Plan your medical practice into a better 2019

The large number of details that physician practice owners are responsible for create significant risk if not managed correctly. This article provides a starting point to help prioritize issues to address now to ensure that your medical practice is ready for continued success in 2019.

A business plan: Are you working towards a specific goal?

As physicians are increasingly focusing on their personal finances, including the worthy goals of debt reduction and wealth accumulation for early retirement, many are failing to plan to make sure the business cashflow to fund those plans is there. What I continually see is that doctors are working as hard as they can to run their businesses and make as much money as possible for their family and retirement but lack specific benchmarks, goals, or plans to actually achieve those goals.


We’ve previously discussed the value of a business plan and how vital it is in hard times, but it’s equally important when things are good. You should have a good understanding of how much you are making, how much of that you are keeping, and a plan to maintain or increase your success. Details include marketing, cashflow, purchasing, hiring, onboarding providers/partners, and even your eventual exit strategy. When you hit that magic retirement savings number, will your practice be an additional, salable asset? It can be if you plan to make it one.

Upgrade your business insurance: How well is your cash cow protected?

I teach a whole national CME course on medical practice risk management that includes a very specific list of specialty commercial insurance coverage. Many doctors have the basics like a medical malpractice policy, some life and disability coverage, and some liability insurance for the office, but that just scratches the surface. Any competent asset protection plan for a practice owner should cover all the predictable exposures you are legally responsible for, including data breaches, premises liability including acts of violence and mass shootings, employee lawsuits, executive and fiduciary liability, payer audits and business interruption, and loss of all kinds, as just a few examples.


I continually discover that doctors are either un-insured or under-insured against these common risks, for example, having only low-limit “riders” of $50K for data and cyber liability as an add-on to their med-mal policy rather than a stand-alone policy with separate, seven figure limits. This means you need to take the time to sit down with an experienced, multi-line commercial insurance agent and understand exactly what is covered, for how much, and if that coverage is shared with any other policy. My thoughts on liability insurance as an attorney are best summarized as follows:
It’s the best, cheapest first line of defense and an indispensable, non-negotiable business expense.
Insurance works best like a bullet-proof vest; it’s a system of many layers. Buy all the right kinds of insurance in the right amount, until it hurts.
It is vital, but incomplete on its own, so always have a good back-up plan for claims that are uncovered or are above your limits.

Review your business documents. Are they complete, available, and up to date?

Does your business have all the required formal legal documents and structure it should? If your answer is yes, are they stored and managed in a way and place that they are easily accessible to yourself and others if you are unavailable? We often see a panicked “search and rescue” operation during an emergency, after a death, when a key employee leaves or is terminated, etc. This list is complex and fact-specific, but here are some of the most basic items you should be able to lay hands on at any given time:

• Corporate formation documents, including articles of incorporation and corresponding operating agreements, buy-sell agreements, licenses, permits, corporate retirement plan records. etc. 
• All insurance policies 
• Tax records and returns 
• Bank records 
• A professionally drafted, state-specific employment manual 
• Business contracts, both internal and with third parties and corresponding invoices for a reasonable period of time 

This assumes that these documents are adequately drafted by professionals and that they have been regularly reviewed and updated to meet the practices actual form and needs, another commonly overlooked planning issue. The best documents and insurance policies, no matter how well they were originally drafted, can be a latent source of liability if they are out of date.

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3 billing codes physicians should use

Doctors and practice administrators are always looking for how to maximize profits. As a coding/billing consultant, chart auditor, and educator, I’m often asked about ways to improve coding. Here are three codes that I find are often misunderstood, underused, or unknown. Practices that know about these codes—and how to use them—may be able to earn additional reimbursement.


99441-99443: Telephone services


Doctors’ offices are busy places, and it isn’t unusual for patients to call in asking to speak with the doctor. CPT offers codes to report telephone services provided by a physician or other qualified health care professional who may report evaluation and management (E/M) services. These codes can only be reported for an established patient and are not billable if the call results in the patient coming in for a face-to-face service within the next 24 hours (or next available urgent visit). These calls are also not billable if they refer to an E/M service performed within the last seven days. The codes are selected from code range 99441 to 99443 and are based on the time spent: 5-10 minutes, 11-20 minutes, or 21-30 minutes, respectively.


