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Webinar Q&A As a follow up to our recent webinar, How Customer Service Impacts Your Bottom Line, speaker Rochelle Glassman and Kareo have answered the many questions posed by participants.

Q: Will you provide the slides from this presentation? A: Yes, you should have received links to the slides and recording via email. If not, here are the links to the recording and slides. Q: Is there a way that I can get CEU credit? A: To apply for PAHCOM CEUs you have to register and attend the event with your name and email address. To request the CEUs, please email marketing@kareo.com. For more information about PAHCOM, visit their website.

Q. Is there an obligation to see a self-pay patient for an urgent visit if they have an outstanding bill? A: You can’t refuse to see a patient because they owe you money. This is especially true during a critical stage of treatment or when the patient is in urgent need. You can reschedule a preventive care appointment if they have a balance. In all patient challenges, the most important goal is to avoid a claim of patient abandonment and liability of a malpractice claim if a patient’s condition should worsen as a result of the urgent care refused to the patient.1 Regardless of the reason for your issues with a patient, whether it’s unpaid bills, failure to follow advice, or mistreatment of staff, the same advice applies:

1. Document any issues you are having with the patient. Make sure not to terminate a patient until there is evidence in the record of the problem(s). Patients should be provided with notice of such problem(s) and an opportunity to modify their behavior. If the particular patient’s issue is an unpaid balance, meet with the patient privately and discuss the issue. Can a payment plan be established? Can the patient demonstrate financial hardship that you are able to document? Document your meeting with the patient, the issues discussed, the patient’s response, and the agreed to modifications moving forward.

1 http://www.physicianspractice.com

How Customer Service Impacts Your Bottom Line

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2. It is recommended that all financial agreements and payment plans be put in writing, signed by the patient and witnessed by a manager at the practice. If no agreement can be reached regarding payment of amounts due, follow up in writing and let the patient know that unless a payment plan is established by a certain date, the practice will provide notice of termination.

3. If efforts to establish a payment arrangement are still unsuccessful, you may need to terminate the patient. Always remember that the patient must be provided with sufficient time to find alternative care before termination from the practice. Reasonable notice can vary depending on the patient’s medical condition and the difficulty which a patient may have in finding alternative care. For example, I recommend that an oncologist not terminate a patient for nonpayment of medical bills until the patient has completed the current course of chemotherapy. Alternatively, a patient of an internist who simply comes in when he or she has a cold or other minor issue may require only 30 days’ notice. There may be state-specific laws regarding minimum notice periods and these must also be observed. There also may be payer contractual termination requirements. It’s not your responsibility to make sure the patient has found a new physician, only to provide sufficient time for the patient to do so. However, in certain circumstances, there may certainly be ethical obligations to provide additional assistance to extremely ill patients to secure continued care.

4. It is the practice’s responsibility to transfer the patient’s medical records to the new practice in a timely manner. Many health plans require that medical records be provided to the new practice at no charge to the patient. It is recommended that you review your payer contract to be sure that you have met your contractual obligations.

5. Termination of a patient from the practice should not interfere with your ability to turn over the patient’s bills for collection. However, at all times through the termination process and thereafter, it should be the goal of the practice to attempt to establish a payment arrangement with the patient and to determine if there is a documented financial hardship.

6. In any notice provided to patients, make sure you clearly note the date on which they will no longer receive care and how they can obtain copies of their medical records. You should also offer assistance in locating a new physician, such as providing contact information for a state medical association or similar organization. Most health plans list their contracted facilities and physician groups online. It is recommended that you provide the patient with that information. The patient should understand that in the event of an emergency or urgent situation (which may depend upon specialty), the practice should take the necessary steps to assure the patient is properly cared for.

7. Like any other business, physicians should not be required to continue to offer services without payment. However, in medicine it’s not all about the bottom line. Take the time to properly handle each patient and to assure their understanding and continued medical care in order to best protect your medical practice.

8. I would recommend that the practice establish a written standard termination policy for all employees to follow, this established policy will also ensure that the practice is never accused of patient discrimination if all the patients are treated the same way.

