PRACTICE OPERATIONS
Seven Steps to Improve Scheduling in Your Outpatient Practice
ABSTRACT: Practices that schedule patients in rigid, non-overlapping blocks of 15-30 minutes each ignore the realities of day-to-day operations. Some patients may need only 5-10 minutes, others may need more than 25 minutes. Some show up late; others come early. A few do not show up at all. Instead of efficiency, you get stress and frustration for everyone: physicians, staff, and patients. This article recommends seven steps to improve outpatient scheduling:
Use “wave scheduling.” Instead of rigid, assigned appointment slots, several patients are scheduled to arrive at the same time, at strategic intervals that allow the practice to shrink and stretch the appointment slots as needed. The added flexibility makes work-in and urgent visits easier to incorporate.
Use two or three exam rooms. Physicians cannot work at optimum efficiency with only one room. Having two or three allows clinical staff to attend to patients for prep, education, medication, wrap-up, etc., while the physician moves on to the next patient ready for services only he or she can provide.
Build in a buffer time. Some practices schedule as much as an hour each day during which no actual appointments are scheduled. This helps serve as a backstop if the day turns out to be busier than anticipated.
Incorporate team-based practice fundamentals. Having an appropriate number of multi-skilled, “float” staffers will improve efficiency as the care team backs one another up to attend to patients needs without unnecessary delays.
Schedule follow-up visits at the conclusion of each visit. Leaving it up to patients to call in later to schedule a visit almost guarantees gaps in care when they forget to do so. It puts extra burdens on your staff to have to chase down forgetful patients to schedule follow-ups.
Make a plan to integrate telemedicine visits. Figure out when it makes the most sense in the day to reserve time blocks for telemedicine visits. Be sure to consider patients’ needs and preferences for virtual care.
Open the schedule 13-15 months in advance. Keeping an adequate length of time open in your system allows patients who do not need immediate follow-up to schedule appointments well into the future.
EXPERT COMMENTARY: The only “innovative” tip offered in this article is the recommendation to incorporate telemedicine visits into your schedule. And considering that we are in the fifth year since the pandemic forced our reluctant industry into virtual encounters, it is not really very new anymore. All the other tips offered here are tried-and-true strategies for optimizing patient scheduling. As is often the case, a return to fundamentals provides the missing “keys” to effective operations. These topics, however, remain “evergreen” in the practice-management space as new clinicians and new administrators work through perennial challenges.
Fortunately, we are still writing and speaking about proven strategies like “wave” scheduling. For example, Family Practice Management has an excellent archived article that gives step-by-step directions for setting up and managing a “wave” schedule (https://www.aafp.org/pubs/fpm/issues/2022/1100/wave-scheduling-tips.html ).
A concept not mentioned in this article is another strategy you should explore. In the late 1990s, many practices overhauled clinic schedules using “open” or “advanced access” scheduling. It proved revolutionary for providers brave enough to adopt it. Consider checking out another archived article from Family Practice Management first published back in 2004 (https://www.aafp.org/pubs/fpm/issues/2004/0200/p35.html ).
Source: Tanya Albert Henry, American Medical Association, January 19, 2023; https://www.ama-assn.org/practice-management/sustainability/7-steps-improve-scheduling-your-outpatient-practice
FINANCE
Give Your Physicians a Financial Literacy Checkup
ABSTRACT: The physicians in your organization, like everyone else in the practice, need to understand their role in the revenue cycle. This article reviews the importance of strategically monitoring denials for:
achieving compliance;
reducing billing errors; and
improving practice revenues.
Further, it points out common errors made by RCM teams, as well as their best practices for collections. Reviewing denials requires identifying and analyzing errors in various categories:
Front desk errors make up the largest percentage of claims-stopping mistakes. Training and monitoring front desk personnel must be tuned to address persistent errors.
Clinical documentation errors are generated by clinical staff who record notes and coders who select appropriate diagnosis and procedure codes. Adequate training and effective monitoring will help eliminate common problems like using unspecified codes or failing to link diagnosis and procedure codes to demonstrate medical necessity.
