One of the best magical examples of the one-ahead principle occurred in 1920 when the world-famous magician Max Malini stunned a formal dinner party in Washington when a U.S. senator asked Malini to do a magic trick.
Malini demurred and said he was unprepared. Finally, he gave in and asked if anyone had a deck of cards. No one did, of course, but fortunately, the magician carried a deck. He removed the deck from his pocket, shuffled the deck, and “forced” (in magic parlance, this means having the spectator take a card that the magician wants the spectator to take) a card on the senator’s wife. Malini asked the lady to return the card she “freely selected” to the deck. The card can no longer be found in the deck. Malini appears annoyed that he has failed and apologizes, stating that this outcome is unusual.
Malini then asked if anyone was carrying a knife. No one offers a knife, so Malini volunteers his own knife. He immediately cuts through the astonished senator’s tuxedo jacket, and down in the silk lining on the inside of the tuxedo jacket, he finds the selected card.
The audience was astounded. How could this card turn up in the very jacket worn by the senator?
The one-ahead principle is the answer. Over the preceding two years, Max Malini reached out and bribed a well-known bespoke Washington tailor to sew a specific playing card into several senators’ suits and tuxedo jackets. When one of the senators at long last happened to request the “spontaneous” performance of a magic trick, Malini was well prepared and waited patiently for the moment to arrive when he could create a miracle of magic that was talked about in Washington circles for years and established the reputation that lasted for the rest of his life. By placing a card in several suits and tuxedos, he was one ahead and just had to wait until the right moment to reveal the card. Malini says, “To identify and craft the pieces needed to bring about the desired effect, no amount of preparation is too much, and no time to wait until the right moment is too long.”
Disney: MyMagic+
A more contemporary example of the one-ahead principle is Disney’s MyMagic+ system. This system allows Walt Disney World Resort guests to plan trips with an app called My Disney Experience. This helps Disney load up information about the guests before they enter the theme park. When families arrive at the resort, they’re given a MagicBand bracelet to skip long lines and access extras, such as souvenir photos. The bands also report the location of the wearers, so Disney can text them suggesting how to get around congestion or where to find a convenient concession stand or restaurant.
By better understanding their guests’ needs and patterns, Disney can enhance their experience, which also helps solidify their brand loyalty and keeps them returning. The collective data from MyMagic+ also amounts to information that Disney can use in planning park improvements. In truth, Disney gains more than guests do from MyMagic+, but the illusion is that the guest reaps all the rewards.
The One-Ahead Principle Applied to Medical Practice
In magic or medical practice, it’s important to be judicious in using data you’ve secretly collected (and, in medicine, that you have not violated HIPAA guidelines). Whether your stage is a gathering of politicians, guests attending a Disney resort, or patients in a medical audience, every step of preparation and anticipation of any event that doesn’t go as planned is important. Remember, magicians spend hundreds of hours on a move or a sleight-of-hand action that is over in two seconds because it’s worth it to achieve that awe effect. Once you’ve identified a goal worth your best effort, load up ahead of when you may need that action or process so that no one else can imagine how you did it. Your moment will come, and when it does, all the care you’ve put into your preparation will make your accomplishment appear effortless — and you will look like a real magician.
Let’s look at some examples that show the importance of preparing for and staying ahead of problems likely to damage nearly every physician’s efficiency and productivity.
Power Failures That Render Your Internet and EMR Impotent
Imagine that you have lost connection to the internet in your medical office. When the internet is not working in a medical office, it can significantly disrupt operations by hindering access to critical patient information, EHRs, prescription management systems, and appointment scheduling tools, potentially delaying treatment decisions because of the inability to quickly research medical data. This can lead to potential delays in patient care and increased administrative burdens for staff.
Loss of internet connectivity can wreak havoc and even cause your practice to grind to a halt. You must be one ahead and ready to take the necessary steps should this occur. This requires careful planning and testing of your system to be prepared in advance should this situation occur.
Your first step is to call your internet service provider to report the issue. You provide them with details such as when the outage started and any troubleshooting steps you’ve already taken.
Then, check social media platforms and forums where other users might report similar issues. This can provide additional insights into the scope and duration of the outage and an estimate of when power will be restored.
It is important to have a plan in place for these troubleshooting steps. This plan can help you determine whether the issue is with your internet service provider or within your internal network, guide you toward the appropriate solution, and reduce your downtime.
