PRE104 MGMA 2015 Mastering Patient Flow Preconference: Moving from Volume to Value

PRE104 MGMA 2015 Mastering Patient Flow Preconference: Moving from Volume to Value

Appendix Mastering Patient Flow Prepared by Speaker Elizabeth W. Woodcock, MBA, FACMPE, CPC www.elizabethwoodcock.com elizabeth@elizabethwoodcock.com For MGMA Pre-Conference Attendees October 11, 2015 Table of Contents 1. Fill Rate 2. Transitional Care Management 3. Chronic Care Management 4. Performance Metrics for Telephones 5. Missed Appointments = Missed Opportunities 6. KPI Operations Dashboard See also: Mastering Patient Flow: 4 th Edition By Elizabeth W. Woodcock, MBA, FACMPE, CPC All contents are Woodcock & Associates 2015; please contact Elizabeth for reprint requests. MGMA Pre-Conference Program Mastering Patient Flow Woodcock & Associates 2015 Page 1

Using Fill Rate to Measure Access by Elizabeth W. Woodcock, MBA, FACMPE, CPC An overview on the Fill Rate - Percent of patients actually seen divided by the capacity as defined by appointment slots available Evaluate the number of patients you saw, as compared to the number of patients for which you have the capacity. Your fill rate should be close to 100 percent. Anything short is a patient who failed to show, a lastminute cancellation, a patient who you had to bump, or a slot that was not ever filled. Evaluate operational strategies to reduce no-shows, last-minute cancellations and bumps, and refine your marketing activities to attract new patients. If your fill rate is consistently 100 percent, carefully review the resources you have dedicated to deflecting the excess demand. If your staff spends more time protecting you than helping you, it's time to make a strategic decision about your practice. Aim for growth by hiring another provider or physician, or slow growth by dropping participation with a low-paying insurance company. Notably, there may be an exception for referral-based specialties. Oncology, for example, needs timely access with a week; Radiology, for example, needs timely access within hours. For some specialty practices, in sum, management should never desire capacity to hit 100 percent. Measure and report these key access indicators every quarter. By monitoring and analyzing the variances in the data, you can keep a pulse on patient access and the future of your practice. If you re full Finding a place for a patient may be your first challenge. When appointment access becomes a problem, physicians turn to the scheduling process to fix it. Their attempts begin with an alteration to the appointment template, then move on to the schedulers process for making an appointment. Although there are certainly gains to be made, the real opportunity is to understand supply and demand. Before exploring the nuances of scheduling, it s important to understand the delicate balance of supply and demand that is required to manage a successful medical practice. When a new practice opens its door, physician supply exceeds demand. This imbalance cannot be sustained for more than two years on average, unless there is external financial support. The two-year period isn t a MGMA Pre-Conference Program Mastering Patient Flow Woodcock & Associates 2015 Page 2

