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Reimbursement Rates: Don’t Settle for Less

As with anything in the healthcare industry, reimbursement rates are constantly in flux. New providers are often caught between the urgency of signing contracts in order to expand their patient base and the time it takes to negotiate fees(1) that accurately reflect their experience and talent.

Lack of experience can definitely be a liability when it comes to negotiating power. Results are what providers need to prove their value to insurance networks. However, providers can’t get results without being part of a network. Lacking results, a provider’s next best asset is data. Do some homework on your available network options, also taking into consideration providers in both similar and parallel specialties. A strong medical network works just as a strong social network does: it’s who/what you know and who/what they know.

Reimbursement rates are influenced by more than a single physician’s skill. The entire office staff is a reflection of what the physician is worth, including any advance practice providers (APPs), such as PAs and APRNs(3), that support the registered physician. The office’s reputation, clinical quality, professionalism, and patient satisfaction are all measurable components that can help you make an argument for increasing your reimbursement rates every time your contract is up for renegotiation. Keep in mind that insurance companies have their own competition to ward off, and every provider that they can depend on in their provider counts is an asset in their marketing arsenal too.

Our partner, SE Healthcare, has published an insightful piece, titled “Positioning Your Practice to Negotiate the Reimbursement You Deserve from Payers.(2)” This ebook explains strategies to uncover missed opportunities and grow your revenue by maximizing reimbursement rates.

Contact us(4) today so you can take advantage of the benefits of your CARE membership to utilize the expertise of our partner, SE Healthcare. They will help you assess your current reimbursement rates and formulate a strategy to maximize your current reimbursement contracts.

Footnotes

  • https://blog.evisit.com/how-to-negotiate-higher-physician-reimbursement-rates
  • https://www.sehealthcarequalityconsulting.com/download-ebook-positioning-your-practice-to-negotiate-the-reimbursement-you-deserve-from-payers/
  • https://www.physicianspractice.com/article/pas-deserve-direct-reimbursement-their-services
  • https://care-ins.com/contact/

The Fine Line Between Supervision and Accountability

In an earlier blog, we discussed the Swiss cheese model as it relates to risk management in healthcare. Today’s article takes a deeper dive into the element of supervision in that model, especially as it relates to Advanced Practice Providers (APPs). These APPs are generally defined(1) as professionals with advanced training, such as Advanced Practice Registered Nurses (APRNs) and Physician Assistants (PAs). A practice itself might employ APPs or managing physicians may simply have supervisory responsibilities due to contractual arrangements directly with APPs or with facilities that use APPs. In either case, APPs are able to practice independently of physicians(2).

As this video explains, APPs are essential to professional practices in that they assist with provider workload and help keep costs down. Any office that is inundated enough to outsource some of its workload to APPs runs the risk of miscommunication, inadequate care, adverse events, and subsequent litigation. This resulting litigation could potentially involve both the supervising physician and the APP. That is why it is immensely important to outline the scope of the APP’s responsibilities, taking in to account their experience and ability to make judgement calls in the absence of the supervising provider.

The RiskFit helpline, managed by OmniSure, serves as a vital resource to CARE Professional Liability Association members. The professionals that operate this helpline can answer questions about the following:

  • Developing a collaborative provider/APP agreement
  • State-specific laws regarding APP scope of responsibilities
  • Hiring protocols
  • Proper risk reduction audit procedures
  • Capturing patient satisfaction metrics

All of these aspects of APP employment need to be carefully planned and documented to avoid potential litigation issues. The partnership between CARE and OmniSure puts a wealth of expertise at your fingertips to help you fill the holes in your risk management plan so that it does not turn into a block of Swiss cheese.

Contact us today if you have questions about whether your plan provides coverage for the APPs in your practice. Laws vary based on the state where you practice(2), and are constantly changing. Put our expertise to work for you in designing a coverage plan that perfectly suits your business.

