Physician group post-merger integration

Closing the deal is a major milestone, but it’s the process that follows where the real value is created. It may be difficult to believe, but the post-merger integration can be even more complicated than the deal itself. Communication is critical during this process, and the two groups need to share documents easily. Information must be transitioned seamlessly throughout, and the whole integration process has to meet physician owners’ expectations for key timelines and capturing synergies in growth and costs.


Taking proactive action within the first 100 days post-closing can significantly realize deal synergies and potential. Practice administrators working in concert with a seasoned consultant must develop a well-structured plan for their post-merger integration efforts to vastly improve their odds for a successful outcome.

The complexities of integration

Many physician owners spend months of time and effort closing merger transactions but stumble when it comes to integration. Oftentimes, buyers significantly underestimate the necessary level of involvement in a successful integration effort. Common mistakes include:
Failing to properly assess the resources to integrate and operate two businesses
Not addressing “people issues” and cultural differences of the physician groups
Losing focus after the signing of a deal
Overloading management with integration responsibilities outside their scope of expertise


These mistakes lead to a significantly slower integration effort that tends to compound these and other mistakes.

Speed is of the essence

Physician groups that move slowly during the integration process are vulnerable both financially and competitively. The announcement of a merger between two groups creates uncertainty among employees of both organizations and fuels anxiety-filled discussions about who will stay and who may be let go. Without proactive and effective communications, employee morale will suffer. Even worse, those key employees who you hope to retain may jump ship to competitors or other organizations.


The turbulence of an announced merger can give competitors a perfect opportunity to call on your referring physicians and even patients. The community at large can spread all kinds of unconfirmed “alternative facts.” A slow response to retention initiatives (retention of employees, patients, and referring physicians) during a merger can leave competitive doors open too wide for too long. Decision-making must be streamlined for the integration effort to move forward. The completion of a few “quick win” integration tasks will bolster confidence in the team leadership and keep the process moving forward. One of the first things to do is host a staff meeting to discuss key human resource issues such as payroll schedule and benefits transition.

A plan of action

Strategic integration decisions should be put in place prior to the completion of due diligence because these strategic decisions may influence the deal terms and structure. It’s important to identify these details and include them into the deal agreement before closing. Ideally, a 100-day integration plan is implemented when the deal closes. This should include identifying tasks to be completed, known issues, milestones, and planned timelines for completion.


Following the deal’s closing, detailed planning sessions should begin with functional department members of both practices. In the beginning stages, joint meetings are essential to establish relationships between representatives of both practices. Once initial on-site discussions are completed, subsequent discussions leveraging virtual meeting technology can take place. The two together will result in more efficient time utilization and reduced travel costs.


If you think of a physician group merger as a marriage, then you can see there is still a lot of work left to do after the wedding date, or day 1. Yes, it’s the day in, day out effort of the marriage that takes patience and thoughtfulness—and also tends to get messy. Compared to a marriage, the wedding is easy. Post-merger integration is critical to realizing the value of a deal. It’s also highly complex, taking place under severe time pressure, and happens in parallel to running the core business—making it one of the most challenging initiatives physician owners and practice administrators will ever undertake.


What's the secret to post-merger integration success? Focus on the strategic objectives of the deal, accelerate synergies, and building a high-performance medical practice.

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How to Set a Budget for Your Social Media Marketing

With its access to millions of users worldwide and very simple use, it’s little wonder that social media is one of the most powerful marketing venues these days.


Both marketers and businesses spend a lot of money on marketing campaigns that involve social media. That doesn’t guarantee success though. Here are some tips on how to determine your social media marketing budget.

Create a Marketing Plan

To know what you can achieve and afford during the marketing campaign, you must know exactly how much you can invest. While a marketing budget takes a certain percentage of the annual revenue, that’s not the case if you’ve just started out. This is where short-term debts come into play.


Most entrepreneurs and business owners need extra cash from time to time or at least once during their careers. Fast cash comes in handy when you want to buy extra labor and/or materials to fill the large orders. It’s also helpful when you should replace or repair an essential tool or device that has suddenly died. Launching a social media marketing campaign is another good reason to take out a loan. Whatever the case may be, fast business loans go a long way toward getting marketing funding.