magical timeframe, it s the reality of paying the bills. If you don t have patient demand, you don t have revenue. Unfortunately, as discussed in chapter 2, you still have the majority of the overhead as that of a full practice. For practices in which the supply exceeds demand, scheduling is simple: schedule the patient when he/she wants to be seen, and move on to the next call. In sum, get them in. Most often, problems with appointment availability stem from demand outstripping supply -- that is, patient demand overwhelming the supply of clinicians. It s easier to deal with this problem in other industries. In the retail industry, for example, the store closes at the end of a business day. If you are a customer demanding a loaf of bread, you wait in line to buy one -- or you wait until the morning. Physicians, on the other hand, have to manage that demand. Physician care is not an eight-hour-a-day need. It often comes in the form of handling calls at night or, if capacity is full, during the day. In addition to this infrastructure cost, poor appointment availability also means other problems that lead to reduced profitability -- and compromised patient care. Determining when patient demand exceeds your supply of physicians is a more complex challenge, but one that is essential to managing your operations. In essence, it s the question that you should ask when you notice signs that your practice isn t keeping up with patient demand, such as a steadily increasing time to next available appointment. The results of poor access are additional overhead costs incurred in an attempt to manage patient s needs primarily over the phone. More importantly, if they can't gain prompt access, patients might get sicker or become well on their own. Either way, it's not good for you: sicker patients are obviously worse off, and well patients turn into no-shows. Alternatively, frustrated patients will see your competitor or show up at the emergency department instead of waiting around for you. Your patients' needs should determine the ideal time to your next open appointment slot. Set a goal and make it a point to measure your practice against this benchmark every month. In sum, having too much demand actually hurts your practice s bottom line. Before you stop scheduling, however, make sure that you don t have a false sense of too much demand. Although your time to next available appointments may be weeks or even months a day, look at yesterday s schedule. See how many slots you had -- your capacity -- and how many slots in which patients actually showed. Divide the latter into the former to calculate your fill rate. Tomorrow s may be projected to be 100 percent, but if you re really running at 95 percent or less, demand may not be exceeding supply. Instead, you just may not be doing a good job at managing it. If supply exceeds demand, or you discover that you ve falsely been assuming that demand exceeds supply, scheduling becomes a practice operations issue, and one that this chapter explores in full. If demand truly exceeds supply, then addressing scheduling from an operations perspective won t do the job. Tweaking the scheduling template won t solve a real access problem. If you have 20,000 patients who need to see you, and you only have the capacity to manage 2,000 of them, no idea is going to make your practice successful. Instead, it s time for your practice to address access. MGMA Pre-Conference Program Mastering Patient Flow Woodcock & Associates 2015 Page 3

Get Paid for the Transitional Care Management (TCM) Codes By Elizabeth W. Woodcock, MBA, FACMPE, CPC As of January 1, 2013, the Centers for Medicare & Medicaid Services (CMS) recognizes two CPT codes for transitional care management (TCM) services to Medicare patients. This provision in the Final Medicare Physician Fee Schedule (MFS) for 2013 opened the door for more physicians and qualified advanced practice providers to claim reimbursement for more of the services they provide to patients transitioning back into the community after hospital stays. Replacing the proposed GXXX1 code that was intended to reimburse physicians for only the non-face-to-face work involved in post-discharge care coordination, the new codes incorporate one face-to-face encounter while also recognizing the additional communication with and about the patient that occurs outside of an office visit. Notably, CMS reports that the face-to-face visit requirement is only a short-term solution: We consider the requirement for a face-to-face visit in association with the non-face-to-face tasks of TCM to be a short-term, transitional strategy while we continue to explore our interest in further improvement to advanced primary care payment. The codes are not to be used for hospital discharges only, however. In adopting the codes, CMS explains that they are for:...transitions in care from an inpatient hospital setting (including acute hospital, rehabilitation hospital, long-term acute care hospital), partial hospital, observation status in a hospital, or SNF/nursing facility, to the patient s community setting (home, domiciliary, rest home, or assisted living). The TCM codes are selected based on the complexity of the patient. They also require the physician or advanced practice provider to communicate with the patient and/or caregiver (through direct contact, telephone, or electronically) within two business days of the patient s discharge and conduct a face-to-face visit within seven to 14 days after discharge, depending on the patient s complexity level. Selecting the proper CPT code is based on level of medical decision making and the timing of the face-to-face visit: 99495 Transitional care management services: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within two business days of discharge; medical decision making of at least moderate complexity during the service period; and a face-to-face visit within 14 calendar days of discharge. MGMA Pre-Conference Program Mastering Patient Flow Woodcock & Associates 2015 Page 4