99058: Services provided on an emergency basis


What can you do when your providers already have a packed schedule and a patient walks in demanding to be seen? What if a scheduled nurse visit is more serious than anticipated, and the provider is called to step in and spend a great deal of time with that patient? When a patient is seen on an emergency basis in the office—and it disrupts other scheduled office services—you may be able to report add-on code 99058 for additional reimbursement.


96160: Health risk assessment


Providers can bill code 96160 when they perform a health risk assessment with a patient or caregiver/guardian in order to assess the risk of conditions such as mental disorders. They can also report 96160 when administering a patient-focused health risk assessment. Providers should report 96161 for a caregiver-focused health risk assessment, such as depression inventory, for the benefit of the patient.

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What’s the best way to fill a critical role at your medical practice?

Whether a position opens up at your practice because of an unexpected departure or practice growth, deciding how to fill it can present a dilemma. Instinct usually says “let’s post the job description and try to find someone who’s had a similar title.” That can be a way to find the best local candidate available – sometimes, you’ll even get an even stronger candidate than you expected.


But what if a close match can’t easily be found in your local market? Should you consider bringing in a person with less experience – perhaps someone from a different specialty or even a different industry? And what about the value of promoting from within?


The answers to these questions may depend on the role itself. Some positions more naturally lend themselves to more creative or expansive recruiting than others. If you need a physician, for example, nothing but a physician in your specialty will do. But in many other hiring situations, there is more flexibility than may be obvious at first.


For example, we’ve worked with practices that have needed clinical support staff or technicians with specialized training or certifications. What if someone on your team would like to become certified or learn a new skill? Helping your employee earn the credential may benefit your practice much more than hiring an outsider who already has it.


We once worked with a practice that offered clinical trials that required regular bone density scans. When their DXA tech left the area, the practice did not find many experienced local candidates to replace her. The ones they did find were available only for part-time work, expected much higher hourly rates, or both. The practice now faced a hit to the profitability of their trials, simply because DXA scanning would suddenly be more costly.


Luckily, the practice learned of a weekend bone densitometry training course. One of their medical assistants (MAs) was quite interested in adding this credential. By funding this course for the MA and then offering her an increase in salary once certified, the practice was able to make a valued employee much happier. The net cost was much less than hiring an experienced tech from outside. The practice got exactly what it needed. And the icing on the cake was that this approach also signaled to other staff that the practice was willing to invest in their skills.


There are many other ways practices can invest in affordable training to tap into skills they need while boosting employee morale and reducing turnover. For example, many practices can benefit from having a certified coder on staff – why not reimburse a motivated biller for this training? Certification for MAs is becoming increasingly valuable as more practices seek to participate in quality programs. It’s often possible for the certification process to be overseen by a physician in your practice, so why not do it in-house? This not only saves money, it ensures that the MAs’ training is aligned with practice standards.


The strategy of “growing your own” can also apply to non-physician providers. When your practice needs a new nurse practitioner (NP) or physician assistant (PA), hiring for experience may be a faster path to productivity – but not always. Sometimes, your protocols or approach to integrating non-physician providers may differ so much from the clinician’s prior experience that there will still be a learning curve to scale. Hiring a new graduate may mean you’ll spend still more time training, but you’ll also be assured that the NP or PA learns your preferred methods right from the start.


The idea of growing the skills and credentials of your team doesn’t have to be just a “when-needed” strategy – nor should it be. Thinking about paths for your employees can help ensure you’re not left with critical vacancies in the first place. If employees know they can continue to build their careers in your practice, they’ll feel less of a need to change jobs to pursue advancement. And when key people do move on, continuously cultivating your team ensures someone else in the practice will be ready to grow into the open job.


In many business organizations, the concepts of succession planning and “the bus test” are considered core manager priorities. Ensuring the business can function even if they’re hit by a bus should be a key priority for managers. But in our consulting work, we’ve encountered few practices who take the idea of developing bench strength seriously – and we think all practices should. If you haven’t done so already, it’s a good idea for owners and management to sit down and work through how your practice will respond if key positions unexpectedly become vacant – and develop a plan for grooming your strongest employees if you don’t have one in place already.