Define Your Target Audience

Not only does social media marketing give you the chance to sell your products or services, but it also allows you to build strong relationships with your customers. Different readers are responding to different content, so it can be a difficult task to define your audience. Luckily, there are a lot of analytics tools that help in identifying the target audience. Make use of them to determine how and where to invest your money when running a social media campaign.

Diversify Your Content

Aside from creating shareable and engaging content on social networks, you should also provide your users with multiple and diverse content types. That may include blog posts, photos, videos, news, GIFs, memes, and so on. Be sure to keep your messaging consistent.

Expand Your Scope

Twitter and Facebook are platforms that feature huge user bases; however, they are crowded with vendors and businesses of all kinds since just about everyone is marketing on these two platforms. To get the most out of your marketing budget, you should constantly look for new opportunities. It’s a good idea to broaden your scope by switching to alternative platforms. Find your target audiences out there and reach out to them.

Go for Innovation

Stagnation is considered one of the most dangerous things in marketing. While it’s smart to go with a marketing strategy that has proven itself to be successful, you are advised to always leave some space for experiments and innovative strategies when creating a budget. Social media platforms are ever-evolving, competitive and fast-paced, so creativity and innovation are necessary if you want to gain success there.


No matter where the marketing funds come from, make every effort to conduct the thorough analysis of all expenses to rest assured that you are making the right decision. Spend wisely instead of throwing your money away when running a marketing campaign. Just as with any other type of marketing, social media marketing must be done with benefits and clear goals in mind.

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How to say goodbye

There comes a time when every practitioner will have to bid farewell to a staff member, patient, colleague, or community. Whether it’s because someone is terminally ill or moving away, these sensitive goodbyes can be challenging.


Here are some common send-off scenarios with suggestions for how to say so long.

Illness or death

When my friend was in the final phase of Stage IV breast cancer, she set the bar high for saying goodbye. A retired RN who was pragmatic at heart, she knew there was no hope for her survival. In her last days of cognition, she sent personalized thank you notes to the people who had touched her life. Her closing words still resonate with me. She wrote, “Farewell. I shall miss seeing you.” What a profoundly simple and thoughtful message.


Doctors need to know how to say goodbye with grace, too. Being the person who notifies someone about their imminent death and accompanies them on their final journey is a sacred position. That’s why it’s so important for medical practitioners to feel comfortable offering a heartfelt farewell when the time comes.


Still, it’s natural to agonize over what to say to the dying. A simple and sincere statement like the one my friend shared can suffice. Offering a similar sentiment to their loved ones goes a long way toward their healing, too.


When it’s a doctor who is facing his or her own mortality, it’s only fair to let patients know that there will be a change in the practice. Since it’s probably impractical to notify patients one by one, a concise general announcement will usually suffice. There’s also the chance that a physician will die unexpectedly, in which case their executive or administrative team will need to promptly decide on a plan of action for notifying patients and colleagues of the sudden death.

Retirement or relocation

A strong physician-patient relationship takes time to develop. Losing a trusted doctor for any reason, including retirement or relocation, can be difficult for patients. But it’s not only patients who will need to accommodate the change: Clinic staff will also be affected.


It’s respectful to offer an explanation to both groups well in advance of closing, selling, or moving a practice. Employees should be notified first so they can begin adjusting their career plans. Letting staff know about the change before patients means they can also help spread the word in a considerate and efficient manner.


One of the final acts of compassion a physician can offer patients is to provide ample time for them to absorb the news of departure. Adding recommendations for practices that are accepting new patients and helping with the transfer of medical files are other caring gestures.

Disagreement or disharmony

Not every relationship works out. It’s likely that at least once in a physician’s career, he or she will have to part ways with a colleague, a group, or a patient.


If all efforts to mediate differences between parties have failed, it’s time to let the relationship go. When it comes to staff, most medical practices have policies in place for terminating an employee. If they don’t, they need to create some. These policies must be followed to the letter to avoid any potential problems down the road.