99496 same elements as above, but medical decision making of high complexity and a face-to-face visit within 7 calendar days of discharge. The new TCM codes are intended to supplement, not replace, the hospital discharge management codes (CPT codes 99238 and 99239) and the codes for nursing facility discharge services (CPT codes 99315 and 99316). While those codes may provide adequate reimbursement for the pre-, post-, and intra-care coordination activities of many physicians, CMS observes: we do not believe that current E/M office or other outpatient visit CPT codes appropriately describe comparable care management work of the community physician or qualified nonphysician practitioner coordinating care for the beneficiary post-discharge. Of particular significance is that CMS clarifies that the services that can be performed by the physician or other qualified health care professional and/or licensed clinical staff under his or her direction. Services that may be performed by licensed clinical staff under the direction of the physician or other qualified health care professional may include: Communication (direct contact, telephone, electronic) with the patient and/or caregiver regarding aspects of care; Communication with home health agencies and other community services utilized by the patient; Education of the patient and/or family/caretaker to support self-management, independent living and activities of daily living; Assessment and support for treatment regimen adherence and medication management; Identification of available community and health resources Facilitating access to care and services needed by the patient and/or family. While there is no required place of service, CMS does note that that the service typically occurs in the office, but can also occur at home or other location where the patient resides. The codes are billable at the end of the 30-day period, can be used by only one physician or provider, and may be reported only once by that physician and/or group during the 30-day period, even if the patient is readmitted. While any physician or other qualified health care professional may use both the discharge code and appropriate TCM code as appropriate; a TCM code cannot be used by a physician who also reports a service to the patient with a global period of 10 or 90 days. CMS suggests asking patients during the discharge process to identify the physician or nonphysician provider whom he or she wishes to furnish the TCM services. If the patient has no preference, CMS reveals that the discharging physician can suggest a specific physician. MGMA Pre-Conference Program Mastering Patient Flow Woodcock & Associates 2015 Page 5

Other considerations for appropriately using the codes are: Days: Communication is required within two business days, which are defined as Monday through Friday, except holidays. According to CMS, communication includes two or more separate, unsuccessful attempts, if made in a timely fashion. Medication reconciliation: Must occur no later than the date of the face-to-face visit. Physician oversight: Must include overseeing the management and/or coordination of services, as needed, for all medical conditions, psychosocial needs and activity of daily living. Reporting physician or advanced practice provider: The CPT description reveals that the provider must have an established relationship with the patient (e.g., visit within the past three years); however, CMS is developing a Medicare-specific guidance to allow reimbursement for new patients. Payment is the same for new or established patients. Skilled nursing facilities: The code cannot be billed if the patient is discharged to a skilled nursing facility. Reporting: The code can be used by the discharging physician, but the face-to-face visit cannot be on the same day as the discharge; a physician or NPP may report both the discharge code and appropriate TCM code. However, a physician who reports a service with a global period of 10 or 90 days may not also report the code. Additional visits: The first face-to-face visit is part of the TCM code and not reported separately, but any E/M service after the first face-to-face visit may be reported separately. Finally, the codes cannot be reported in conjunction with a number of other common post-discharge activities including care plan oversight services, prolonged services without direct patient contact, medical team conferences, telephone services and medication therapy management services. CMS assigns 4.82 RVUs to 99495 and 6.79 RVUs to 99496. Based on the 2013 conversion factor (with no geographical adjustment), that works out to approximately $163.99 and $231.36, respectively. If your practice cares for patients after they are discharged from a hospital, skilled nursing facility or other facility recognized in the new codes, get busy scheduling meetings with these facilities to determine the best way to seamlessly and quickly - transition patients from discharge back to your care. If you care for Medicare patients, these new code may put you in a good position to improve reimbursement for post-discharge care. For more information about the code, please see the November 16 Federal Register and http://www.cms.gov/medicare/medicare-fee-for-service-payment/physicianfeesched/downloads/faq- TCMS.pdf Woodcock & Associates, 2014. For reprint requests, please contact Elizabeth at elizabeth@elizabethwoodcock.com MGMA Pre-Conference Program Mastering Patient Flow Woodcock & Associates 2015 Page 6

