t have time to execute these sorts of marketing activities yourself, hire a vendor who specializes in medical marketing and branding. If funds aren’t available to develop a relationship with a marketing agency, consider contacting a local college or university for an intern majoring in marketing. They may bring fresh ideas; you gain the resource, and they gain experience.

Bottom line:

“A satisfied customer is your best marketing tool.” That pithy marketing phrase applies to your practice just as it does to any other business.

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Is my practice required to offer a patient portal?

It's one of the most common questions practice administrators ask as they navigate the tangle of federal health IT rules: Do we legally have to offer patients a portal? The short answer is nuanced. No single law flatly mandates that every practice deploy a patient portal, but a web of overlapping regulations creates powerful incentives, and in some cases real obligations, that make offering one nearly unavoidable.

Q: Is there a law that specifically requires practices to have a patient portal?

Not exactly. No federal statute contains language saying "you must operate a patient portal." But as the American Medical Association explains, the legal landscape is more like a puzzle, with HIPAA, state laws, the Promoting Interoperability program and the federal information blocking rules all fitting together, and that puzzle strongly favors providing patients with electronic access to their records. HIPAA provides patients a right to access most of their health information in their preferred form and format, as long as the practice is technically able to do so. A portal is the most practical way to deliver that access at scale.

Q: What does the 21st Century Cures Act have to do with this?

Quite a bit. The 21st Century Cures Act was signed into law in 2016 with overwhelming bipartisan support, and information sharing is central to its requirements. The law's final rule, enforced by the Office of the National Coordinator for Health Information Technology, or ONC, prohibits what regulators call "information blocking." Beginning in November 2020, federal regulation prohibited healthcare systems and providers from blocking health information from patients, requiring the immediate release of information such as clinical notes, laboratory data, imaging and pathology reports.

As Physicians Practice has reported, that definition of information blocking is broad. ONC has provided examples of practices that may constitute information blocking, including imposing fees that make exchanging electronic health information cost-prohibitive, using organizational policies or contractual arrangements that prevent or limit sharing, and inappropriately citing HIPAA as a reason not to share information. You don't need to be doing something obviously wrong to run afoul of the rule.

Q: Does this mean my practice could be penalized for not having a portal?

Potentially, yes, though enforcement has been uneven. As Physicians Practice has covered, the 21st Century Cures Act information blocking rules carry real teeth. More than 75% of the complaints HHS has received regarding organizations barring access to patient data have involved health care providers. Complaints can be filed with ONC, and HHS has signaled that closing the enforcement gap is a priority.

It's also worth noting how the rule is framed. According to Physicians Practice's coverage of Cures Act compliance, patients who have trouble with portal technology may mistake a poor user experience as an intentional attempt at information blocking and lodge a complaint. Even a clunky or outdated portal can create legal exposure.

Q: What about the Promoting Interoperability program? Does that apply to my practice?

If your practice participates in Medicare or Medicaid and wants to maximize reimbursement, then yes. The Promoting Interoperability program, formerly called Meaningful Use, ties payment incentives to demonstrating that patients can electronically access their records. As Physicians Practice has explained, Stage 2 required that more than 50% of all unique patients seen by an eligible provider be given online access to their health information within four business days, and that more than 5% of all unique patients view, download or transmit their health information to a third party. A patient portal is by far the most common vehicle for meeting those thresholds.

Practices that fail to participate face Medicare payment reductions. In that sense, while a portal is not legally mandated, the financial consequences of going without one in a Medicare-participating practice can be significant.

Q: Are there exceptions? What if we're a small practice or don't use an EHR?

The information blocking rule applies to any practice that qualifies as a healthcare provider under the Cures Act, regardless of size. However, the rule does recognize exceptions. The information blocking rule does not require practices to store records in any particular file system or adopt any particular technology. The rule prohibits only an unnecessary delay in providing patient records from whatever storage format or system the practice currently uses. So if you do not maintain electronic health information at all, the information blocking rule's scope is limited.

That said, the information blocking law applies only to electronic health information, and therefore information that exists solely in paper form is exempt from its scope entirely. Practices that have not yet adopted an EHR face a different calculus, but as EHR adoption has become nearly universal, the practical shelter of a paper-only argument has largely closed.

Q: What kinds of information must be made available if we do have an EHR?

The scope has expanded considerably since the rule took effect. As Physicians Practice has reported, ONC expanded its definition of information blocking so that data required to be accessible applies not only to the data elements contained in the United States Core Data for Interoperability, but also to electronic protected health information as defined under HIPAA's designated record set. In plain terms, that covers a wide range of clinical and billing records.

Physicians Practice has also broken down the key definitions of PHI, ePHI and EHI, noting that knowing the exceptions to information blocking and having an alternative method to deliver patients their electronic health information is just as critical as knowing what may constitute an information blocking violation.

Q: Even if we're not strictly required to have a portal, is it still a good idea?

Most practice management experts would say it is an operational no-brainer. Physicians Practice has covered patient portal adoption extensively and the business case is strong. As reported in Patient Portals: Beyond Meaningful Use, letting patients make their own appointments on a portal has reduced call volumes by 20% to 30% at some practices, and the elimination of most faxes has allowed some practices to get by with fewer support staff.

As Physicians Practice has noted, portals help patients take a more active role in their care and control the way their information is managed. And the cost of running a practice can be reduced by using a portal. Getting patients off the phone gets staff off the phone, which either frees staff to do other tasks or reduces how many staff are needed.

The patient satisfaction angle matters too. Physicians Practice has highlighted must-have patient portal features that help practices reduce no-shows and cut phone tag, including self-scheduling with live provider calendar availability and HIPAA-compliant secure messaging routed through clinical staff.

Q: What should we do if we're uncertain about our obligations?

Start with your EHR vendor. Most certified EHR systems include a patient portal or can connect to one, and your vendor can help identify what information is automatically flowing to patients and what may require configuration. The AMA's Patient Access Playbook is a solid free resource for understanding how HIPAA, state law and the Promoting Interoperability program intersect. ONC also maintains an information blocking FAQ that is updated regularly.

When in doubt, consulting a healthcare attorney familiar with HIPAA and the Cures Act rules is prudent. The regulatory landscape continues to evolve, and the cost of a compliance review is far lower than the cost of a complaint or penalty.

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