money your practice may be throwing away

How To Reclaim How To Reclaim Money Your Practice May Money Your Practice May

Be Throwing AwayBe Throwing Away

The Cost of The Cost of Inadequate Documentation Inadequate Documentation

and Incorrect Codingand Incorrect Codinge-medtools.come-medtools.com

Basic PremisesBasic Premises

Most physiciansMost physicians Are not practicing medicine “for the Are not practicing medicine “for the

money!”money!” Are competent, compassionate doctorsAre competent, compassionate doctors Enjoy helping othersEnjoy helping others Work long, hard, often thankless hours Work long, hard, often thankless hours Deserve the money they earn!Deserve the money they earn!

Stressors Physicians Stressors Physicians ExperienceExperience

Rising clinic practice costsRising clinic practice costs Generally 40-60% of a physician’s revenueGenerally 40-60% of a physician’s revenuePractice costs expected to increase 20% in 2008Practice costs expected to increase 20% in 2008

Decreased reimbursement from insurance companiesDecreased reimbursement from insurance companiesIncreasingly complex medical fieldIncreasingly complex medical fieldIncreased requirements and cost for maintaining Increased requirements and cost for maintaining

licensurelicensureIncreased pressure to improve quality without Increased pressure to improve quality without

compensationcompensationExorbitant, rising medical liability costs and jury Exorbitant, rising medical liability costs and jury

awardsawardsIncreasing violence directed at healthcare workers Increasing violence directed at healthcare workers

28% of ED physicians are assaulted each year 28% of ED physicians are assaulted each year Annals of Emergency Medicine 2005 46(2):142-7Annals of Emergency Medicine 2005 46(2):142-7

Additional StressorsAdditional StressorsUnrealistic expectations from the general public, Unrealistic expectations from the general public,

legislators, lawyers, and insurance companieslegislators, lawyers, and insurance companies

Idealistic, virtually perfect performance from physiciansIdealistic, virtually perfect performance from physiciansQuality is an unfunded mandate!Quality is an unfunded mandate!

Essentially free medical care is a “moral imperative”Essentially free medical care is a “moral imperative” (Hillary Clinton’s, 2008 Presidential Candidate, address to George Washington (Hillary Clinton’s, 2008 Presidential Candidate, address to George Washington

University Medical News Today May 2007)University Medical News Today May 2007)

Healthcare providers will bear the cost of public healthHealthcare providers will bear the cost of public healthEmergency departments must treat all people who walk through their Emergency departments must treat all people who walk through their

doors regardless of ability to paydoors regardless of ability to payHospitals require that doctors be on call for the emergency department in Hospitals require that doctors be on call for the emergency department in

order to have the privilege of working at that hospitalorder to have the privilege of working at that hospitalDoctors must then see patients who cannot pay for their careDoctors must then see patients who cannot pay for their care

There is No Free LunchThere is No Free Lunch

Food, Shelter, Clothing and HealthcareFood, Shelter, Clothing and Healthcare Should the government provide these for Should the government provide these for

free?free? Should businesses be required to provide these for Should businesses be required to provide these for free?free?

Why should doctors provide free Why should doctors provide free healthcare?healthcare?

What Physicians Already DoWhat Physicians Already Do““Physicians are an important source of healthcare for Physicians are an important source of healthcare for

many uninsured and underinsured patients, as many uninsured and underinsured patients, as evidenced by the fact that a physician’s office is the evidenced by the fact that a physician’s office is the usual source of care for about one third of uninsured usual source of care for about one third of uninsured persons, and physician uncompensated care costs persons, and physician uncompensated care costs were estimated as high as $11 billion in 1994”were estimated as high as $11 billion in 1994” Managed Care Managed Care and Physicians’ Provision of Charity Care JAMA 1999 281:1087-1092and Physicians’ Provision of Charity Care JAMA 1999 281:1087-1092

Physician SurveyPhysician Survey (American Medical News 2006)(American Medical News 2006)

76%76% of physicians provided free or low cost healthcare in 1996-97 of physicians provided free or low cost healthcare in 1996-9768%68% of physicians provided free or low cost healthcare in 2004- of physicians provided free or low cost healthcare in 2004-

20052005

Physicians spent 10.6 hours/week providing Physicians spent 10.6 hours/week providing uncompensateduncompensated care!care!