Chronic Care Management Services: New in 2015 By Elizabeth W. Woodcock, MBA, FACMPE, CPC In 2015, the Centers for Medicare & Medicaid Services (CMS) begins payment for CPT code 99490. This code can be used for non-face-to-face chronic care management (CCM) services, without restriction on specialty. Given the multitude of work that you provide outside of the exam room to care for your patients, this new code represents an important opportunity for getting paid what you deserve. The American Medical Association describes 99490 as follows: Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements: Two or more chronic continuous or episodic health conditions that are expected to last at least 12 months, or until the death of the patient. Chronic conditions that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline. Comprehensive care plan established, implemented, revised or monitored. The code is reported when, during the calendar month, at least 20 minutes of clinical staff time is spent in care management activities. Only one physician can bill and receive payment for 99490 for providing the service to a Medicare patient, with payment at a rate of approximately $42. (The Medicare contractors are currently loading the post April 1, 2015 fee schedules; the exact amount will be known soon.) While $42 may not sound like a lot, consider that s $504 per patient per year. With just 25 patients under active care, that equals $12,600 in new revenue! CMS makes special note that the services may be provided under general supervision, which does not require the presence of the physician. However, you must have an electronic health record (EHR) in order to bill the code a first for CMS. A newly certified EHR isn t necessary, however; physicians can use whatever certified EHR version you have on December 31, 2014 in order to bill in 2015. Furthermore, CMS requires the following: Provision of 24/7 access to address the patient s acute chronic care needs; Continuity of care with a provider with whom the patient is able to obtain successive routine appointments; Systematic assessment of the patient s medical, functional and psychosocial needs; The creation of a documented patient-centered care plan; Care transition management; and MGMA Pre-Conference Program Mastering Patient Flow Woodcock & Associates 2015 Page 7

The ability to communicate with the patient and caregiver through secure messaging or other asynchronous communication methods, not just the telephone. In the Final Rule, CMS revealed that 99490 will be subject to cost-sharing. Because of this, CMS announced: we are requiring that providers explain to beneficiaries the cost-sharing obligation involved in receiving CCM services and obtain their consent prior to furnishing the service. Thus, you ll need to develop a consent form for patients to complete, and keep a signed copy in the patient s record. According to CMS, the document must include informing the patient of his or her right to discontinue the CCM services at any time, and the fact that only one physician can furnish and be paid for the services. CMS released this fact sheet: http://www.cms.gov/outreach-and-education/medicare-learning-network- MLN/MLNProducts/Downloads/ChronicCareManagement.pdf, and you can read more about CMS reimbursement policy in the Final Rule. In the meantime, consider what may be the biggest stumbling block of all how to account for time across the month. Sure, you may be able to record the time of one transaction (for example, one phone call with the patient s spouse about your recommendations for the plan of care), but summing up the time across the month may prove to be more difficult. Discuss the situation with your vendor; if an electronic tracking mechanism isn t possible, opt for a manual one instead. First, run a report from your practice management system querying all of the active patients who have two or more chronic illnesses using ICD-9 codes. The parameters may be 12, 18 or 24 months, depending on how actively the patients are being managed. Review that list with your clinical team, and extract all of the patients for whom you have or will establish a comprehensive care plan. Create a CCM spreadsheet, and sort the patients by last name in alphabetical order. Incorporate a marker for the consent (so as to ensure that a signed consent is on file). Put the dates of the month across the top, with each tab of the spreadsheet serving as a month. Save the spreadsheet on a shared drive. Instruct your clinical team to access the spreadsheet when they render any chronic care management-related activity, search and find the patient s name, and record the minutes of the activity in the cell below the specific date. At the end of the month, sum the time to see if any met or exceeded 20 minutes, and voila - you ll have your list of patients to bill! Remember that this spreadsheet can t (and shouldn t) be your only documentation. The documentation of the activity should be in the patient s record, accompanied by an accounting of the time. Your CCM spreadsheet is really just a redundant system to allow you to easily and comprehensively ensure that you are capturing all patients for whom CCM billing is possible. MGMA Pre-Conference Program Mastering Patient Flow Woodcock & Associates 2015 Page 8

