Wednesday, December 27, 2006

2006: Things that I've learned.

2006 will undoubtably go down as one of my greatest years. Here is a list of all the things (maybe not ALL) that I have learned the past 12 months.
  • How to set-up a blog
  • How to set-up a website
  • The difference between a Cat 5 and Cat 3 cable
  • What VPN stands for
  • What VOIP means and how to use it
  • How to insert a meta-tag
  • How to develop a good system to keep track of outgoing patient labs, studies and referrals
  • How to maximize patient compliance with follow-ups
  • How to set-up an andrology lab for semen analysis
  • How to write a QC manual for a lab
  • How to do QA and QC for my lab
  • The difference between QA and QC
  • How to extrapolate lab QA to overall practice management QA
  • How to enroll in PT
  • How to report a semen analysis result by CLIA standards
  • How to get a CLIA ID
  • How to become a lab director of a moderate complexity CLIA lab
  • What CLIA'88 is
  • What COLA is
  • How not to write an operational manual
  • How to write an operational manual
  • How to collect a copay
  • How to get a Federal TIN
  • How to incorporate
  • Why to incorporate
  • Why to elect an S-corporation
  • How to manage cash flow (still learning that one)
  • How to autoclave instruments
  • How to disinfect a flexible scope in cidex
  • How to install a reticle in a microscope
  • A more efficient way to do a semen analysis
  • The code 257.8
  • How to use Iweb
  • How to use FrontPage
  • How to use an FTP client
  • An in-depth meaning of the Quarter
  • How to set up a medical practice
  • How to quickly set up a credentialing packet
  • How to design an inexpensive an efficient EMR for a solo practice doc
  • How to develop a near paper-less office
  • How to bill for a sperm retrieval
  • How to interpret an EOB
  • How to submit a claim
  • What a clearinghouse is, though not why
  • How to hire
  • How to fire
  • How to "sniff out"a really bad employee
  • That I have no clue about how to interview a prospective hire
  • How to build a practice
  • How not to run a practice
  • How to market a practice in a non-"cheesy" way
  • That I really like Thai food
  • An efficient and effective way to do a scrotal sonogram
  • A great way to do a painless, no scalpel vasectomy in my office
  • How to do a "Q"urine, who to do it on, and why I seldom do it any longer
  • The value of "nickles and dimes"
  • The real value of money
  • The value of independence
  • The BS of the buy-in
  • The worth of a medical practice
  • The value of myself
  • How to be mentally tough as nails
  • That I possess skills I never knew I had
  • That I can live on much less
  • That money and income do not equal happiness
  • That difficulty paying bills stinks
  • The value of surrounding myself with really good people
  • That creating a successful endeavor that had never existed before I got there is awesome
  • That it truly is the struggle that makes success so sweet
  • That I have an amazing wife
  • That I have an amazing family
  • That I miss Granpa George more than I thought I would
  • That I have a lot more to learn

Have a happy, healthy, and successful new year.

The Independent Urologist

Sunday, December 24, 2006

Santa came to my office!

Santa must have come to my office, and instead of toys he brought a whole bunch of EOB's. Wow. I believe, I believe!
Or maybe its because the 4th quarter is about to end, and the insurance companies want to offset their incredible gains before the year is up through disbursements owed to their payees, the doctors.
Nahhh. It's Santa!
Have a Merry Christmas, Happy Hanakah, Happy End of Year Tax Planning.

Saturday, December 23, 2006

Going Solo? Understand the EOB.

EOB stands for explanation of benefits and is the perhaps the most important aspect pertaining to the financial health of your practice, perhaps more important even than the amount printed on the disbursement (reimbursement) check. Understanding the EOB will allow you to develop an appreciation of how much you get paid per service--per encounter--and can serve as a gauge for how effective you--or your team--are as billers. Here are several EOBs that I recently recieved that I find illustrative.