““A Growing Hole in the Safety Net: Physician Charity Care Declines Again” Center for Studying Health System A Growing Hole in the Safety Net: Physician Charity Care Declines Again” Center for Studying Health System Change 2006Change 2006

Impact of Physician Impact of Physician StressorsStressors

Medical practices are BUSINESSES!Medical practices are BUSINESSES!– A business is not sustainable unless income exceeds expensesA business is not sustainable unless income exceeds expenses– Unlike most businesses, medical practices (physicians) are legally Unlike most businesses, medical practices (physicians) are legally

restricted in setting fees for servicesrestricted in setting fees for services

Reimbursement for physician services are Reimbursement for physician services are decreasing, therefore physicians mustdecreasing, therefore physicians must– See more patients to sustain the medical practiceSee more patients to sustain the medical practice– Spend less time with individual patients in order to see more Spend less time with individual patients in order to see more

patientspatients

The consequences of an increased workload can The consequences of an increased workload can result in result in – An increased likelihood of missing problemsAn increased likelihood of missing problems– Decreased patient satisfactionDecreased patient satisfaction– A significant drop in physician job satisfaction A significant drop in physician job satisfaction – Hastened “burnout”Hastened “burnout”

To Err Is Human . . . To Err Is Human . . . But Don’t Err On Insurance But Don’t Err On Insurance

Documentation!Documentation! Incorrect billing for the documentation Incorrect billing for the documentation

providedprovided

Regardless of the complexity, lack of clarity, and unending Regardless of the complexity, lack of clarity, and unending

changes made to the systemchanges made to the system IS ASSUMED TO BE IS ASSUMED TO BE FRAUD!FRAUD!

And can turn a doctor And can turn a doctor

into a criminal!into a criminal!

In less time than it takes to receive In less time than it takes to receive payment from the Centers for payment from the Centers for Medicare and Medicaid!Medicare and Medicaid!

In less time than it takes to receive In less time than it takes to receive payment from the Centers for payment from the Centers for Medicare and Medicaid!Medicare and Medicaid!

The InjusticeThe InjusticeDemands from insurance companies are Demands from insurance companies are

increasing increasing -more paperwork, denial hassles, phone calls, audits, etc.-more paperwork, denial hassles, phone calls, audits, etc.

Meanwhile Meanwhile Physician practice costs have Physician practice costs have increased by 20% since 2001 (AMA)increased by 20% since 2001 (AMA) Health insurance costs have nearly doubledHealth insurance costs have nearly doubled

Yet insurance companies are reducing Yet insurance companies are reducing reimbursement to physicians!reimbursement to physicians!

– By 2013 it is predicted that Medicare reimbursement By 2013 it is predicted that Medicare reimbursement will be 50% of the reimbursement seen in 1991! (Vital will be 50% of the reimbursement seen in 1991! (Vital Signs March 2005)Signs March 2005)

– 2008 Medicare cuts will average 9.9% (AMA)2008 Medicare cuts will average 9.9% (AMA)– 5% cuts are planned for 2009 (AMA News, Aug 2007)5% cuts are planned for 2009 (AMA News, Aug 2007)

How Can Physicians Afford To How Can Physicians Afford To Work?Work?

Give up coveted independence in favor of employed Give up coveted independence in favor of employed positions?!positions?!

Stop seeing Medicare and Medicaid patients?! Stop seeing Medicare and Medicaid patients?! (MMWR 56(10);230)(MMWR 56(10);230)

In 2004 20% of physicians no longer accepted Medicare patients In 2004 20% of physicians no longer accepted Medicare patients 9.3% no longer accepted Medicaid 9.3% no longer accepted Medicaid 60% of physicians interviewed in 2007 by the AMA state that 60% of physicians interviewed in 2007 by the AMA state that

they will limit the number of new Medicare patients as a result they will limit the number of new Medicare patients as a result of aggressive, proposed cuts to physician reimbursement of aggressive, proposed cuts to physician reimbursement (AMA)(AMA)

Surviving requires understanding AND playing the insurance game!Surviving requires understanding AND playing the insurance game!