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Q: How do you suggest an office deal with a patient who never pays their copay and has balances piling up? A: It is recommended that the practice establish a payment policy that clearly articulates the practice’s financial and payment policies, the patient must be required to read and execute the agreement prior to the patient being treated and annually thereafter. See previous answer for more. Q: How do you deal with patients who cancel appointments regularly? A: Patients who cancel appointments or surgeries at the last minute can be a huge drain on your practice’s cash flow. Consider implementing a strategy to prevent unexpected holes to minimize the impact of last minute cancellations and no shows on your medical practice. Set a cancellation policy, and be sure it’s communicated to every patient. Ideally, this takes the form of a document that new patients sign when they first come to the practice. Afterward, make it a point to discuss your policy at the time of booking subsequent appointments or surgery, and when reminder calls or emails go out to patients. In the cancellation policy, many practices require patients to cancel their appointment at least 24 hours before their scheduled appointment time. For surgeries, the required notice time can be even longer. For those patients who do not comply, consider charging a late cancellation fee. Collecting cancellation fees can be achieved much more easily than you think when your office is set up to bill for cancellations and accept credit card payments. By creating a cancellation code, you can bill the patient using electronic statements. The day of the cancellation or no-show, process a patient statement and direct the patient to pay online by credit card. Enabling patients to pay online can increase patient payments and speed the turnaround on those payments whether it is for the cancellation fee or for standard co-pays and deductible payments. If your practice identifies a cancellation or no show pattern, for example on average one is every six patients do not show up. I would recommend that the practice double book every sixth patient to maintain cash flow. Q: Can you refuse to schedule a patient after a certain amount of no shows? A: I recommend implementing a no-show and cancellation policy as laid out in the previous answer. You may eliminate this problem with a no-show fee. If the problem continues then utilize the information above about how to terminate a patient to avoid a claim of patient abandonment.

Q: We request that patients reschedule appointments if they are more than 15 minutes late. Does that sound fair? A: Yes, this is fair if the physician or provider never runs late. I have never been seen by a physician on time, and if I ran late on occasion and showed up only to be told I would not be seen by the provider I wouldn’t go back to that practice. On the other hand, if your providers consistently see their patients on time then it is recommended a policy be established as

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mentioned above. Keep in mind that a disadvantage to this policy versus one that requires patients to call ahead of time and reschedule could mean lost appointments. If you wait until someone is already late then you have lost that appointment slot and the revenue that comes with it. Q: What is the best way to address patients who keep calling regarding the same bill even after explaining the bill to the patient? A: Healthcare reimbursement and payment processes are complicated and often patients do not understand their payment obligations. I would recommend that prior to treating the patient a staff member (financial counselor) explain to the patient their financial obligations (how much they have left to pay prior to meeting their annual deductible, copayment, non-covered services and percentage of the payment the patient is responsible for, etc.). I am a huge advocate of explaining the potential costs upfront rather than having a confused, upset and often angry patient after the fact. Regardless of your efforts to explain the patient’s financial obligations to the patient they still may not understand the payment obligations under their insurance plan, especially elderly patients who will always need you to explain things more than once. However, if this is a common problem, it may be your staff who are not clear with their communication or how they are explaining the patient’s statements. I always recommend asking patients as you talk if they have questions, do they understand what you are covering, etc. If it is a common problem, you might ask someone to be a test case and call in to ask questions to your staff about their statement. Then, have that person tell you if there were areas where things were not explained well or if something caused confusion. That will allow you to address those issues. Q: I want to provide good customer service but I also want to ensure HIPAA compliance. How do I do this with phone calls? Is there a best practice for leaving messages? A: As part of your new patient documentation you need to provide patients with options on how they would like the practice to handle any type of communication related to their treatment and test results. It is recommended that a document be prepared allowing the patient to identify approved methods of communication. This may include but not be limited to email communication, leaving messages at certain telephone numbers, who the practice can speak to related to the patients care, would they prefer communication via text or even snail mail. It is important that the patient sign this document on an annual basis as their circumstances may change. Q: How do we deal with patients who are upset about a bill from a laboratory even though they were informed on the consent form that they signed that a lab bill would be sent separately? A: When this happens after the fact, I would suggest always listening calmly to the patient concerns. Then, you can review the actual signed consent form with the patient and as you go through the consent form ask the patient if they understand why they have additional charges from the laboratory or pathologist, then ask if they have questions. If they do, make sure you are able to answer them all thoroughly. You should be confident in your communication style so that you come across knowledgeable. If you are unable to answer the question, do not make up your answer, let the patient know that you will need to research