Performance Expectations for Quality Metrics Measurement Abandonment rate Service level Average speed to answer Duration of call Average handle time Trunk blockage Hours of operation On-hold time Staff occupancy Availability Callback rate Service Script compliance rate Message quality Expectation Three percent or less 80 percent within 30 seconds 24 seconds or less (maximum of four rings, if manually calculated) Set in accordance with practice protocols; monitored by management but not a component of employee performance Set in accordance with practice protocols; monitored by management with a focus on after-call employee efficiency Zero percent 30 minutes prior to office hours opening until 5 p.m. 30 second or less 80 percent or more, but depends on size of operation and expected performance quality 85 percent or more, based on workday unless excused for training or other duties Clinical: Within 30 minutes of initial call. All others: All calls acknowledged within three hours of receipt regardless of ability to fully answer the request. Answer by end of day, unless extenuating circumstances 100 percent of callbacks made, and performed within established timeframes. 100 percent professionalism, courtesy, compassion and empathy; use of service recovery 100 percent 100 percent Source: It s Your Call by E. Woodcock and D. Walker Keegan, 2013. MGMA Pre-Conference Program Mastering Patient Flow Woodcock & Associates 2015 Page 9

Missed Appointments = Missed Opportunities Proven Strategies to Reduce Your No-Shows By Elizabeth W. Woodcock, MBA, FACMPE, CPC 1. Thank patients for keeping their appointments and arriving on time. 2. Do not celebrate when patients don t show up. 3. Engage providers to explain the reason and timing of the next appointment to the patient. 4. Address patients fears and anxieties about their treatment proactively. 5. Calculate your no-show rate today and set a goal to improve it. Monitor your progress, and display your results in a colorful graphical format (e.g., a bar graph) in the staff break room (or another area that is well travelled by physicians, advanced practice providers and employees). 6. Educate patients who have chronic conditions that their status and medications need to be monitored with regular office appointments, even if they feel fine. 7. Develop a relationship with a patient by performing pre-appointment screening (e.g., reviewing history and films or coming in to complete the registration paperwork), which requires an investment of time on the patients part and engages them in the relationship with you. 8. Hold a team conference before every clinic and prioritize a review of the schedule for today. For example, cancel patients who have been admitted to the hospital the night before. 9. Ask patients how they want to be reminded of their appointment and provide options for cell phone and home phone. 10. Deliver great service; be nice during the confirmation call. 11. Try different times during the day determine what time works best to reach your patients. 12. Seek written permission to email appointment confirmations to established patients. 13. Perform automated telephone appointment confirmation calls using appropriate technology. 14. Document disconnected phone numbers in the practice management system. MGMA Pre-Conference Program Mastering Patient Flow Woodcock & Associates 2015 Page 10

15. Don t remind ; confirm! 16. Post no-show rates for patients to see, accompanying by language regarding the impact of no-shows at the practice. This community service message may sway some patients. 17. Make the confirmation call at least 36 business hours prior to the appointment (e.g., call on Thursday afternoon for a Monday morning appointment). 18. Ease patients ability to notify you of a cancellation by offering 24/7 cancellation line with voicemail or email, or via your portal. 19. Develop a protocol for how cancelled appointments will be rescheduled for other patients. 20. Rebook the cancelled slots with emergent patient appointments for the day. This strategy requires constant communication between the scheduling and phone triage teams. 21. Establish a waitlist of patients who want earlier appointments for rescheduling. Call it a priority list. (Don t forget to cancel the patient s original appointment when you take them off of the priority list.) 22. Provide information via your phones, portal and website about transportation, location and travel advisories. 23. Communicate the importance of being a good neighbor. 24. Document history of patients no-shows; and identify chronic no-show-er or CNS in your practice management system alert messaging. Add a number at the end CNS1, for example to indicate the number of offenses. 25. Do not offer prime appointments to patients with a history of no-shows. 26. Charge patients who don t show. See memo from CMS regarding charging Medicare beneficiaries: http://www.cms.hhs.gov/mlnmattersarticles/downloads/mm5613.pdf. 27. Take a credit card number to reserve the slot and charge patients if they don t show up. (Please seek legal advice before implementing.) 28. Do not bump patients; they will bump you. 29. Contact patients who miss appointments and rebook them promptly. 30. Engage the patient in the relationship with the practice by making statements such as: Dr. Jones was very disappointed that you didn t show up for your appointment, I ll let Dr. Jones know that you wish to reschedule. When shall I tell him that you would like to reschedule? 31. Send correspondence about no-shows directly from the physician. MGMA Pre-Conference Program Mastering Patient Flow Woodcock & Associates 2015 Page 11