  • EOB 1: The Check amout was for $160. Not bad. Now lets look at the EOB. Oh, I see that this check represents payment for 3 encounters. Encounter 1 was a level 4 visit. I was payed $36, and I see here that the patient had no copay. Therefore from this particular plan, I get $36 for a new patient consult. Shabby! Encounter 2, on this same EOB, is also for a new patient visit, for which I recieved $120 and the patient had a $15 copay. Therefore, my contracted amount, the amount I get per encounter on patients with this exact plan is $135. Interesting, the patient from encounter 1 and 2 had the same insurance company, but different plans within the plan. Encounter 3 was for a urine analysis, an 81000 in CPT talk, for which I got $3.70. Not bad for a UA.
  • EOB 2: Check amount was for $28. Looking at the EOB, it was for 1 encounter. The patient paid $20 in copay. Therefore for an extablished visit, I got $48.
  • EOB 3: Check amount was for $0.00. Looking at the EOB, this was a denial because the claim occured during a global period for a 52000, a vasectomy.
  • EOB 4: The check amount was for $38. It is for 1 encounter, an established office visit. The patient paid $15, and the insurance paid $38 + $3.70 for a UA. Therefore, from this carier, on this particular patients sub-plan, within the plan, within the plan, I get ~$50 for an established patient level 3 visit.
  • EOB 5: The check was for $240. By examining the EOB (often more complex than examining the patient), I can determine that the payment was for a 52000, a vasectomy. So now I know that from this insurer, at least on this patients subplan within the plan within the plan, I "contracted" to recieve $240 for a vasectomy. In addition, the carrier did not pay me for a visit on the same day as the vasectomy.

So there you have it. If you add up the total devided by the number of encounters, you can get an analysis of dollar/encounter, which as an important number to know. In this case, I made, on average, $99 per encounter. So as you can see, it takes a lot of encounters to make just overhead, not to mention take home a salary.

Good luck!

Thursday, December 21, 2006

Going Solo? Where do claims go and how do I get paid?

When I first entered solo practice, I had no idea how I was supposed to go from seeing a patient to the point that I actually get a reimburesment check in the mail. I knew the terms, like charges and claims and submissions, and electronic filing, but that was basically it. I now have a somewhat better understanding of the process, and what I have learned I find, well, somewhat disturbing. Here's how it works.

Lets start with our hypothetical patient, Richard Cockworthy.

  • Richard enters the office, fills out forms and give us his insurance card. We then get the copay. So far so good. (When I first started, I did not even know how to do this!)
  • Do what I studied/trained 11 years to do; see patient.
  • Fill out encounter form, the form that has the ICD9 and CPT codes.
  • Give Richard his next appointment then exit him.
  • Open up practice management software, and enter charges, i.e. enter into the appropriate fields the CPT codes (99213, 81003 etc) with the corresponding ICD-9 code (257.8), along with all other vital info, such as referring doctors UPIN, site code (office, hospital ,etc).
  • Now it gets really interesting! I can either print the claim on a HICFA 1500 or submit it electronically using, yes its true, a 56K dial up modem (Their choice, not mine.)
  • If I use a paper claim, HICFA 1500, the form is mailed directly to the payer, ie the insurance company.
  • If I decide to submit electronically, I press the e-file button, and the claims go over the internet via my dial-up to a clearinghouse.
  • What, pray-tell, is a clearinghouse. Well a clearinghouse is a middleman. And you guessed it, he has his hand out.
  • The clearinghouses--many of them exist, such as Webmd, which is the largest--provide "services" such as adjutication of claims, what ever that means, and "cleaning" of claims (I'm not sure if I like that).
  • Then the clearinghouses submit the claim on to the actual payer.
  • Electronic claims, from what I've heard, get processed more quickly than paper claims, but for this priveledge, you must pay a fee. The fee varies based on volume of claims submitted and the clearinghouse.
  • Paper claims do not have fees associated with them, other than stamps and printer ink, but some payers take extra-time to process these claims. Some simply never seem to recieve them the first time around and you must follow-up and re-submit the claim with the notation, 2nd attempt on the claim.
  • If all necessary boxes are filled, all ICD-9's and CPT's match, all UPINs are correct, and the stars align, the check gets drafted and either mailed along with the EOB to you directly or are auto-deposited into your bank account.
  • EOB means explanation of benefits, and the EOB lets you know how much you were paid per service, what you were not paid on, and sometimes why.
  • Then you enter the reciepts into your software, and voila!

Complicated, convoluted, redundant, expensive, and ours. A system only a middleman could love.

Sunday, December 17, 2006

Going Solo? Embrace Technology.

A long time ago, 20 or 25 or more years ago, a doctor coming out of training had the option to just "hang a shingle." Perhaps the costs were low, or there was not such a saturation of physicians as today, or practice management was simpler then. But I don't actually believe that. Having spoken to physicians and dentists and lawyers who hung their own shingles years ago, it was pretty hard and pretty scary in those days, just like it is now. While costs for them were low by today's standards, these professionals assured me that they were financially stretched to the limit during their own start-up years. I actually believe it is easier today, or at least not anymore difficult.