Medical partnerships that decide to disband will benefit from having legally binding, documented, and signed dispute and dissolution clauses in their contracts from the get-go. No matter how well practitioners get along in the beginning, it is prudent to discuss the eventuality of the partnership dissolving long before it actually comes to an end.

Whether because of distrust, disrespect, or dispute, sometimes patients need to be released from a practice. There are ethical and professional standards to be followed in these cases. The process of severing patient connections can range from being difficult to being frightening. Having a well-thought-out statement, a witness, a firm tone, and fixed boundaries can ease the gravity of the situation, though it’s rarely an easy thing to do.

No matter what circumstances lead to the need to say goodbye, preparation and forethought are the keys to easing the transition. And in some cases, as demonstrated by my dearly departed friend, it never hurts to end with, “I shall miss seeing you.”

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How to Come Up With a Business Idea

•••

Wondering how to come up with a business idea? Well, business ideas are all around you. Some come from a careful analysis of market trends and consumer needs; others come from serendipity. If you are interested in starting a business, but don't know what product or service you might sell, exploring these ways of coming up with a business idea will help you choose.

1) Examine your own skill set for business ideas.

Do you have a talent or proven track record that could become the basis of a profitable business?



The other day I spoke to a man who had spent years managing cleaning services at a hospital. Today he runs his own successful domestic and business cleaning service. An ex-logger is now making his living as an artist; he creates "chainsaw sculptures" out of wood. And the examples of professionals who have started their own agencies or consulting service businesses are legion.



To find a viable business idea, ask yourself, "What marketable skills and experience do I have? Will people be willing to pay for my products or services?"

2) Keep up with current events and be ready to take advantage of business opportunities.

If you watch the news regularly with the conscious intent of coming up with a business idea, you'll be amazed at how many business opportunities your brain generates. Keeping up with current events will help you identify market trends, new fads, industry news - and sometimes just new ideas that have business possibilities.



For instance, after same-sex marriages became legal in Canada entrepreneurs began selling tourist travel packages that include a marriage ceremony to same-sex couples from other countries. Would you have identified that business opportunity when you heard that the Canadian marriage laws had changed?

3) Invent a new product or service.

The key to coming up with business ideas for a new product or service is to identify a market need that's not being met. For example, back in 2004 a Harvard University psychology student named Mark Zuckerberg recognized a need for a campus-wide social-networking website that would allow students and staff to share personal profiles and other information. He went on to develop Facebook and became one of the youngest billionaires in the world.



The explosion of mobile devices has created a huge demand for mobile apps. In 2008 a pair of young entrepreneurs named Travis Kalanick and Garrett Camp had trouble hailing a cab in Paris. They decided that you should be able to tap a button on your mobile phone and get a ride, and as a result went on to found Uber.



Look around and ask yourself, "How could this situation be improved?" Ask people about additional services that they'd like to see. Focus on a particular target marketand brainstorm ideas for services that that group would be interested in. For example, there are millions of aging gardeners across North America. What products or services could you create that would enable them to garden longer and more easily? Finding a niche market and exploiting it is one of the best paths to success in business.

4) Add value to an existing product.

The difference between raw wood and finished lumber is a good example of putting a product through an additional process which increases its value, but additional processes are not the only way value can be added. You might also add services, or combine the product with other products. For instance, a local farm which sells produce also offers a vegetable delivery service; for a fee, consumers can have a box of fresh vegetables delivered to their door each week.



What business ideas can you develop along these lines? Focus on what products you might buy and what you might do to them or with them to create a profitable business.

5) Investigate other markets.

Some business ideas aren't suited to local consumption - but appeal greatly to a foreign market. My own little town is surrounded by acres of wild blueberries. For years the bushes produced berries that mainly fed bears and birds; B.C. has a thriving blueberry industry that doesn't leave room for a wild blueberry market.