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The impact of locum tenens

Last August, the National Association of Locum Tenens Organizations (NALTO) celebrated the first-ever National Locum Tenens Week. The healthcare staffing industry is doing so again this week, and it’s an opportunity to thank locum tenens providers for their dedication to serving millions of patients at medical facilities every day in this country.


As many as 50,000 doctors, more than 5 percent of the physician workforce, practice medicine as a locum tenens doctor in more than 90 percent of our healthcare facilities to provide care for an estimated 7.5 million Americans every year, according to the most recent reports.


Temporary physicians continue to serve medical facilities hardest hit by the physician shortage, now projected to reach as high as 120,000 doctors by the year 2030.


This includes rural communities most in need of both primary care doctors and physicians specializing in vital areas such as behavioral health. The shortage will also be felt in urban settings that rely on coverage for peak times of patient demand.


Locum tenens physicians, once defined by both ends of the age spectrum, are now a diverse group that includes doctors throughout all stages of their career. Employed physicians are picking up shifts to supplement their income in order to pay off debt. They’re also taking advantage of temporary positions to travel, explore new communities before relocation, and experience different types of practice settings. The higher pay also allows individuals to make a full-time career out of locum tenens assignments while maintaining better control of their schedule and potentially achieve a healthier work-life balance.


Time away from patients spent dealing with the bureaucracy that’s come with government intervention, the business of medicine, exhaustion, and baseline pay are all working to drive physicians away. However, getting back to the basics of medicine has become a major draw for locum tenens providers. Physicians are reporting that practicing locum tenens alleviates those symptoms and renews their original passion for directly helping others.


Please join us in celebrating our locum tenens physicians as part of National Locum Tenens Week. Visit NALTO.org for more information and a free marketing toolkit available for download regardless of NALTO® membership status. Follow and chime in on social media using the #locumtenensweek hashtag.

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The Scary Side of Emojis: Hackers Love Them as Much as You Do

It is estimated that every day there are more than 5 billion emojis shared through Facebook Messenger alone. As emojis are getting more and more popular, scammers, hackers and various shady digital companies are taking advantage of it. If you are obsessed with emojis, you can quickly get into the trap and expose your private data.


“There’s one important rule when talking about cybersecurity – never open links, press on ads or download apps or add-ons if you are not sure where those came from. These days you have to check twice, even if we are talking about such a fun thing as emojis,” explains Daniel Markuson, Digital Privacy Expert at NordVPN. “One of the growing trends is scams through downloadable emoji keyboards. Be especially cautious of free emoji keyboards, as nothing of value is free”.


According to the NordVPN expert, if the emoji keyboard is free, it usually means, that the developers behind it rely on a data-driven business model. This means that everything you type on your device, be it a computer or a smartphone, will be continuously tracked and later sold for big money to advertising or other third-party companies. This may seem like not much of a problem, but it becomes an issue if those companies are hacked because of their poor cybersecurity. Then your personal data might be exposed much more than you would like.


Be careful not only with the usual emojis, but with various custom keyboards as well – those allow users not only to add an emoji keyboard, but to create personalized avatars as well. Again, if the virtual emoji keyboard is free and you have never heard about its publisher – don’t trust it. Better check your official app store and choose something there.


“There are way too many cases when free emoji keyboards spread viruses or other malicious content. So if you would like to use one, at the very least choose one from the official app stores”, NordVPN expert Daniel Markuson suggests. “Viruses and malware usually slow down your computer as they mess around with everything – from pushing ads or phishing sites to hijacking your browser. So if this happens after you install an emoji keyboard – remove it and run a malware scan right away.”


And then there is another way how cybercriminals use the cute emotion pictures – emoji malware scam. In recent years, emojis have become their bait of choice, especially when various studies show that emails and newsletters with emojis in the subject line are opened 66% more frequently. If that works for pesky marketers, why not use it for malware scam campaigns?


“Such scammy emails often contain deals that are too good to be true. However, the smiling emojis winking at you at the end of the sentence have a way to convince us that this is a real thing sent by a friendly person,” says Daniel Markuson, NordVPN Digital Privacy Expert. “You open the email, press the link and get that malware into your computer. Those adorable emojis may lead to serious headaches.”


On a final note, most of us chat with friends and send zillions of emojis to kill some time on our daily commute, while waiting for a bus or metro. However, if you or your friends are too much into emojis, you might need a VPN (virtual private network) like NordVPN. It will encrypt your Internet data and protect your identity and personal information from hackers or identity thieves.