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the answer to the question(s) and get back to them within twenty four hours. It is important that you do get back to the patient within the timeline you agreed to. It is also recommended that you stay calm and show your sympathy, it may help alleviate their frustration. Moving forward, I would always make sure that you review the consent form with the patient in person prior to the treatment being provided. I would also recommend that you give the patient a copy of all the documents that they are signing for their files. Ask them if they understand and have any questions. Patients sign many forms and they don’t always read them closely or understand everything in them and are too embarrassed or feel too intimidated to ask the staff questions related to the documents they are signing. Q: How do we deal with a patient who is upset because first treatment did not work and they have to pay for another treatment? The consent they sign stated it may take more than one treatment and sometimes several. A: I believe the same basic principle applies as stated in the previous answer. Q: How do we deal with a patient who wants treatment at initial visit otherwise they have to pay another copay? A: I would explain to the patient that the proper time has to be allocated in the providers schedule to provide the services or procedure(s) the provider is recommending to the patient.

Q: How do you deal with a patient who wants treatment you don’t feel is the best medical plan or even a viable option? A: Be clear with the patient about what you recommend and why. Explain why you don’t think the other option is appropriate in their case. All this communication must be documented in the patient’s medical record in as much detail as possible, this should include the reason the provider feels that the treatment is not necessary. Ask if the patient understands why the treatment(s) is not recommended and if they have any questions. If the patient is adamant about another treatment, I would recommend they seek a second opinion. A patient has the right to refuse treatment and a provider has the right to say they can’t provide a certain type of treatment or care and refer the patient elsewhere. A provider should never provide care that they feel is not in the patient’s best interest or is not medically necessary when dealing with the health plans Q: Would it be a good idea to send a feedback form in the mail? We do have patients fill out a form when they are discharged, but it's done in the office. A: I think either way is fine. If providing the feedback form in office is working for you then keep doing it. If it isn’t, then you may want to try mailing or emailing a survey instead. Q: Do you recommend taking a credit card number to keep on file? A: I absolutely do. This has been well established now as a best practice for medical practices. It can help reduce A/R and the costs associated with patient collections. However, you must obtain a signed authorization from the patient to either take a specific dollar amount as a deposit to be applied to the unpaid balance of their claim. I would also establish in writing and executed by the patient that when the claim is paid and the EOB shows up at the practice, the practice is permitted to charge the credit card up to a certain dollar amount. In addition, when you set up payment plans I would recommend that the patient agrees that you

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can either charge X amount of dollars to their care per month or you can take the money directly from their bank on a certain date per month. It is recommended that you send the patient a receipt for the payment. Q: Doesn’t HIPPA prevent a practice from keeping a patients credit card on file? A: No. Credit card on file is not a HIPAA violation. There are security requirements for keeping a credit card on file, however. The merchant must be PCI DSS (The Payment Card Industry Data Security Standard) compliant. When compliant, you can legally store credit card information, with the exception of the CVV code. You can never, store the CVV code. Your merchant services provider should meet these standards. Details on the requirements can be found at PCI Security Standards Council: www.pcisecuritystandards.org. Q: Where can I find information implementing a credit card on file? How do you deal with customers who do not want to have a credit card on file? Have you seen a trend towards having a credit card on file? A: It is not only a trend, but it is becoming an accepted best practice to use credit on file for payment plans as well as routine copays and deductible costs. For more details on using the credit card on file, you can view my last webinar with Kareo, 3 Innovative Strategies for Increasing Collections. It provides an overview of the process. As a summary, I recommend having a clear payment policy in place and using a credit payment agreement and authorization form. A payment agreement stays in effect until the balance is paid in full. When an agreement is made, it spells out the length of the agreement and the patient signs that agreement with the understanding of the length of the agreement. Recurring payments can be set up using a payment processing service . if you already accept credit cards, your merchant services department may already have a service in place which you can add to your current plan. Many banks such as Chase and Wells Fargo offer this option to their merchants for a monthly fee. This service is also available through other vendors such as Paypal, Chargify and Authorize.net.