People starting out today have 1 advantage over our yesteryear start-up counterparts. One huge advantage. Today we have amazing and inexpensive technology that can do for us meaningful work in an efficient manner; work that enables us to be more profitable, more available, more productive, more independent more quickly and more easily. Technology such as electronic faxing, EMR, VOIP, cell-phone, miniturization, IM, e-mail, FTP, fiber optics, OCR, etc, if you know how to use them, can help you substantially not only throughout the start-up phase, but beyond. Here are some examples of how.

  • Miniturization: Electrical components that formerly would take up a room's worth of space are now available, at an affordable price, that are the size of a lap-top computer, even smaller. Whether these components are client computer stations, handheld PDA's, sonographic equipment, or light sources, the small sizes frees up valuable square footage for more efficient and profitable usage.
  • Electronic Medical Records: From issues relating to paper management to the physical space required for chart storage, and everything in between, the advantages of an electronic medical record system are obvious. Recently some vendors have come down in price so that a physician can afford it, but perhaps even better, an industrious and resourceful solo person can make his/her own system using off the shelf software.
  • Communications: I can't imagine what doctors used to do before cell phones. I guess they needed to travel with a wad of pocket change or tell the maitre'd at a restaurant that "Dr Schoor is over there." Now it is truly an amazing time to put the power of technology to your advantage and nowhere is this more apparent than in the area of communications. Cell phones, VOIP, VPN, voicemail, instant messaging, text-messaging, video conferencing, electronic faxing are all realities, inexpensive ones at that, and are all available using nothing larger than an inexpensive laptop computer. These technologies may all have their role in your start-up. All you need to do is evaluate your situation and then try them out.
  • Billing: Billing used to take a team of people, just on your end. People to enter charges, submit claims, follow-up on claims and denials, and people to follow accounts recievable. Now all this can be done electronically by no more that 1 or 2 people, including the doctor/owner. With electronic you no longer have the not-insignificant-expense of tonors and printer ink and postage and proof of mailings. By the very of nature of the electronic submission process, all transactions leave their electronic footprint so that "I'm sorry, we never recieved it" no longer applies. In addition, claim turn-around-time is faster than with paper claims, and that helps with cash flow.
  • Advertising: Many years ago doctors never dreamed of advertising, but now many of them do. Traditional advertising, print, radio, TV, is extremenly expensive, and frankly, for most of us, is not cost-effective. Fortunately, the internet exists and has revolutionized commerce. E-commerce, the new word that describes internet based businesses, can apply to your start-up as well. For relative peanuts, you can have your website hosted and quickly start to sell items from it or to book appointments from it, and by learning basic source code, you can make your site more search engine friendly with metatags, and keywords, and etc. In addition, if you embrace the new blogging technologies, you can help drive even more traffic to your site.

Embrace technology!

Friday, December 15, 2006

Going Solo? 5 reasons why you would benefit from a SINGLE PAYOR SYSTEM.

The United States has terrific health care for people with good insurance, yet millions of Americans who pay taxes and have jobs do not have adequate health coverage. Most of these people, in fact most Americans whether they know it or not, are 1 severe illness away from personal bankruptcy. Though most of us agree that a problem exists, people have not been able to come to a consensus regarding the solution to the problem. Single payor health insurance has been discussed by many as a possible solution to the health care problem that exists and it has many supporters as well as detractors. As a solo practitioner, you should be a supporter of a single payor system that covers everybody. Here are 5 reasons why.