Finally, discuss with your staff that in the event of a power failure, you may have to temporarily revert to paper charts and enter the data into the EMR when the power has been restored.
Temporary Staff Shortages
To manage temporary employee shortages, consider strategies such as cross-training existing staff to fill gaps, using temporary staffing agencies, prioritizing patient appointments, communicating clearly with patients about potential delays, optimizing staff schedules, leveraging technology to streamline tasks, and proactively addressing the root causes of staffing issues to prevent future shortages. And, of course, always ensure high-quality patient care remains the top priority.
The easiest solution for coping with temporary gaps in employees in a medical office is to cross-train staff members to perform tasks outside their usual roles. This allows them to cover absent colleagues in different areas, such as the front desk, clinical support, escorting patients from the reception area to the exam room, or working with patients to enter their demographic, insurance, and health questionnaire data into the EMR. You should regularly evaluate staff performance during annual staff evaluations to identify areas for improvement and potential opportunities for cross-training.
A more expensive and less effective option is to use temporary staffing agencies to quickly fill gaps with qualified medical assistants, nurses, or administrative staff when needed.
Insurance Denials
Managing insurance denials requires reviewing and addressing denied medical claims by identifying the root causes of the denials, analyzing trends, taking corrective actions to prevent future denials, and appealing justified rejections.
Begin by trying to identify the causes of denied claims. Thoroughly examine each denied claim to understand the specific reason for rejection, whether it’s because of errors in entering accurate patient data such as patient’s name, date of birth, Social Security number, date of service, or insurance identification number; coding errors; missing documentation; patient eligibility issues; or payer policy changes. Sometimes, a small error, such as misspelling the patient’s name or not providing the exact date of birth, will trigger a denial.
You can get one ahead of denials by regularly training billing staff on proper coding, documentation, and payor guidelines to minimize errors. It is also necessary to verify patient eligibility and coverage before providing services to prevent unnecessary denials.
Finally, there are automated tools to identify potential billing errors on claims before submission.
The national average of denied claims for a medical practice is in the range 10% to 20%.(1) Anything greater than 10% requires attention, because the time, energy, and loss of income will be profound.
Delays at the Hospital Operating Room or the ASC
If you are a surgeon or perform procedures in an ASC, there will be instances when the cases before your scheduled operation or procedure took longer than expected, causing you to be delayed seeing patients in your office. It is imperative to be one step ahead, because this situation is, unfortunately, likely to occur.
When operating room delays occur, it is necessary to keep your office informed and give them an estimate of when you will complete your procedure and return to the office. If the delay is going to be longer than expected, your staff can offer to reschedule the patients for another day. It is imperative to keep patients informed of delays. If such delays are frequent, consider seeing patients in the office in the morning and operating in the afternoon.
Patients Calling to be Seen That Day
Doctors need to become more efficient and productive. One of the best ways to enhance efficiency is effective scheduling. Nearly every practice has several daily urgent appointments or emergencies that must be worked into the schedule, and these few additional patients can wreak havoc with the schedule. Although physicians usually are willing to work urgent cases into their schedule, that may mean that other patients must wait or that doctors must work longer hours, which risks paying overtime for staff.
Every practice has several urgencies or emergencies that must be worked in every day. You can get ahead of this situation by leaving at least two open time slots available — one in the late morning and one mid-afternoon — that can only be filled after the practice opens in the morning. These slots are reserved for emergencies, urgencies, or new patients. Leave a block of 15 to 20 minutes each morning and afternoon open each day for patients who call or walk into the office seeking healthcare that day. The number of open slots can range from just a few to a substantial chunk of the daily schedule.
Consider offering brief five-minute visits that the practice makes available at lunchtime or at the end of the day so people know they can get access to medical care quickly. Not only should this help to improve continuity of care when reimbursement is increasingly linked to outcomes, but it will also help to remain competitive as more doctors make it easier for patients to get appointments. You will also maintain the loyalty of your existing patients when you provide them access to care instead of sending them to urgent care centers.
Bottom Line: I think that doctors can perform magical miracles. With just a few clues (i.e., the history) and a few findings (i.e., the physical exam and tests), doctors can arrive at a conclusion or diagnosis and improve the health of our patients. By using the one-ahead principle, we can improve care by managing patient expectations.
Reference
Lo J. Claims denials and appeals in ACA Marketplace Plans in 2023. www.kff.org/private-insurance/issue-brief/claims-denials-and-appeals-in-aca-marketplace-plans , January 27, 2025