Q: Is notifying another healthcare provider of a patient termination considered a HIPPA violation? A: Yes, this is because they are not directly involved in the patient care. I would recommend that you provide the patients with the health plan webpage address that will list all the physicians that participate in their health plan. The patient can then choose their new provider. Once the patient has signed a release of medical records form then the practice can forward the patient’s file to the new physician.

Q: A $25 copay can be overlooked when insurance is going to pay $125 for the visit, but it is hard to overlook a $70 specialist copay for a $78 visit when the insurance is only going to pay the practice $8 on the claim. Do you still recommend letting that go. A: What I recommend is doing an analysis of each situation so you don’t terminate a patient for a $25 copay when that patient has brought in thousands in revenue and may continue to bring in thousands more in the years to come. I would not recommend terminating a patient over $70 if that is a one-time thing and it is a small amount when weighed against the total

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amount paid over time. I would recommend that you offer them a payment plan. But if it is an ongoing problem and the amount owed is beginning to outweigh any past or potential income then consider the process laid out above for patient collections and termination. Q: Can you please repeat formulas you used to calculate value of patient? A: To get the average annual revenue per patient, take your total revenue for the year and divide it by the number of patients seen. That will give you an average revenue per patient. Then take the number of patients seen and divide by the number of visits and divide by total revenue for a per visit average. To easily do this, visit www.upshealthcare.com where you can use a free calculator and spreadsheet to calculate your lifetime value of a patient and obtain other documents related to this webinar. Q: Many copays for preventative care are going away with health reform. Does that include behavioral health services? A: The changes resulting from health reform apply to preventive care guidelines laid out specifically by the US Task Force for Preventive Health.

Q: What is the most diplomatic way of curbing employee gossip, especially when the owner is involved? A: All new employees on their first day of employment before they start their training or job tasks they must review the practice’s employee handbook. All employees must read and sign an acknowledgement form that requires them to follow all the practice’s policies, procedures and behavior requirements. The employee handbook should also detail the disciplinary action the practice may follow should the employee not follow the policies. It is important to be consistent with your performance expectations and follow the guidelines in the handbook. It is a huge challenge to correct an issue when the owner is part of the problem and not the solution. I would recommend that you meet with the owner first and explain the situation and go over the corrective action plan you would like to implement and make sure you have the owners buy-in and support. If not, the entire exercise is futile and you will be undermined by the owner. If the owner does agree to be part of the solution, I would meet with all the staff and go over the practice’s policies and expectations related to professional behavior and what the consequences maybe if the policies are not consistently maintained. If the gossip continues beyond this point, I would deal with the individual employee based on your established policies, which may include disciplinary action up to and including termination. If the owner is not willing to change then you have a problem because without the support of the owner it is very difficult if not impossible to implement change. Q: What do I do about a provider who will answer a personal phone call while seeing patients? A: No employee should be taking or making personal calls in the presence of patients—at the front desk or in the exam room. All employees must be treated the same; you cannot discriminate because someone is a provider. This type of behavior should be covered in your employee handbook. For more on this, see the answer above.