Maximize reimbursement throughMaximize reimbursement throughAdequate and thorough documentationAdequate and thorough documentationAppropriate CodingAppropriate Coding

Get Paid For The Work You Do!Get Paid For The Work You Do!

Many Physicians Under Many Physicians Under Code!Code!

Most physicians do more work than their documentation Most physicians do more work than their documentation supports!supports!

And, as the saying goes,And, as the saying goes,

if it isn’t documented, it didn’t happen! if it isn’t documented, it didn’t happen!

Fear of fines and loss of licensure have forced Fear of fines and loss of licensure have forced physicians into under-coding!physicians into under-coding!

How Much Is At Stake?How Much Is At Stake?33-52% of patient encounters are under coded33-52% of patient encounters are under coded

(JABFP 2001;14:184-92 and FPM October 2003 “How to get all the 99214s you deserve”)(JABFP 2001;14:184-92 and FPM October 2003 “How to get all the 99214s you deserve”)

AssumptionsAssumptions $30 difference in reimbursement (99213 to a 99214)$30 difference in reimbursement (99213 to a 99214) 30 patients per day30 patients per day = lose ~$300 per day!= lose ~$300 per day! [33%(30 patients/day) x $30/patient = $300/day][33%(30 patients/day) x $30/patient = $300/day]

For a physician working 5 days/week for 50 For a physician working 5 days/week for 50 weeks, that is $75,000 annually per physician!!!weeks, that is $75,000 annually per physician!!!That’s no small chunk of change!That’s no small chunk of change!

What Is The Gain?What Is The Gain? Decreasing billing and coding errors by just Decreasing billing and coding errors by just

50% could mean an increase of nearly 50% could mean an increase of nearly $40,000 per year in practice revenues!$40,000 per year in practice revenues!

The equivalent of seeing an additional 690 (99213) The equivalent of seeing an additional 690 (99213) patients/yearpatients/year

Or, an extra 3 patients/day!Or, an extra 3 patients/day! WITHOUT THE EXTRA WORK!WITHOUT THE EXTRA WORK! $40,000 per year / $58 per patient = 690 patients per year$40,000 per year / $58 per patient = 690 patients per year 690 patients per year / 250 work days per year ~ 3 patients per day690 patients per year / 250 work days per year ~ 3 patients per day

Put another way . . .Put another way . . . Losing $300 per day is like seeing nearly 3 new patients per day for free! Losing $300 per day is like seeing nearly 3 new patients per day for free! ($90 per each 99203 new patient)($90 per each 99203 new patient)

This won’t make physicians rich!This won’t make physicians rich!This merely decreases the impact of ongoing losses This merely decreases the impact of ongoing losses due to decreasing reimbursement and shifting healthcare costs!due to decreasing reimbursement and shifting healthcare costs!

Tools to Improve Tools to Improve Documentation Documentation

Electronic Medical Records (EMRs)Electronic Medical Records (EMRs)– Electronic medical records are available, but are often cost-Electronic medical records are available, but are often cost-

prohibitive prohibitive

Standardized forms Standardized forms – Proven to improve documentationProven to improve documentation– Less expensive Less expensive – Most are designed to be completed by hand and kept in a Most are designed to be completed by hand and kept in a

paper chartpaper chart– Many are specific for particular complaintsMany are specific for particular complaints

such as cough, sore throat, etc., such as cough, sore throat, etc., yet lack the scope needed to address multiple comorbiditiesyet lack the scope needed to address multiple comorbidities

– Few contain remindersFew contain reminders Physician Quality Reporting InitiativesPhysician Quality Reporting Initiatives Risk of excessive alcohol intakeRisk of excessive alcohol intake Severity index scoring, etc.Severity index scoring, etc.