But one entrepreneur realized that there is a high demand for products such as these in Japan - and those same wild blueberries are now being harvested and shipped. Finding out about other cultures and investigating other market opportunities is an excellent way to find business ideas.

6) Improve an existing product or service.

You know what they say about the person who builds a better mousetrap. That person could be you! A local entrepreneur has created an improved version of the hula hoop; it's bigger and heavier so hula-hoopers can control it more easily and do more tricks. How did she come up with this idea? She thought hula hooping would be a fun thing to do with her daughter, but found the commercially available product too flimsy.



There are very few products (or services) that can't be improved. Start generating business ideas by looking at the products and services you use and brainstorming ideas as to how they could be better.

7) Get on the bandwagon.

Sometimes markets surge for no apparent reason; masses of people suddenly "want" something, and the resulting demand can't be immediately met. For example, during the SARS epidemic, there was an insatiable demand for facial masks in several countries - and many entrepreneurs capitalized on the demand.



A "bandwagon effect" is also created by larger social trends. There is much more of a demand for home-care services for the elderly than is currently being supplied. And the trend for pets to be treated as family members continues, creating demand for all kinds of pet-related services that didn't exist decades ago.



Look at existing businesses and the products and services they offer and determine if there's a need for more of those products or services. If there is, develop business ideas to fit the market gap.

Tips for Coming Up With a Business Idea

Are you brimming with ideas for starting a business now?



Write your ideas down. Let them swirl around in your head and coalesce. And keep an open mind and continue to assess everything you read and hear from an entrepreneurial point of view.


You don't want to run with the first business idea you think of; you want to discover the idea that's best suited to your skills and desires. Dream, think, plan - and you'll be ready to transform that business idea into the business you've always wanted.

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How to talk to the medical practice manager about career advancement

If medical practice staff desire to improve their career skills, they will likely need to have a conversation with their boss, often the practice manager. Together, they’ll need to explore opportunities to advance to a new role, take time off to pursue improvements, or ask for reimbursement of costs.


Wendy Terwelp, a career coach who works with healthcare professionals of all kinds and founder of Opportunity Knocks of Wisconsin, recommends medical professional staff frame the conversation around the employer’s return on investment.


“If they can leverage the conversation into how it will benefit the practice, that’s going to help them get reimbursed or sponsored to attend a conference,” she says. “Operational efficiencies can turn things around and increase profit, so if they can learn better ways to implement different technology, that can help.”


If the boss is a particularly challenging person, or if dollars are tight, Terwelp says staff should make the case that healthcare changes rapidly, especially with technology. New skills can help a practice avoid so many hassles. Training can improve procedures and documentation, which helps avoid lawsuits. That, in turn, can improve compliance with the joint commission.


And if employers still aren’t convinced, show them the research. For example, a 2010 study in the Journal of Oncology points out that the payoff for better trained staff manifests in better employee retention, staff morale, practice efficiency, job competency, and patient satisfaction.


But approaching these conversations can mean walking a fine line between sounding self-serving and making a case for how individual professional development can benefit the practice.


If this is a nerve-wracking prospect, Carol Aiken, CMM CPAR, clinical operations administrator of Smith Family Clinic for Genomic Medicine in Huntsville, Ala., advises staff to look at the situation from the administrator’s point of view. Aiken, a practice manager with more than 30 years of experience in hiring and running a medical practice, says she keeps a keen eye on those motivated employees.


“I’m never going to look at anybody for advancement opportunity unless they have been self-motivated to present an opportunity to me for consideration,” she says. “I always tell younger people don’t be arrogant and think that you know it all, but also don’t shy away from the discussion. Maybe there is no real opportunity for improvement today but let your employer know ‘I want to be as valuable to you as I can.’”


Aiken says improving skills is a win-win for both parties. When staff let employers know in a concise and succinct way they would like feedback, that shows they are serious about their job. That can lead to further discussions about opportunities for advancement, too.


However, professional development is ultimately an investment in the future, so if a boss isn’t supportive, Terwelp says it may be worth trying to find another job where advancement is possible. “If you’re not growing, then you’re not moving forward.”

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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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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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