  • Overhead reduction: Anyone in solo or group practice will tell that they spend huge sums of money not on the delivery of health care, but on its administration. In fact, 45% of GDP health care dollars go towards paying administrators, be they CEOs, call center workers, claims processors, billers, managers ect. Countries that have single payor systems spend far less on this beuracracy than we do in the US and practices in regions of the US that have less managed care penetration have lower administrative overheads than similar practices do in other, more MCO saturated environments. Practices that see a predominantly medicare population can operate at a fraction of the cost of a practice that takes 30+ plans, period.
  • Improved cash flow: We already have national health insurance, it's called medicare, and not only is it now one of the best payors, it is one of the fastest payors. Since payroll comes every 14 days, and bills come every 30 days, cash flow requirements dictate that payors pay at 30 days as well. In the wonderful world of managed care, most payments come not at 30, but at 45, and sometimes 90 days, despite electronic submission. Medicare payments come in the quickest and with the least hassle factor. With medicare alone can I estimate cash flow accurately and plan accordingly.
  • Practical Practice Simplification: Medicare, our national plan, does not care if I send a urine specimen to OurLab, or Quest, or Sunrise, or if I do it myself. As long as the claim is submitted correctly and it meets their requirements, medicare will pay. In addition, medicare does not care if I do a surgery at hospital 1 or hospital 2 as long as both participate. Finally medicare does not care if I send a patient for a CT scan at Medical Arts Radiology or Zwanger or Zilka or even if I do it myself. They'll pay regardless, as long as the claim is sent correctly and I meet their well documented requirements. Now contrast that to the managed care world where there are plans within plans within plans, each one with different, ambiguous requirements, preferred providors and labs, preferred meds, providor ID numbers, PRIS#'s, TIN's, etc. Some patients have plans that require pre-certs from many things, while other patients, often with identical ID cards, do not need such pre-certs. Finally, with medicare, you easily know what is and is not covered. Now contrast that to the commercials where coverability is often not known until after the fact, despite bonafide attempts to find out otherwise.
  • You'd make more money: Combine the effects of overhead reduction, practice simplification, amd improved cash flow with an absence of forced pro-bono work, and the math becomes easy to see. This is most true for physicians like orthopedists and general/trauma surgeons who do lots of ER work, especially in poorer areas. Because of a good law called EMTALA, these same surgeons must work very hard for these patients and neither the surgeon not hospital has any guarantee, nor prospect, or payment. Under a universal coverage plan, single payor or not, these doctors and hospitals would get paid.
  • It is the right thing to do: Enough said.

Thursday, December 14, 2006

Going Solo?: 5 things I've learned about human resources.

I personally know doctors who have had employees that caused havoc on the doctors' practices and careers. Here are 5 things I've learned.

  • If you suspect, eject! If you suspect that an employee is dishonest trust your intincts and act quickly. It is human nature, bacause you are a good and honest person, to look the otherway, turn a blind eye, or give the benefit of the doubt. But resist this temptation. IF YOU SUSPECT, EJECT! Whether or not you wish to catch them in the act or simply terminate them is your personal choice. Employess think that showing up late or leaving early when you are not there, or stealing a copay, or downloading an illegal music file on the computer will go unnoticed. They are wrong! They always get caught, eventually. At the earliest signs of dishonsesty, you must act, either by setting up a sting, firing the employee, calling the authorities, or any of the above. Certainly theft of a large sum of money warrants involving the police. If you suspect, eject.
  • Good behavior is often short lived. Most people put their best foot forward at the interview. However, it has been my personal experience with employees that bad habits which become noticable within the first few weeks of working will never go away and you must act accordingly. Employees who show up late in their first 1-2 weeks, especially more than once, will never be punctual despite their agologies, protestations, and sob-stories. If you value punctuality, you must act accordingly. Similarly, employees that behave in non-professional manners early on will not change EVER. Get rid of them before they hurt you.
  • Effort and intentions are everything. Every body learns at different rates and has different skill sets coming into a new job or environment. But I have found that almost anyone can learn almost anything if they apply the effort and approach the task with the best intentions. I'll take the former high school drop out with desire and amibition over the IVY league college student who just wants to coast for a while until they move on to something else. I'd take the former person any day of the week and twice on Sundays. But there is a corrolary (see below)
  • Some people just can't learn. In my experience, this applys most to the aquisition of new computer skills. Of course everyone writes on the resume that they are proficient in computers; Windows and Office Suite, medical manager, databases, etc. But on the job, well, they don't know right click from double click from a whole in the wall. I actually have started to make prospective new hires open and close documents, fax things, open emails use IM, etc during the interview process. Of course it applys to other skills as well. If an employee just can't learn a very simple skill, such as doing a urinalysis, either they lack the intelligence for the job or are not making the effort. Either way, show them the door.
  • Keep the good ones happy! Good employees can be very hard to find and when you get lucky enough to find a person that shows up on time, takes pride in her/his work, and can learn new things, you best keep them happy. This does not necessarily mean that you must keep giving them raises or bonuses. But a simple "thank you" or "good job" or "strong work" goes a long way. Keeping them happy means repecting them and their personal time and their requests for personal time. Keeping them happy means showing them that there work is important and meaningful and helpful to you.

Tuesday, December 12, 2006


I'm skeptical. Read NYT article from todays NY Times.

Saturday, December 09, 2006

Going Solo: Practical Document Management.