Electronic Medical RecordsElectronic Medical Records

In 2004 President Bush created the Office of In 2004 President Bush created the Office of the National Coordinator for Health the National Coordinator for Health Information Technology whose mission is toInformation Technology whose mission is to– ““Implement an interoperable health information Implement an interoperable health information

technology infrastructure nationwide”technology infrastructure nationwide”

System costsSystem costs– Software, hardware, training, implementation, ongoing Software, hardware, training, implementation, ongoing

maintenance and supportmaintenance and support

Induced costsInduced costs– Costs involved in the transition to an electronic medical Costs involved in the transition to an electronic medical

record, such as the temporary decrease of productivityrecord, such as the temporary decrease of productivity

AA Cost Benefit Analysis of Electronic Medical Records in Primary CareCost Benefit Analysis of Electronic Medical Records in Primary Care The American Journal of Medicine 2003 The American Journal of Medicine 2003 114(5):397-403114(5):397-403

E-Health 101:Electronic Medical RecordsE-Health 101:Electronic Medical Records Reduce costs, Improve care, and Save lives American Electronics Association Reduce costs, Improve care, and Save lives American Electronics Association 20062006

Electronic Medical Records Electronic Medical Records Capabilities May Include*Capabilities May Include*

ViewingViewing– Medical notes, labs, reports, formulariesMedical notes, labs, reports, formularies

DocumentingDocumenting– Medical notes, labs, reportsMedical notes, labs, reports

Ordering Ordering – Prescriptions, labs, tests, consults, durable medical Prescriptions, labs, tests, consults, durable medical

equipmentequipment MessagingMessaging

– Physician-Staff; Physician-Physician; Physician-Patient Physician-Staff; Physician-Physician; Physician-Patient and vice versaand vice versa

Care Management/Follow upCare Management/Follow up Analysis and ReportingAnalysis and Reporting

– Adverse drug reactions, drug-drug reactions, chronic Adverse drug reactions, drug-drug reactions, chronic disease reminders, preventive care reminders, statistical disease reminders, preventive care reminders, statistical analysisanalysis

Patient-directedPatient-directed Billing and SchedulingBilling and Scheduling

* All capabilities are not available for all EMR systems* All capabilities are not available for all EMR systems

Who Uses Electronic Medical Who Uses Electronic Medical Records?Records?

~ 25% of office-based ~ 25% of office-based physicians used physicians used some form of EMR in some form of EMR in 20052005

National Center for Health Statistics National Center for Health Statistics National Ambulatory Medical Care National Ambulatory Medical Care

SurveySurvey

Implementing Electronic Medical Implementing Electronic Medical RecordsRecords

$2,500 - $44,000 initial start-up cost/provider$2,500 - $44,000 initial start-up cost/provider– SoftwareSoftware

50-200% of initial costs50-200% of initial costs– Hardware Hardware

$5,000-10,000/provider$5,000-10,000/provider– Implementation Implementation

$3400/provider$3400/provider– Additional maintenance costs Additional maintenance costs

$700-1500/provider per month$700-1500/provider per month Providers include MD, NP, RN, LPN, PA, MA, receptionistProviders include MD, NP, RN, LPN, PA, MA, receptionist

Lost productivity estimated at >$10,000 in the first Lost productivity estimated at >$10,000 in the first yearyear

Average time to return on investment is 2.5 yearsAverage time to return on investment is 2.5 years– This makes electronic medical records unobtainable by most This makes electronic medical records unobtainable by most

medical practicesmedical practicesThe Value of Electronic Health Records in Solo or Small Group PracticesThe Value of Electronic Health Records in Solo or Small Group Practices Health Affairs 2005 24(5):1127-Health Affairs 2005 24(5):1127-11371137

A Cost Benefit Analysis of Electronic Medical Records in Primary CareA Cost Benefit Analysis of Electronic Medical Records in Primary Care The American Journal of Medicine 2003 The American Journal of Medicine 2003 114(5):397-403114(5):397-403Electronic Medical Records Systems Cost Effective, Study ShowsElectronic Medical Records Systems Cost Effective, Study Shows Medical News Today 2007 Medical News Today 2007