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Top 10 KPIs Every Marketing Manager Should Track

So you’ve had your marketing budget approved and your marketing strategy is now in place. What’s your next step?

Should you start implementing your strategies and tactics?

Not too fast.

You still need to set up your business dashboard — in this case, a marketing dashboard — to ensure you’ll be measuring the right key performance indicators or KPIs.

Tailor your marketing KPIs to your strategy.

You may have heard the old saying: “Half my advertising dollars are wasted, but which half?”

All businesses are different and have unique needs — particularly for marketing. A retail store will use entirely different strategies and tactics compared to a B2B service firm.

So it’s important that you set your own marketing KPIs that support your marketing plans that will, in turn, help achieve your business goals.

To get started, here are the top 10 key performance indicators that you, as a marketing manager, should be tracking:

1. Sales Revenue

Sales revenue is ultimately the reason for all of your marketing efforts. And sales revenue should also be found on the executive dashboard and the sales team’s dashboard.

As a marketing manager, you want to track how much impact your marketing efforts have on the sales revenue. Don’t lose sight of what’s important. At the end of the day, the CEO will be more concerned about the results of your marketing campaigns, which are measured through the revenue that comes in.

While “feel-good” metrics like number of leads collected at trade shows, Twitter followers, or webinar attendees are important for marketers to track, they lack impact at the executive level. You should be thinking “opportunities” rather than “leads” and “investment and return” instead of “cost and spend.” – Phil Fernandez, President and COO of Epiphany

KPI In Action: Monitor closely other marketing metrics that drive sales revenue. Those metrics vary depending on your campaigns. For example, if you invest in email marketing, you will have to track metrics such as open rates and click-through rates.

Mapping your marketing activities against your sales revenue helps you see what’s working and what isn’t. And whenever you change your marketing tactics, you’ll use this to measure the impact on your bottom line.

2. Customer Count

How many people purchase your products or avail of your services?

An increasing trend in the customer count is good; however, a declining number in the number of customers is not necessarily negative.

For example, if having fewer customers means that you’re swapping out low-spenders for more profitable customers, that’s good for the business.

KPI In Action: Analyze customer count in relation to the sales revenue trend. Gaining fewer new customers that are profitable can be better than gaining more customers who are low-spenders.

An increase in sales revenue could be due to several factors including upselling, recent price increase, increase in premium products sold, etc.

In refining your marketing strategies, make sure you have a grasp of both the customer count and the sales revenue.

3. Customer Lifetime Value

MarketingProfs defines a customer lifetime value as “the projected revenue that your customer will generate for your business during that customer’s relationship with you.”

Simply put, how much revenue are you generating over the course of your relationship with your customers? That’s their lifetime value.

KISSmetrics suggests different ways to calculate your customer lifetime value or LTV and emphasizes that investing in acquiring “good” customers could be more costly, but they are more profitable in the long term.

KPI In Action: Monitor the month-over-month LTV of your customers to quickly identify the factors that contribute to the increase or decrease in the LTV. The insights you’ll discover can help your marketing team adjust your campaign strategies and budget allocation.

4. Customer Acquisition Cost (CAC)

How much do you have to spend to get each new customer?

Here’s how to calculate for the CAC:

Total sales and marketing investment in acquiring new customers / No. of customers acquired = CAC

If you’re spending $225 to get a $100 customer, that might be a problem in the long term. If your business has a long sales funnel, you might want to track this in more detail. You must know what it costs to get a lead, and then move that lead through each sales stage.

5. Churn (Customer Attrition Rate)

How good are you at keeping your customers?

Every time a customer leaves you for a competitor, you have to spend marketing dollars replacing them. So unless you sell once-in-a-lifetime products or services, you should track this.

KPI In Action: Keep the customer attrition rate low and customer retention rate high. Tracking attrition rate on a weekly basis can help you identify issues and immediately rectify any problem, whether it pertains to customer services, technical issues or pricing concerns.

6. Customer satisfaction

How contented are your customers?

Customer satisfaction is a critical marketing KPI, which is particularly helpful in reducing churn. Depending on your products or services, you can create your own measure for customer satisfaction.

One common measure that many companies use is the Net Promoter Score or NPS.