Footnotes

  1. https://www.forbes.com/sites/realspin/2017/03/16/advanced-practice-providers-are-key-to-americas-healthcare-future/#2c8596759985
  2. https://www.studergroup.com/resources/articles-and-industry-updates/insights/august-2016/optimizing-the-value-of-advanced-practice-provider
  3. https://www.healthleadersmedia.com/clinical-care/aprn-and-pa-scope-practice-rules-draw-fire

Risks of an AMA Discharge

The hospital term “AMA” usually refers to when a patient decides to leave the hospital and the care of the attending providers against their medical advice. The AMA designation is used so that future healthcare providers are aware of how the patient/provider relationship came to an end while the patient was hospitalized. This serves to legally shield the attending doctor and hospital from liability if a patient gets ill or dies as a result of the discharge(1).

Patients most often opt for an AMA discharge for the following reasons:

  • Cost
  • Lack of insurance
  • Disagreements over standard of care
  • Errors or mistakes in administering care
  • Previous bad experiences
  • Fear of contagion
  • Wait times are too long
  • Personal reasons

Patients who discharge with the AMA designation definitely pose a litigation risk(2). Without proper treatment and monitoring, these patients are left to make major medical decisions without the advice of a professional. And further, if a patient is in the hospital in the first place, it is likely that they cannot properly treat themselves at home for the same illness/injury. Should the patient’s case come to litigation, the outcome will hinge on what was said, done, and documented when the patient left the hospital, especially the conversation about the AMA designation(3).

Prevention is key when it comes to managing whether a patient even considers an AMA discharge in the first place. The best course of action for a hospital or provider is to diffuse any potential situations before they escalate into an AMA discharge request(4). This is best accomplished by utilizing patient advocates to mediate between the patient’s concerns and the hospital’s directives. This method ensures that both parties are heard and understood by an objective source. Plus, the likelihood of achieving a mutually agreed upon plan of care (and hence, the quality of the care itself) increases when all parties’ concerns are addressed.

Contact us today to determine if your liability coverage is sufficient if your practice incurs an AMA-related lawsuit.

Footnotes

  1. verywellhealth.com
  2. the-hospitalist.org
  3. thesullivangroup.com
  4. today.mims.com

Partner Spotlight: Digital Surgery’s “Touch Surgery” Platform Receives Centre Accreditation

One of our professional partners, Digital Surgery, has great news to share: its Touch Surgery platform has received Centre accreditation to award CPD points by the Royal College of Surgeons of England (RCS). This is the first time that the RCS has offered Centre accreditation to a mobile-based simulation platform in its 500-year history. (For detailed information, please see the original article, posted on Digital Surgery’s website.) (1)

With this accreditation, surgeons can now gain CPD points through the Touch Surgery mobile platform. CPD points are awarded for specific measures, such as cognitive rehearsal and case reflection. Digital Surgery is aiming to obtain CME accreditation soon in the US as well.

What does this mean for CARE clients? Like many of us in the healthcare industry, Digital Surgery wants to improve the delivery of healthcare across the globe. The tools and training provided by Digital Surgery, coupled with the coverage and expertise of CARE Professional Liability Association, ensure that our clients have the proper foundational elements to run a successful practice. This kind of support takes the weight of apprehension (of both training and risk management) off your shoulders so that you can focus on what you do best. 

All successful partnerships (2) have a few things in common. The most important element is to ensure that their customers realize the two-fold benefits of that partnership. Digital Surgery’s mission is to improve surgical performance using technology to provide safe and accessible training. This type of training translates into safer, better outcomes. Successful procedures increase provider confidence, in turn increasing patient satisfaction (3). All three of these elements in turn mitigate risk and reduce litigation possibilities.

Another advantage of membership with both CARE and Digital Surgery is having a strong network of resources at your disposal. This knowledge exchange (4) grows exponentially as members exchange ideas, solutions, and best practices.

Contact us today for more information about our partnership and the benefits that CARE policyholders have with Digital Surgery.

Footnotes

  • https://digitalsurgery.com/2019/10/03/finally-software-eats-surgical-video-storage-and-management-2/
  • https://blog.hubspot.com/marketing/best-cobranding-partnerships
  • https://blog.sprucehealth.com/five-evidence-based-ways-increase-patient-satisfaction/
  • https://bloomfire.com/blog/522359-5-ways-to-encourage-knowledge-sharing-within-your-organization/

CARE partners with SE Healthcare

At CARE Professional Liability Association, we partner with companies that not only help our members, but also understand the healthcare industry and its specific challenges. Our latest partnership with

SE Healthcare provides additional resources to help our members improve operational performance.