Benefits of Electronic Medical Benefits of Electronic Medical RecordsRecords

Improved documentationImproved documentation Reduce paper chart pullsReduce paper chart pulls

– Estimated to cost $5/chartEstimated to cost $5/chart Decrease costs for transcriptionDecrease costs for transcription Reduce redundant labs and tests Reduce redundant labs and tests

orderedordered Some provide promptersSome provide prompters

– Preventive carePreventive care– Medication optionsMedication options– Adverse drug interactionsAdverse drug interactions

A Cost Benefit Analysis of Electronic Medical Records in Primary CareA Cost Benefit Analysis of Electronic Medical Records in Primary Care The American Journal of Medicine 2003 114(5):397-403The American Journal of Medicine 2003 114(5):397-403

Financial Benefits of EMRsFinancial Benefits of EMRs 5-year net BENEFIT of a “full EMR”5-year net BENEFIT of a “full EMR”

– $86,000/provider$86,000/provider– Full EMR includes electronic prescriptions, chronic Full EMR includes electronic prescriptions, chronic

disease reminders, drug interactions, and preventive disease reminders, drug interactions, and preventive care prompterscare prompters

5-year net COST of a “light EMR”5-year net COST of a “light EMR” – $18,000/provider$18,000/provider– used only to reduce paper chart pulls and transcription used only to reduce paper chart pulls and transcription

costscosts

A Cost Benefit Analysis of Electronic Medical Records in Primary CareA Cost Benefit Analysis of Electronic Medical Records in Primary Care The American Journal of Medicine 2003 114(5):397-403The American Journal of Medicine 2003 114(5):397-403

MedicalTemplatesMedicalTemplates Standardized patient encounter Standardized patient encounter

formsforms Adobe PDF TechnologyAdobe PDF Technology

– Use as a paper form ORUse as a paper form OR– Use as an electronic formUse as an electronic form

MedicalTemplates FeaturesMedicalTemplates Features

Documentation promptersDocumentation prompters– HCFA 1997 documentation guidelinesHCFA 1997 documentation guidelines

Quality remindersQuality reminders– Medicare PQRIMedicare PQRI

Checkboxes Checkboxes – Save timeSave time– Save energySave energy– Time is MoneyTime is Money

Implementing Implementing MedicalTemplatesMedicalTemplates

Required Hardware and SoftwareRequired Hardware and Software– Free Adobe Reader from Adobe.comFree Adobe Reader from Adobe.com– Basic computer ($350 or less)Basic computer ($350 or less)

Intel Pentium III or better for WindowsIntel Pentium III or better for Windows PowerPC G3 or better for MacOSPowerPC G3 or better for MacOS

– One or more MedicalTemplatesOne or more MedicalTemplates $150 per template$150 per template

MedicalTemplate BenefitsMedicalTemplate Benefits Inexpensive implementationInexpensive implementation Minimal learning curveMinimal learning curve Improved documentationImproved documentation Reduce paper chart pulls Reduce paper chart pulls (if using electronic (if using electronic

format)format)– Estimated to cost $5/chartEstimated to cost $5/chart

Decrease costs for transcriptionDecrease costs for transcription Prompters/RemindersPrompters/Reminders improveimprove

– Preventive carePreventive care– Quality of careQuality of care– Treatment optionsTreatment options– Evaluation optionsEvaluation options

MedicalTemplates ROI MedicalTemplates ROI AssumptionsAssumptions

Template cost $150 per practitionerTemplate cost $150 per practitioner Computer cost $350 Computer cost $350 (most offices already have >1 computer)(most offices already have >1 computer)

Baseline under coding rate 30% Baseline under coding rate 30% ($300 lost revenue/day)($300 lost revenue/day)

Reduction in under coding 50%Reduction in under coding 50%– If 33% of 30 patients seen in one day are under codedIf 33% of 30 patients seen in one day are under coded

10 patients are under coded by $30 apiece = $300/day10 patients are under coded by $30 apiece = $300/day A 50% reduction = Only 5 patients are under coded A 50% reduction = Only 5 patients are under coded Increased revenue = $30 x 5 patients now coded correctly Increased revenue = $30 x 5 patients now coded correctly

= $150= $150

Increased revenue of $150/day equates to a Increased revenue of $150/day equates to a savings ofsavings of $750/week$750/week $3000/month$3000/month >$36,000/year! >$36,000/year!