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Q: Do you find that most practices’ staff are adequately trained in using their EHR systems? A: Actually, there is research to suggest that one of the top reasons for EHR dissatisfaction results from inadequate training. Don’t skimp on EHR training. In the long run, it’s better to spend more time and money on upfront training than have to deal with problems that result from poor training. Q: You said we don’t want patients to be kept waiting and then you said consider double booking. What happens when everyone shows up and you fall behind? A: I recommend double booking as an option when you have done an analysis on your no shows and identified patterns that indicate predictable gaps in your schedule. For example, if you know that 30% or more of your Medicaid patients don’t show up then you might consider double booking some of those slots. If you find that you double book and everyone shows and you are running behind, apologize to the patient and let them know you are running behind and they will be seen in XX minutes. Q: A lot of these examples are for a medical practice. I am in behavioral health office. Do the same things apply to me? A: Yes, most of the things we are discussing are about customer service and how we treat patients. While each specialty has its own unique aspects, the basics of customer service are the same.

Q: What is the number one complaint that patients have about a primary care doctor's practice? A: Not getting a convenient appointment.

Q: If a new employee answers the phone and doesn’t know an answer, is it ok to let the patient know that someone will need to return the call? A: Yes, but you should have a set timeframe to return calls, tell the patient the timeframe, and be sure the call is returned within that timeframe. The important thing is that the patient feel informed, treated politely, and that your staff follows through. You don’t want to have patients calling back because no one returned the phone call. Q: If a provider is out of network and payments go directly to patient, can a provider terminate patient treatment for not bringing checks? A: When a physician accepts a patient out-of-network many insurance companies pay the patient directly. I would recommend that if your practice accepts patients for out-of-network services then the practice should collect the patient’s health plan insurance usual and customary payment based on the CPT codes for the treatment provided at the time of service. Remember for out-of-network patients you are providing an administrative service to the patient by billing for the services provided on the patient’s behalf. I would also recommend that all new patients of the practice and existing patients sign as, part of their financial agreement with the practice, a form that states that in the event the insurance company pays the patient directly, the patient must either endorse the check over to the practice or pay the practice within 5 business days from receipt of the payment. If

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payment is not received, then as part of the practice’s financial agreement the patient must leave a credit card deposit with the practice or complete the necessary paperwork for EFT from the patient’s bank account. If the patient does not make the payment or endorse and hand over the check, then the practice should send out a statement to the patient and if payment is not forthcoming then the recommendation would be to send them to collections or to small claims court depending on the balance owed. Please note that I would not terminate a patient from the practice for nonpayment of a small balance. You have to consider the cost of lost income for terminating a patient. The assumption is for a cardiologist for example that each patient brings in revenue stream that includes testing of up to $250,000 dollars over the life time of their patient’s visits. It would not make financial sense to terminate the patient from the practice for a balance of $100.00, so in this situation I would recommend that you put the patient on a payment plan, or have them complete a hardship financial statement to be reviewed by management to establish a legitimate hardship. If this is established based on the practice’s financial hardship policies then the practice’s management team may decide to write-off the balance. I believe if the patient does not make the payment they are in breach of their contract with the insurance company and the financial policies of the practice. The practice can also decide for repeat offenders to terminate the patient from the practice with the proper notice based on the payer contract patient termination and notification policy.

Q: Is Kareo Meaningful Use certified? A: Yes. Kareo is certified for Stage 1 Meaningful Use and is in the process of getting certified for Stage 2. For more information, visit www.kareo.com/ehr. Q: Does Kareo integrate with other EHR systems? A: Kareo does integrate with man third-party EHRs. For more information on what those EHR solutions are, visit www.kareo.com/marketplace.

Small Practice & Billing Company Resources Please visit Kareo Resources at www.kareo.com/resources for helpful tools, webinars, whitepapers, and tips for how to help small practices become best practices. You can also view recorded webinars or register for our next event at www.kareo.com/resources. About Kareo Kareo is committed to providing education and insights to small medical practices. We work with in-the-trenches influencers, consultants, and Kareo customers to provide relevant tips

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on how to successfully manage medical practices and medical billing services. Find out more at www.kareo.com. About Speaker Rochelle Glassman Rochelle Glassman, President & CEO of United Physician Services. Rochelle brings a passionate, very practical “do it today” approach to making medical practices successful and getting physicians paid more. For more about Rochelle and for resources related to this event, visit www.upshealthcare.com.