Even in a small EMR friendly medical practice, such as mine, document management can become problematic. When I first started, I had an EMR (see previous post) that easily handled 95% of paper in my office, such as notes, labs, studies, correspondance letters, etc. But we still needed copies of the patients' insurance ID cards, drivers licenses, HIPAA forms, and patient demographic information forms. While this may, or may not, seem like a mountain of paper, it quickly grew into a management problem. We found ourselves, on a growing number of occassions, having to expend time and energy on filing, copying, and retrieving documents.

Not what I had in mind!

So in order to overvcome this hurdle, I brainstormed.

  • Buy expensive copier that copies and scans quickly and automatically inserts into EMR. Awesome, but can't afford ("Oh but Dr, we have attractive leasing options!").
  • Buy flatbed scanner, and have staff manually scan documents daily or weekly into appropriate folders in EMR. No way!
  • Once a week or month, I or staff can place the mound of paper into the ADF of my multifunction scanner and then manually separate the digital copies into the appropriate folders in the EMR. Yeh!! It took forever just to write that down. Actually doing it, impossible!
  • Use my old digital point and shoot camera and take photos of the cards against a black background. Tried it. Staff didn't like it. I liked staff. Nixed camera!
  • CardScan! Yes, now this may work. For $99 I purchased a business card scanner with OCR software included and tried it out. It has worked beautifully. My staff and I can scan patients' insurance cards, front and back, and driver's licenses quickly and easily, and the software extracts the information into unique, searchable fields. We can even make re-prints of the crads or just insert the data extracted from the card into a form. Yes, this works great.

So I still have HIPAA forms and patient demographic forms, and this is managable for now. Yes I do have ideas to eliminate even these forms.

Any suggestions from the blogosphere?

Friday, December 08, 2006

Doctors beware!

Patients can get their revenge on us if we don't prvide them with a positive experience.
See article.

Tuesday, December 05, 2006

Going Solo? 6 steps to getting new patients.

An established medical practice, chiropractor, transcriptionist, etc, can survive on repeat visits or business from their existing patients or clients. But for a start-up or a specialty practice, such as an infertility specialist or plastic surgeon, new patient business is essential. But how do you attract new patients.

1: WORD OF MOUTH--This is no doubt the best way, but it takes years to get there in the best of circumstances. While waiting, you'll go broke or into deep debt or both. Do not rely on this method alone, in my view, ever. I believe it is essential to actively attract new patients thoroughout the life of your business or practice.

2: PRESS THE FLESH--This is a great way. In my opinion and, with all things considered, it is the best way. It involves literally going door to door to referring doctors and introducing yourself. It requires a car, gas, business cards, and a very thick skin. Be prepared to be treated rudely by staff who mistake you for a drug rep. Be prepared to be turned away. Be prepared for failure! But every so often, in my experience, 1 in 10, you'll hit it and convert your visit into a new referral. The rest is up to you and if you provide a good service, you'll get more. After several months and persistence you can generate 10-15 good referral sources who can support you, and aside for gas and guts, it cost you nothing.

3: ADVERTISE--I was told this would be a good way, but in my experience, it was not. In fact, I spent approximately $10,000 on traditional print media advertising (newspaper, yellow book, etc) and from it got 2 patients. In retrospect, it was a mistake, and not one I'm likely to make again. There are much better, more cost effective approaches. In fact, I believe that I would have had more publicity and more enjoyment had I taken the $10,000 and burned it! Or better yet, donated it to an infertile couple. But this is just my opinion.

4: ACCEPT INSURANCE--Sorry to say this, but participation with health insurance, while no doubt an evil, is a necessary one. And actually, I don't even think insurance is an evil, and I, like most physicians, actually does better because of insurance. Insurance companies direct new patients into your office by listing you in their "books." It's free and effective advertising. As long as you feel their reimbursement rates are fair and the companies actually pay you, you can grow because you take insurance.

5: TAKE ER CALL--I didn't do this for personal reasons, namely because I don't like ER call. Moreover, for urology, we don't have enough ER business to make it worth our while. But I have a friend who is in start-up practice as an orthopedist and a hand surgeon and he has built up his practice at an incredibly fast pace by taking ER call. In fact, he approached older orthopods with established practices who no longer wished to take ER call and offered to take call for them. Good for him!

6: HAVE A WEBSITE--This is good advice namely because hosting has become so cheap and easy. But is is certainly not enough because your website, without proper SEO, will be lost in the crowd. You can hire SEO firms, but these are $$$$. I chose to blog, which works quite well and has resulted in increase website exposure and new patient business. Plus, I like it.

Friday, December 01, 2006

An Interesting Question.

If you could prevent a potential competitor from entering the market place, would you?