KPI In Action: Whichever measure you use to get feedback on your customers’ satisfaction level on your products or services, make sure to track them on a regular basis. But don’t just track them. Tackle common customer concerns and encourage everyone in the organization to be proactive in keeping your customers happy.

7. Reach

To get customers, you need to go where they are and drive them to your landing pages or website. Reach can take many forms – visits to your website, footfall in your store, clicks in your email newsletter, etc.

The critical thing is to understand what your specific strategy is for reaching new customers. Then track the right KPIs to check if your plan is working.

Reach measures brand awareness. At times, tracking your brand’s reach in real time can be helpful especially when you’re running a brand awareness campaign.

KPI In Action: Within your marketing team, assign sub-teams to be responsible for driving reach either by channel or by activity. If it’s by channel, for example, assign a specific team member to track website traffic, then another member to monitor email reach and another for social media reach. They are also responsible for driving the numbers on their respective metrics.

8. Engagement Rate

When you initiate a conversation with potential customers, how many of them do actually respond?

For most businesses today, marketing is about more than eyeballs. Blogs and social media allow businesses to have conversations with their customers and understand more about their needs. Again, the form that engagement KPIs take will be specific to your business and the channel.

KPI In Action: Monitor engagement rate in real time, especially when you’re running a campaign. Look at net sentiment, as well, when analyzing social engagement. A high engagement rate with strongly negative sentiments is generally not good for the business.

Each social media platform has its own algorithm that impacts engagement rate. You can set a target engagement rate or a benchmark based on industry standards or based on your own goals.

9. Conversion rates

How do you turn reach and engagement into customers?

Some businesses focus only on website traffic or the number of followers on social media. But the point of those reach and engagement numbers is to generate leads that your sales team can turn into customers.

Understanding the ratio of hits/clicks/opens to leads and customers helps you to weed out the least useful tactics.

10. Marketing Return on Investment (MROI)

Marketing return on investment (MROI) is also called return on marketing investment (ROMI). However you call it in your organization, both refer to the amount that a company gets for spending their marketing dollars.

“The key is to remember that while marketing expenditures hit the P&L immediately, every dollar you spend today is building your brand as an asset for the future.” –Jill Avery, Senior lecturer at Harvard Business School

Here’s a formula you can use to compute for the MROI:

MROI = (Incremental financial value gained as a result of the marketing investment – cost of the marketing investment) / cost of the marketing investment
Final Words

You want your team to contribute to the company’s top-line growth, so it’s wise to monitor closely all key performance indicators that will pull sales revenue up and will generate an impressive MROI.

Without a marketing dashboard, it will be hard for you to keep track of all the marketing activities, metrics and KPIs, especially in real time.

Without a marketing dashboard that is accessible to your entire team, keeping track of who’s responsible for specific metrics and tactics could also be a challenge.

With a powerful marketing dashboard, you are in control.

A quick glance at your dashboard will help you see the big picture, identify problem areas and leverage opportunities that can boost your marketing performance.

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‘Patients over Paperwork’ or bait and switch?

A “bold proposal” to reduce the documentation burden on physicians was released as part of CMS’s 2019 proposed Medicare Physician Fee Schedule (PFS). This seemed to have begun as an effort to listen to stakeholders and address the problems of out-of-date guidelines, cloning, EHR misuse, and problems that have evolved since the inception of the documentation guidelines. However, this proposal introduces a wholly self-serving and uninvited component of a change to payment rates and methodology that no one asked for.


The catchy tagline of “Patients over Paperwork” implies a quality issue caused in part by administrative overkill, but let’s not forget that these are the federal guidelines that have been enthusiastically enforced for more than 20 years by this same CMS.


Last year, when CMS sought input from stakeholders about the need to reduce the documentation burden caused by “administratively burdensome and outdated” guidelines—their own words—the decision was hailed within the industry.


CMS had said, “We are … specifically seeking comment on whether it would be appropriate to remove our documentation requirements for the history and physical exam for all E/M visits at all levels.” The agency went on to say that, “We believe medical decision-making and time are the more significant factors in distinguishing visit levels and that the need for extended histories and exams is being replaced by population-based screening and intervention, at least for some specialties.”


No argument there. Physicians have been looking forward to the results of the comment period and hoping for some regulatory relief.


