Rheumatology Practice Management
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Best Practices for New Patient Development and Retention

At the Coalition of State Rheumatology Organizations 2020 Fellows Conference, Ethel Owen, CPC, Practice Administrator, Arthritis & Rheumatology Associates of Palm Beach, FL, a 7 physician rheumatology practice, shared her experiences on practice management and best practices for new patient development.

Ms Owen began the session with an overview of practice governance and what she thought was important. When interviewing, attendees should ask for an employee manual and ask pertinent questions: “What is your vacation time off? Is it different from an average employee? Are there policy and procedure manuals?” Ms Owen explained the importance of communication among physicians, front office, and back office. “Everything we do is moving the patient forward and building your practice,” stressed Ms Owen.

She then discussed compliance training for Health Insurance Portability and Accountability Act (HIPAA) and Occupational Safety and Health Administration. Ms Owen said she hoped that the attendees would never have to get involved with HIPAA but that someone should understand HIPAA in your office.

“Four hospitals were shut down in 2019 from ransomware. Is there a standard within your organization? When shopping for a practice, these are things that indicate a well-managed and well-organized operation,” she said.

Building a Successful Practice

Ms Owen stressed that new patient development and retention are “really how you begin to build your practice. Think about your referral bases. You’re a rheumatologist. You’re not going to spend a lot of time in the hospitals now…or have a lot of interaction with primary care internal medicine unless you go out within the community and your medical societies and build those relationships.”

The number one referral base actually may become your patients. “What are your expectations? Evaluation and management visit and no records? Notes but no labs? New labs? Cost to the overall system? Say, ‘What do I need? What do I want?’ Take ownership of the new role in this practice. Set that real-life expectation up. Make sure your staff is obtaining a referral. If you’re treating a patient with a certain insurance that requires a referral and they show up without it, you get paid zero.”

Ms Owen suggested to develop a checklist and work with the internal staff. In her practice, where there are 10 providers, they will not schedule new patient appointments until they have that paperwork for the patients.

“New patient rheumatology visits can be upwards of 6 months. Do you want your patient to wait up to 6 months to get in? Your patient is your customer. Make sure you have everything set up,” she stated. Copay policies should be reviewed and set up with that new patient and those expectations should be set at the first visit.

Onboarding new patients

Ms Owen told the attendees what the physician staff can do with patient check-in, such as complete new patient information, obtain a list of current medications and copies of medical and pharmacy insurance cards, review referrals and office policies, collect any copay, and enter demographics. She referred to this process as being locked and loaded.

“When the physician walks into the exam room, everything is locked and loaded. Medication lists are loaded. Weight, height, and initial patient history are loaded,” she explained.

The importance of a medical assistant is to assist with the patients in the office, and physicians should check if one will be assigned to them. “Your [medical assistant] should be able to do most of the things on the checklist. Things for you, such as a medication list, weight, height, and initial patient history. One of the most important things you will do is take a detailed history. You might be the third or fourth specialist that the patient has seen by the time they get to you,” said Ms Owen.

Check-Out Procedures

So, what should the physician think regarding patient check-out and the accompanying protocol?

“Think about [the patient] as a consumer,” Ms Owen said. “I’m the patient who thinks, ‘I want good quality care.’ When the patient is checking out, your staff should verify physician orders…and follow the payer mandate of where patients may have to go to get these services.”

She said that ancillary services should be scheduled in accordance with physician orders. Prescription refills should be verified as a way to inform and educate your patients about your policy. Ms Owen said that many patients can call the pharmacy for their prescription refills. The message is sent through Escribe, which reduces many phone calls and eliminates daily phone calls. “You can eliminate all refill phone calls. Lab orders should be written down and drawn 2 weeks before the next visit,” she explained.

Services provided, such as medication refills, should be documented so you can get these services authorized. Services ordered by the physician should be tracked, follow-up appointments scheduled, and services documented in the office. She suggested having a “tickler” system, “which is something that your staff should do.

As a management team, they can help set that up. But you are actually becoming employers. As an employer, expectations can be set with the staff to deliver what you need to become successful,” she stated.

Know How to Document and Know How to Code

The International Classification of Diseases, Tenth Revision (ICD-10) coding system communicates a patient’s diagnosis to insurance companies to receive payment. It also supports medical necessity, reduces compliance risk, and supports necessary procedures and testing.

“Proper ICD-10 documentation enables quality patient management and ensures proper reimbursement,” explained Ms Owen.

Medical necessity supports the following:

  • Level of office visit
  • Tests and imaging
  • Labs ordered (every lab needs an appropriate ICD-10 code)
  • Procedures (eg, ultrasound, joint injection)
  • Outside orders (eg, a note needs to go to a payer when you are trying to get an authorization for a diagnostic test or for a medication)

Education on ICD-10, evaluation and management (E/M), and Current Procedural Terminology (CPT) codes are vital to your practice.

“You’ll be learning the [electronic health record] and the overall practice. You need to become proper coders, to make sure you understand how to do E/M coding and ICD-10 coding. Coding consultants can educate you on how to code for E/M services and other ancillary services. Make sure you are managing documentation within your practice,” Ms Owen stated.

Ms Owen stressed that one of the most vital takeaways from her presentation is that attendees understand the importance of documenting and coding. She shared an example of a physician who learned the difference in coding between a CPT 99213 code and a CPT 99214 code. The average reimbursement difference was approximately $35 per patient encounter. Proper coding changes led to an average revenue increase to the practice of approximately $27,000 annually.

“The physician didn’t understand coding and was choosing the lesser service level. It was about how to code properly,” she explained. Ms Owen said that beginning in 2021, coding is changing and that 6-hour training courses should begin at the end of 2020.

Accounts Receivable and Claims Management

Accounts receivable is money owed for services rendered from insurance companies primarily. The other part is from patients (eg, copays, coinsurance deductibles).

“There is no such thing as 30-, 60-, and 90-day collections. In rheumatology, it is 7, 14, and 21 days; 95% collection is not acceptable. You need to be at 100%, because for many of our product drugs (infusions), the profit margin can be as small as only 4%,” said Ms Owen.

Ms Owen explained that with accounts receivable claims management, “there is tracking on everything you do. There should be access to denials. Track denials by procedure, department, and payer. Meet with management to review performance quarterly, develop a relationship and communicate your goals with management.”

Preparation Equals Success

To conclude, Ms Owen shared the following tips to build a successful practice: “Understand your employment contract, clinic governance, and how to build and retain a referral base. Retain your new patients. Develop a basic understanding of clinic operations 6 to 12 months from starting. Train and prepare to become an expert coder for the CPT codes (governance published by American Medical Association for all the procedures we do), the Healthcare Common Procedure Coding System (J codes for injections and medication fees), and ICD-10 codes (tells the payer the story).”

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