Urology practice success: Control what you can control

As we have analyzed practices across the country over the past year, a common theme has emerged: The organized practice, with clearly defined roles for each member, is the most efficient and profitable. Consistent and strong leadership is common among these successful practices; however, a clear structure and protocol have also proven invaluable during any change in leadership. Based on these experiences, it is clear that the best practices incorporate written structure and protocols, with measurable review standards that can be understood and implemented by all within the practice.

Devoting time to business side crucial

Here are the top three areas in your practice that you can influence. Regardless of practice type, each provider and employee needs to understand each of these:

The decision-making process. Who is capable of implementing systemic change within your practice? In short, the management structure should be clearly defined. As issues are identified, this person or group will need to be able to make a decision and follow through with an implementation program.

Analyze your current administrative structure. Are decisions made fairly and efficiently? If decisions are consistently deferred, a restructuring of the process should be undertaken. Ownership has the power to change this structure. Egos and politics should be taken into account; however, logic and data should dictate direction.

Have there been multiple changes in administration? If the leadership of the management team has changed frequently, the practice must realistically determine whether the issue is the ownership and employees or the hiring process. One or the other is usually at fault; of course, illness and competitive hiring in the area can also play significant roles. Be objective and make changes accordingly.

Does the current management have the core capabilities required for the job? Often, physician practices promote from within. Loyalty is a valuable asset and should not be discounted. However, an office manager for a small group may not have the training or skills to manage a large group. Develop a job description as if you were going to hire a new person and compare the qualifications of your current manager against the list.

Alignment with core values. As a health care provider, your life can be made more stressful if you are trying to adjust to a set of values that you do not agree with in principle. Understand that with any group, it is next to impossible to align the group with the individuals 100% of the time. If everyone at least understands the core values, however, the individuals can choose either to adapt or leave the group.

It is important to be able to adapt. No group or individual can remain entrenched in a particular value set with the changes that are pressuring the business of health care. Intrinsic growth of an entity will also foster change in values. Many large urology groups were formed with the promise of little or no change to the groups that were merged; however, as the utilization of health care has declined recently, many of these groups are being forced to make changes to the smaller groups to cut costs and take advantage of the new, larger entity. A "growing pain" such as this is expected and needed for the health of the group.

Billing and coding structure. Regardless of the shape or the structure of a practice, the heart and soul of the revenue stream is coding for services rendered. Without clear involvement and a coordinated team effort, you will lose money.

As the provider of services, the clinical staff is the only group capable of documenting and coding the services rendered with any accuracy. We have all seen groups in which the providers simply document services they provide and allow others to code and bill. With electronic health record systems, codes are increasingly driven by the templates chosen for documentation. In either case, the clinical service provider must understand the coding outcomes in order for the documentation to accurately reflect the services rendered. In the case of the EHR, if the appropriate template is not selected, the codes sent to the billing program will not reflect what has been done.

Ultimately, it is the responsibility of the service provider (physician) to correctly code for the services rendered. Therefore, it is recommended that the practice train the clinician on coding, develop and maintain tools for these individuals, and measure coding through compliance reviews on a regular basis.

Coding issues: Administrative staff's role

The administrative staff in charge of processing charges and payments must be provided the tools and training to bill each payer by their rules and to appeal claims that are incorrectly paid. The staff must actively research coding issues and receive regular training to keep up with changes. Additionally, it should be tasked within the system to provide feedback to the providers and other staff members relative to write-offs, denials, and other actions that affect payment. This can prevent unneeded losses from the provision of services that are not contractually allowed.

Efficiency is key and can be measured, but be careful. A squeaky-clean accounts receivable may not be indicative of excellent collections but can instead reflect an efficient but costly write-off policy. Systems should be set and maintained that constantly question charges and payments within the practice. Staff members should expect to be questioned.

These are only a few of the issues that can be addressed by physicians to make life easier. Hope is not a business strategy. Change is not the enemy. The business of medicine can be tamed so that the clinical work you became a physician to provide can remain your primary focus.

Urologist Ray Painter, MD, is president of Physician Reimbursement Systems, Inc., in Denver and is also publisher of Urology Coding and Reimbursement Sourcebook. Mark Painter is CEO of PRS Urology SC in Denver.

The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.