CMS didn’t say, “While we’re at it, let’s change the way providers are paid. Let’s find a way to pay providers less, particularly for the most complex patients.” But that’s exactly what they’ve done with this new proposal.

The CMS traveling medicine show

Last month, CMS administrators and physician leadership from the offices of Health Information Technology and Center for Medicare and Medicaid Innovation (CMMI) gathered for a telecast promoting “Patients over Paperwork,” or their E/M coding reform.


Touting their heartfelt desire to reduce documentation burdens and save individual physicians 51 hours a year in documentation time (roughly an hour a week), these former practicing physicians went on to give some real examples of how the current documentation guidelines don’t work well in the EHR environment, which was also mandated by CMS, if you recall.


Side note: Adam Boehler, CMS deputy administrator and director for the CMMI made an interesting comment that in the next couple of years, everyone’s EHR will be available on your phone. Heads up, HIPAA.


It’s true that it’s difficult to find the real information in an over-templated note, and this could be a danger to patients. It’s a little less true that docs can’t write real notes. Docs don’t—or won’t is more like it—but some EHRs don’t make it easy, either.


The first part of the proposal is directed at the real issue: the documentation burden. The proposal states, “We propose to apply a minimum documentation standard where, for the purposes of PFS payment for an office/outpatient E/M visit, practitioners would only need to meet documentation requirements currently associated with a level 2 visit for history, exam and/or medical decision-making (except when using time to document the service).”


The proposed rule doesn’t specify what level 2, new or established, but let’s assume established since most visits are established. That’s a surprising choice since the documentation burden is so low—no reviews of system (ROS), one exam element, and subacute decision-making.


A 99213 is the most widely reported E/M code and is generally recognized to represent one unit of provider work, an acute uncomplicated problem, or a stable chronic illness. It is somewhat surprising to see, then, that the documentation level wasn’t set there, since it is still very easy to achieve without “note bloat.” But perhaps that is intended as more of the bait, because here comes the switch. Cue the theme music from the Paul Newman and Robert Redford movie The Sting.


CMS writes: ‘‘We believe our proposed documentation changes for E/M visits are intrinsically related to our proposal to alter PFS payment for E/M visits. … We are proposing to create a single rate under the PFS that would be paid for services billed using the current CPT codes for level 2 through 5 E/M visits. It would not be material to Medicare’s payment decision which CPT code (of levels 2 through 5) is reported on the claim.”


Yes, you read that right. Now that we have reduced the documentation burden for all E/M levels within a code category to a level well below what most codes report and require, it doesn’t matter what code you pick. CMS will pay you the same amount.


Somehow, documentation reduction has now introduced payment consolidation and in many, if not most cases, payment reduction for some providers. This is not an unintended consequence. This is calculated and deliberate.


The rest of the proposal dealing with E/M goes on to say that you can use a time basis to select your code, MDM, or even the old 1995 and 1997 guidelines as the basis for your code selection. The point is, it no longer matters what codes you choose because get paid the same.


CMS will likely find that providers lose interest pretty quickly in coding and documentation once it is uncoupled from payment. What they had been complaining about, justifiably, was the time it took to document, not to code. Half of the documentation issue is on EHR’s themselves and their ease of use, or lack thereof.


Were this proposal to be passed as is, it could result in some real unintended consequences. The first provider to comment on this to me said, “Fine, if you make all the visit and payments the same, I’ll just fire all my complex patients.” There’s a consequence. It’s probably not the majority view, but it’s one that CMS should have considered.


We won’t get into the CMS bad math behind the assertion that change in payment methodology amounts to a 1 or 2 percent change in revenues. For some specialties, the loss in the E/M revenue is in double digits, clearly a significant cut. The specialty societies will no doubt follow-up with some projected numbers very shortly.


Perhaps CMS should just do what it said it set out to do: reduce the documentation burden that they created. Make it a little easier to use the EHR that they mandated, and don’t disguise a budget initiative as a regulation reduction.


Perhaps the lesson of the old traveling medicine shows shouldn’t be lost on CMS. Snake oil doesn’t cure anything. That all the promises don’t make it so. The sound bite of “Patients over Paperwork” doesn’t disguise the money grab, so don’t try to hide a bad motive beneath a good one.

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