Joe Capko

The Affordable Care Act has affected the health insurance of many of your patients. ACA mandates that most health plans cover a wider variety of services that were previously not covered-birth control and maternity and psychiatric care, just to name a few. While some of your patients’ plans will be “grandfathered” and exempt from some of these coverage requirements, many patients will struggle to understand how their new coverage has changed. If you’re in private practice, your profits will be directly affected by how your staff can manage and adapt to these changes.

Widening coverage puts squeeze on patients

	While insurers have been forced to widen their coverage in terms of the types of services covered, they have done so by increasing premiums, co-pays, and deductibles. (The popular press contains countless anecdotes.) Your patients who have had the same large employer for many years will be the least affected because their plans are likely grandfathered; patients who haven’t enjoyed the same job stability (eg, self-employed or employed but economically stressed patients) will find themselves responsible for a greater proportion of your fees than ever before.

	NBC News cited sources “deeply involved in the Affordable Care Act” estimating that 50% to 75% of the 14 million self-insured will have their current plan canceled. Those whose plans are canceled are being offered one of the similar “compliant” plans with considerably higher premiums and/or higher co-pays and deductibles.

	For practices with lax collection practices, these changes can prove catastrophic. Starting on Jan. 1, 2014, new plans with higher and freshly reset deductibles mean greater demands on-and challenges to-your practice to collect fees directly from patients.

	Non-standardized collection practices are a frequent problem, particularly in smaller offices. Physician-owners, management, and front office staff need to be unified and focused on collecting every cent due from the patient at the time services are provided. To the extent it’s practical to inform patients of their financial responsibility prior to their arrival in your office, so much the better. Above all, your patients must not think of their physician as a credit-extending institution!

	Asking patients for permission to maintain a credit card on file can help speed the checkout process, to the benefit of your patients and staff. We still see practices asking patients if they prefer to be billed-a terrible error since the practice will expend resources chasing many dollars destined to go uncollected.

	Another poor practice that is disallowed by your payer contracts, but still not uncommon, is the ad hoc waiving of co-payments by physicians. Patients quickly learn how to “game” the system. Questions of financial responsibility should never be addressed by the physician, but referred to the appropriate administrative staff. If your front desk staff is collecting as it should, your practice may see considerably more cash.

Embezzlement: All-too-common source of losses

	Poor collection practices aren’t the only contributor to losses in your practice. Embezzlement is all too common, and financial controls need to be solid all the way around.

	As an example, our firm recently helped a practice recover from a practice manager who exploited a lag in the deposit schedule to steal cash. The manager substituted checks from a later day for the same dollar value-an ingenious and costly scam that cost the practice many thousands. The same practice had a safe full of cash stolen (it wasn’t bolted to the floor) with the practice manager and janitorial crew as prime suspects!

	If it’s been a while, consider whether your internal systems might benefit from an objective assessment from an outside firm.

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Articles

If you’re in private practice, your profits will be directly affected by how your staff can manage and adapt to ACA-related coverage changes.

ACA changes create fresh collecting challenges for urology practices

"Problem" employees can sometimes be misunderstood thoroughbreds. They have the best interests of the practice in mind, but may need more clarity or more support to do their best. Often, a thoroughbred's complaints can illuminate trouble spots that are brewing with the practice-issues that your team's easygoing workhorses are suffering without complaint, but that really should be fixed. Sometimes the thoroughbred's extra sensitivity to minor workflow issues is a gift to the practice that allows management to head off problems while they're still minor. 

Is your complainer a thoroughbred in disguise? The type of complaints you're hearing provides a clue. Recently, we worked with a practice with a "problem" employee who was driving the practice manager crazy with her "issues" and requests. She was frustrated that the office network was frequently down, wanted headsets for her and the other receptionists, and was repeatedly offended by the shoddy work of the practice's cleaning service. Instead of being annoyed with these requests, though, the manager should have been listening. Every one of the employee's complaints involved an issue that would diminish productivity, adversely affect patient service, and could explode into a bigger problem if not addressed. 

 For thoroughbreds and workhorses alike, clarity of roles and a clear path to providing feedback to management are essential to top performance. 

A lack of clearly defined staff roles is one of the most common operational problems we see in urology practices. Knowing exactly what is required to do a good job is essential for employee morale, especially for highly motivated or perfectionistic thoroughbreds. Clarity of roles is also essential to creating accountability-to ensure everything that needs to get done gets done. If you've been repeatedly bothered by a squeaky wheel or wheels, be sure your own internal communication and HR systems are up to snuff. 

Every urology practice faces this situation eventually: a difficult employee who demands disproportionate time and attention from management.

Your high-maintenance urology office staffer: Worth the hassle?

The essence of cloud computing is that data are stored on remote servers and accessed via the Internet, rather than maintained on local computers inside the practice. Storing data remotely allows for access from anywhere using the Internet, so, for example, a cloud-based EMR allows urologists in your practice to access and update charts from home or on the road using a smartphone or tablet. 

Moving a processing-intensive task like medical billing to a cloud-based provider such as Kareo, CareCloud, or athenahealth can be an efficient solution for many reasons, and is often a good first step for a practice considering utilizing the cloud. 