At $150 per template, the template pays itself off in 1 day!

MedicalTemplate ROI MedicalTemplate ROI CalculationCalculation

Including Computer CostsIncluding Computer CostsIn just 1 month, In just 1 month, the Return On Investment (ROI) could be:the Return On Investment (ROI) could be:

Average improvement in reimbursement in 1 month Average improvement in reimbursement in 1 month X 100 = ROIX 100 = ROI Cost of Template + Cost of ComputerCost of Template + Cost of Computer

$3000 $3000

X 100 = X 100 = 600%600% $150 + $350$150 + $350

MedicalTemplate ROI MedicalTemplate ROI CalculationCalculation

Without Computer CostsWithout Computer CostsIn just 1 month, In just 1 month, the Return On Investment (ROI) could be:the Return On Investment (ROI) could be:

Average improvement in reimbursement in 1 monthAverage improvement in reimbursement in 1 month X 100 = ROIX 100 = ROI Cost of TemplateCost of Template

$3000 $3000

X 100 = X 100 = 2,000%2,000% $150$150

Time to Recover Cost of Time to Recover Cost of MedicalTemplateMedicalTemplate

MedicalTemplate + Computer ($500)MedicalTemplate + Computer ($500)$500/$150 ~ 3 days$500/$150 ~ 3 days

MedicalTemplate without Computer ($150)MedicalTemplate without Computer ($150)$150/$150 = 1 Day!$150/$150 = 1 Day!

Savings Not included in ROI Savings Not included in ROI EstimatesEstimates

Reductions in down codingReductions in down coding Reductions in claim denialsReductions in claim denials Reduced time spent on Reduced time spent on

documentationdocumentation Reduced time pulling chartsReduced time pulling charts

MedicalTemplatesMedicalTemplates

General formsGeneral forms Clinic H&PClinic H&P Clinic Follow Up NoteClinic Follow Up Note Hospital H&PHospital H&P Hospital Follow UpHospital Follow Up Pulmonary/Critical Care Pulmonary/Critical Care

H&PH&P Pulmonary/Critical Care Pulmonary/Critical Care

Follow UpFollow Up Pulmonary Clinic H&PPulmonary Clinic H&P

Problem specific formsProblem specific forms AsthmaAsthma COPDCOPD PneumoniaPneumonia Pleural EffusionPleural Effusion Lung MassLung Mass Interstitial Lung DiseaseInterstitial Lung Disease Chest PainChest Pain Pulmonary HypertensionPulmonary Hypertension

MedicalTemplatesMedicalTemplatesMedicalTemplates has created multiple medical MedicalTemplates has created multiple medical

templates appropriate for evaluating patients templates appropriate for evaluating patients in the clinic or hospital setting.in the clinic or hospital setting.

MedicalTemplates are fillable PDF forms that allow the MedicalTemplates are fillable PDF forms that allow the physician to type historical information directly into the form. physician to type historical information directly into the form.

They can be saved electronically for later reference.They can be saved electronically for later reference.Documentation time is decreasedDocumentation time is decreased

Most components of the history and physical exam can be Most components of the history and physical exam can be completed by checking the appropriate box.completed by checking the appropriate box.

Reducing documentation time by 5-10 minutes per Reducing documentation time by 5-10 minutes per patient could save the physician >2 hours per day!patient could save the physician >2 hours per day!

30 patients / day x 5 minute decrease / patient = 2.5 hours / day SAVED!30 patients / day x 5 minute decrease / patient = 2.5 hours / day SAVED!