Modifier errors often prove to be at the root of “medically unlikely edits” (MUEs) and “National Correct Coding Initiative” (NCCI) edits that stall processing and incur denials.
Establish benchmarks of KPI data in your RCM processes. Data like the following can point you in the right direction for identifying errors to correct:
Days in A/R: When compared to industry averages, anything greater than 60 days indicates a below-average revenue cycle process.
Percentage of rejected claims (i.e., claims not even processed because of errors like ID numbers or birthdates): Watch for trends that point you toward front-desk issues.
Percentage of denied claims (i.e., claims that were not rejected but denied for payment): This usually indicates problems in documentation and coding.
EXPERT COMMENTARY: I have written in the past about a managing partner for a general surgery group I led years ago. He liked to say, “I don’t know anything about billing! To me it looks like I do a procedure, fill out a form or two and hand it to a staff member. She puts it in some sort of ‘black box,’ and like magic, money comes out the other end.”
Well, doc, there is a bit more to it than that. While I have worked with a few doctors through the years who made a point of studying coding and billing, most of them are happy to delegate RCM management to someone else. They seldom understand the connections between their behavior and the revenue received from month to month. And if the practice compensation plan is heavily weighted on personal production, the physicians need to know what they can do to optimize revenue collection.
The following summary of actionable strategies comes directly from the article. The suggestions focus entirely on the processes performed by the billing staff.
“Set internal deadlines for daily performance targets:
Set a 24- to 48-hour turnaround time for rejected claims.
Run a daily report of rejected and denied claims.
Establish a process to prioritize the working of claims, identifying and working those approaching the timely filing deadlines and/or that have the highest dollar amount.
Run a claim status report to identify activity in the collection cycle. This provides the biller with a roadmap as to where their focus should be.
Perform a line-item review of explanation of benefits to detect denials at the line-item level (partial payments) that should be addressed with a corrected claim or that require an appeal.”
It is a good list, but it misses a key ingredient: Provider feedback and accountability. It is very hard — almost impossible — to influence physician behavior if you do not teach them about the impact and consequences of their practice habits. That will require clear, succinct reports with suggestions for improvements.
Source: Sabrina Skeldon, AAPC Knowledge Center, February 3, 2025; https://www.aapc.com/blog/91949-give-your-physicians-a-financial-literacy-checkup/
Easier Said Than Done: Why Scaling Up Value-Based Care is So Hard (and What We Can Do About It)
ABSTRACT: Despite the excitement and hype, value-based care (VBC) programs continue to prove extremely difficult to actually set up and manage — it is a case of “easier said than done.” Most medical practices lack the resources and expertise necessary to design and manage the overwhelming responsibilities that VBC demands. At the same time, payers have not really figured out how to analyze performance, how to generate reasonable contracts across various providers, or to establish uniform, predictable, and “successful” outcomes.
The challenges that become stumbling blocks to success include:
Risk management. Managing VBC’s shared financial risk effectively requires sophisticated actuarial capabilities and risk assessment technology, which very few practices and payers possess.
Data sufficiency. Very few practices have a sufficiently large pool of patients under any one payer to accurately assess risk, performance, and value. Again, the data-processing resources would be out of reach for most providers and payers.
Operational burdens. Moving from traditional FFS schemes to VBC models represents a fundamental shift requiring comprehensive changes in
patient engagement;
care coordination;
technology; and
billing and revenue collection.
The “not-so-secret ingredient to success” in VBC is scale — large scale. CenterWell Health, provider for some 30,000 seniors, has reported demonstrable health improvements based on data-driven VBC principles. But what about smaller organizations? The challenge presents an opportunity for entrepreneurially-minded developers who are creating services that can enable VBC for smaller provider-groups. Those developers are finding ways to bring broader management resources, more robust information technology and analytics, and the potential to diffuse risk-sharing across a wider pool of fellow clients. For obvious reasons, both providers and payers alike are eyeing these developments with a certain optimism about the future of VBC.