Perhaps the most obvious benefit is that even though the software is complex and powerful, such systems generally don't require in-house support. Cloud-based software is accessed remotely via a browser or downloaded interface, usually doesn't require an investment in better or faster computers to get started, and requires very little (if any) effort to install. Updates are usually automatic, so there's no need for an IT person to upgrade computers separately or maintain control of versions across your team's PCs. Adding or subtracting users is generally just a matter of one more or one less monthly fee. 

Cloud-based systems can also be accessed from anywhere you can connect to the Internet, so even if your office network goes down, your billing manager can submit claims from a home computer or a laptop off site. (A 4G-enabled tablet, accessing the Internet over the cellular system, would take this convenience and redundancy a step further.) 

Even if you're using a third-party billing service, a cloud-based billing system can be a big plus. If you decide to switch providers down the road, you can usually find a new service or independent contractor that uses the same system easily through the vendor's online community. In addition, an SaaS-based system that your team already uses in-house for practice management and insurance verification would smooth the process of bringing the billing piece in-house if you decided to do so in the future. 

Running your own EMR server within your practice requires significant resources and, often, dedicated IT support. There are significant "hidden" costs, too, namely energy and office space. And updates are notoriously common with an EMR, especially customizations and features needed for meaningful use-significantly more hassle if you need to implement these frequent version changes in-house. 

Given these challenges, starting your EMR journey with a cloud-based solution could save you time and money. It can be especially efficient to do so if you're shopping for both an EMR system and a practice management system; this creates an opportunity for either a single, integrated solution or a pair of solutions that are demonstrated to integrate seamlessly. 

If you've already set up an in-house EMR and it's well integrated with your PMS, moving to the cloud may not have as many obvious benefits. However, once you're facing a large-scale hardware or software upgrade to accommodate your systems, that might be the right time to evaluate converting. This may also be true if your in-house EMR doesn't offer enough patient communication or customization tools to satisfy meaningful use requirements. 

Storing data remotely allows for access from anywhere using the Internet, so, for example, a cloud-based EMR allows urologists in your practice to access and update charts from home or on the road using a smartphone or tablet.

What is cloud computing, and how can it help your urology practice?

It's also important to understand why employees are repeatedly leaving a key staff role of their own volition. You or your practice manager should be conducting exit interviews to understand why employees keep leaving. If, for example, conflicts are creating an unpleasant work environment, you'll have the opportunity to address this situation before the next employee is hired. Sometimes, training issues emerge through exit interviews. Learning this gives you a chance to take corrective action. 

Often, the reasons for turnover are simple: Your lowest level jobs pay low salaries and don't really offer much variety or responsibility. While some people appreciate predictability in their work, others require a sense of growth and progress over time. In a larger urology practice, you may be able to address these issues by offering your employees a career path and possibility of promotion and new challenges. But there are often limits to what you can offer, and smaller practices may have little flexibility. 

When some of your staff jobs are by-necessity routinized and require a limited range of skills, it can be difficult to find someone who wants to stay in them forever. What's more, you can't afford to sacrifice commitment to quality or attention to detail in exchange for longevity-and when you hire for those skills, somewhat faster turnover is likely, since the most attentive and committed employees will have more options and may be more ambitious. 

In situations like this, your practice might be better off hiring, say, an energetic recent grad who wants to go to nursing school in a year-opting for completely predictable turnover-instead of trying to find the perfect long-term hire who just may not exist. 

 In situations like these, the key is to plan for the revolving door; accept that in order to have committed and energetic staff, you might need to incur the costs of replacing them more frequently. The goal is to minimize the costs and errors and maximize productivity. For example, cross training will help ensure you don't suffer productivity losses-or worse, errors-when an employee departs. (This can also help keep your more ambitious, variety-seeking employees interested in their jobs a bit longer.) Making sure your job descriptions, employee manuals, and other documentation are refreshed at least yearly will help accelerate training for new employees. To speed up replacement times for employees, analyze the effectiveness of the media you use for recruiting so you know what is likely to work best. (Get plugged into social media, too; tools like LinkedIn and BranchOut can be very handy for quickly getting the word out.) 

Keeping open communication with all your employees can also help you manage turnover and transitions better. When you know an employee is planning a big step like going back to school, let him or her know that a long notice period-3 or 4 weeks instead of the traditional 2-would be appreciated, and not punished with a request they leave sooner. And, sometimes your ambitious exiting employees will also appreciate an option to work part-time while you look for a replacement-a win-win that can help everyone involved. 

is a senior health care consultant with Capko & Co. who specializes in research, marketing, social media, business development, and strategic planning. 

is a health care consultant and the author of 

Take Back Time-Bringing Time Management to Medicine

Whenever an employee leaves, you incur expenses to advertise the open position and set up and train a new employee. And, of course, there can be productivity losses in the interim.

Joe Capko

Articles

ACA changes create fresh collecting challenges for urology practices

Your high-maintenance urology office staffer: Worth the hassle?

What is cloud computing, and how can it help your urology practice?

Urology staff turnover problems require careful analysis