32. Target manual or warm confirmations (phone calls or emails) to patients who are pre-disposed not to show for their appointment. Patients pre-disposed not to show are those with a history of more than two no-shows, Medicaid and uninsured patients, patients scheduled for diagnostic procedures, patients who were previously bumped, and patients who were scheduled more than 60 days in advance. 33. Confirm that you have cancelled previously scheduled appointments in the practice management system when a patient calls for an acute appointment request. 34. Offer patients who have more than two no-shows stand-by appointments only. 35. Develop a scheduling template for the no-show doctor. Book patients who have a history of noshows on this template. If they do show up, rotate responsibility for seeing patients among the physicians. The no-show template will mean that these patients won t take slots away from patients who do show up! 36. Ask patients what date and time work best for them. Avoid scheduling slots based on strict internal availability first caller gets the 8:00 a.m. slot, second the 8:30, third the 9:00 a.m., etc. Instead, ask the patient, When would you like to come in? 37. For specialty practices, avoid scheduling exclusively with the referring physician s office, particularly if the patient isn t present. At minimum, contact those patients who have been scheduled by their referring physician s office directly to confirm the time and date. 38. Dismiss, terminate or excuse patients who are chronic no-shows. (Discuss the strategy and logistics with your malpractice carrier, paying careful attention to the discussion of the abandonment of care.) 39. If you can t or don t want to terminate patients who chronically don t show, use wave scheduling. Schedule a bolus of patients at the top of each hour, and then a few more during the second quarter. For example, if you see five patients an hour, schedule six at 9:00 a.m., and two more at 9:15. Even if three don t show and a couple are late, you aren t wasting the provider s time. And, no patient waits more than 45 minutes to be seen (which is typically better than average wait times at practices where patients are chronically late or don t show at all). 40. Text patients regarding their visits two hours prior to the appointment time. 41. Require the nurse or medical assistant to confirm his or her patients; packing your own parachute engages employees in the process. 42. Interview patients who have failed to present for their appointments ask the following questions: (1) can you tell me why you missed your appointment with Dr. Smith?; (2) is there anything that we can do to help you keep your next appointment with Dr. Smith? Document your answers, and look for patterns. 43. Proactively doublebook appointment slots with patients who have disconnected numbers, as determined during the confirmation call. MGMA Pre-Conference Program Mastering Patient Flow Woodcock & Associates 2015 Page 12

Articles of interest: Reducing the Rate of "No-Show" Appointments Isn't Easy, but It Can Be Done, by Debra C. Cascardo, Medscape, 2005. http://www.medscape.com/viewarticle/500543 Some physicians charge deposits to curb no-shows, by Karen Caffarini, Practice Management, 2008. http://www.ama-assn.org/amednews/2008/06/02/bica0602.htm Why We Don't Come: Patient Perceptions of No-Shows, by Naomi L. Lacy, Ph.D., et al, Annals of Family Medicine, November/December 2004. http://www.annfammed.org/cgi/content/full/2/6/541 Research Reveals Reasons for Underlying No-shows, by Stacey Butterfield, ACP Observer, February 2009. http://www.acpinternist.org/archives/2009/02/no-shows.htm Reducing No-Shows: Q&A, by Mark Murray, MD, Family Practice Management, 2007. http://www.aafp.org/fpm/2007/0700/p50.html#fpm20070700p50-sa1 Managing the Habitual No-Show Patient, by Tito Izard, MD, Family Practice Management, February 2005 http://www.aafp.org/fpm/20050200/65mana.html Missed Appointment Rates in Primary Care: The Importance of Site of Care, by Karen E. Lasser, MPH., Ira L Mintzer, MD, Astrid Lamber, MA, Howard Cabral, PHD, MPH, David H. Bor, MD, Journal of Health Care for the Poor and Underserved 16 (2005): 475-486. http://muse.jhu.edu/journals/journal_of_health_care_for_the_poor_and_underserved/summary/v016/16.3la sser.html (Links cited active as of January 1, 2015.) MGMA Pre-Conference Program Mastering Patient Flow Woodcock & Associates 2015 Page 13