EXPERT COMMENTARY: If you lead a large, sophisticated organization with resources to manage VBC contracts, and if you have the authority and cooperation of your providers behind you, you can probably afford to take on the risks involved with transitioning to VBC contracts. For smaller, less complex provider groups, you will need to plan on getting outside help.
For decades, small practices and not-so-small practices have explored various pathways — short of giving up their independence — to cooperate in cost-control and risk-sharing. Starting with IPAs (Independent Practice Association) and Clinics Without Walls, physician-owned practices tried to achieve economies of scale and more clout at the contracting table with payers. Some of these minimal consolidations worked well — many did not.
Chances are, an independent practice will find that the local hospital or health system takes the lead and pays most of the development costs for community-wide contracting arrangements. They might form a clinically integrated network (CIN) that includes financial incentives for providers (pay-for-performance).
If you are considering joining collaborative arrangements (or if you are reviewing one you have already joined) it would probably be worth the cost of hiring a consultant with a record of success in these complex arrangements.
Source: Dr. Lalan Wilfong, MedCity News, December 15, 2024; https://medcitynews.com/2024/12/easier-said-than-done-why-scaling-up-value-based-care-is-so-hard-and-what-we-can-do-about-it/
HUMAN RESOURCES
Acing Your Self-Appraisal (Even If It’s Your First)
ABSTRACT: If you work for an organization that incorporates self-appraisals in its employment policies, you may find yourself agonizing over the daunting task of evaluating yourself. If you are overly positive, you might appear unrealistic or egotistical. On the other hand, if you focus on your shortcomings, you just might sow some seeds of doubt in your boss’s mind.
Performance reviews are unnerving for almost everyone, and being required to review your own performance can be maddening. The key to writing a good review is your approach: Step away from the tendency to view it as “judging” yourself. Instead, view it as reporting information about your work. Focus on what you have produced rather than who you are. Avoid sentences that say, “I am,” or “I tried,” or “I wanted.”
Discuss your positive outcomes and your disappointing outcomes — and include objective reasons (not excuses) for wins and losses.
Take a journalistic approach: Describe the work, not yourself, and describe both sides of each story or example you give. Honestly describe what you have learned from successes as well as failures. Describe what you might do next time to improve results. Try to view your work through the eyes of those around you (bosses, teammates, direct reports, clients). Think about the effect you have had on them. Ask yourself questions like these suggested by the author:
What problems did you solve for them?
What can those customers, clients, or communities do that they could not do before?
What value did you create for them or for your organization?
What hard evidence, including data or numbers, do you have to prove these points?
Finally, the author urges us to avoid a common mistake in the employee-appraisal process: the mistake of appearing open to feedback but closed to change. It is easy to posture as a person interested in the boss’s feedback, but if you meet that feedback with resistance, debate, or closed-mindedness, the boss will likely see you as a stubborn — and perhaps fearful — member of the team. However, when we ask, listen, and act, our credibility increases as well. We no longer need to walk the fine line between self-defense and self-promotion.
EXPERT COMMENTARY: Self-evaluations can be an excellent managing tool for anyone with supervisory responsibilities — that is, if you create a safe and constructive space in which you and your direct reports operate. Here are strategies that I have found useful over the years:
Cultivate a genuine relationship with your employees. Get to know them. Learn about their background, their experiences, and their families. People like telling their story — give them that chance by asking questions and sharing your own story.
Be consistent in giving your honest feedback — constantly, not annually. Go beyond being open — set an expectation for questions of all kinds. Never make them feel belittled or foolish when they ask for clarification.
Make accountability a part of your culture. Hold yourself accountable not only to your superiors, but also to those who report to you. You owe them support and resources to succeed.
Train them in the art of self-appraisal. Articles like this one are plentiful. Do not assume your employees know how to evaluate themselves.
Be ready to help them address knowledge, skills, or habits that need improvement. Provide education and resources for development.
The more you can do to create an open, accountable, and mutually-supportive culture, the better your chances of creating a growing, learning, and powerful work team.
Source: Liz Wiseman, Harvard Business Review, March 31, 2023; https://hbr.org/2023/03/acing-your-self-appraisal-even-if-its-your-first