SE Healthcare’s Physician Empowerment™ Suite, a set of high-impact data analytics tools, leverages key performance metrics to help practices increase revenue. This is accomplished through enhanced reimbursement negotiations, coupled with an improved industry reputation, once providers have the power of analytics backing their performance.

Other tools provided by SE Healthcare include:

  • Patient Experience Platform
  • Five-Star Reputation Tool
  • Clinical Effectiveness Platform
  • Long-Term Care Assessment
  • Reimbursement Effectiveness™ Platform
  • Physician Burnout Prevention Program
  • Performance Improvement Tools

Both CARE and SE Healthcare understand the intricacies and inherent risks involved for healthcare providers because both companies were built by people with intimate knowledge of the industry. This not only includes physicians, but also top minds from the legal and compliance fields, as well as professionals who continue to shape the future of healthcare. You get the benefits that the years of experience this collaboration creates, including what we have learned from past mistakes, and best practices we’ve developed.

In future partnership blog articles, we’ll discuss the multitude of benefits that providers can gain from SE Healthcare’s analytics tools, including:

  • Getting fair reimbursements from payers
  • Making your practice more attractive to networks
  • Improving your reputation and transparency to convert website visitors into new patients
  • Retaining current patients by creating a better patient experience
  • Enhancing the workplace culture for physicians
  • Enhancing patient engagement and satisfaction
  • Addressing critical issues like physician burnout, quality, and safety

Contact us today for more information about how this CARE/SE Healthcare alliance can benefit your practice.

Medical Records Maintenance: Making an Asset out of a Liability

While Rolf Smith (see quote in the text box on the right) was not an expert on medical records, his wise words do apply to the healthcare industry. Detailed record keeping, including both initial intake and maintenance, are paramount to risk mitigation for healthcare practitioners.

Medical records ensure continuity of care between providers (2). They also act as a means of communication between providers and members. Patient records cover everything from preventive care to treatment, as well as standards and expectations for delivery of care. And while excellent record keeping should be evidence enough that your healthcare practice is doing its best to avoid litigation, a solid audit plan is also imperative to ensure that record maintenance is done properly. Your firm’s records, and your actual recordkeeping practices, will be scrutinized should you ever be sued for malpractice (3). Even outside of a malpractice lawsuit, data breaches are a growing concern when so much PHI (protected health information) is collected by a single source. And data breaches can turn into class action litigations.

While the future lies in EMRs/EHRs (electronic medical records/electronic health records) (4), that does not mean that manual (paper) records are obsolete. And they definitely shouldn’t be discarded. All data that is collected, no matter the format, is subject to privacy laws, and therefore can easily turn into a potential liability.

Accuracy is paramount in recordkeeping (5). Every individual encounter should create a snapshot that stands alone from prior visits (and prior diagnoses). The challenge lies in maintaining this separateness while also creating a ‘big picture’ view of the patient, merging both history and current issues.

Contact us today if you would like to learn more about auditing your recordkeeping system. We know what issues to look for and can uncover them before they become a risk to your practice.

Footnotes

Swiss Cheese and Malpractice Litigation

What do Swiss cheese and malpractice litigation have in common? Neither exist without the holes in them. In a clinical care setting, as depicted by the image to the right, the probability for error increases as your gaps in care increase. The more ‘holes’ you have, the better chances of those holes aligning, making way for adverse events that could result in a malpractice suit.

Areas of particular concern (1) include:

  • Consent
  • Supervision
  • Patient history and physical
  • Documentation
  • Provider collaboration
  • Pain management
  • Staff training
  • Communication

We’ll explore each of these clinical elements in more depth in future blogs.

Generally speaking, errors and adverse events are often a combination of human, electronic, and technical errors. The goal shouldn’t be to assign blame, but rather to mitigate the issues (2) so that they don’t happen in the first place, or in the very least, so that they don’t recur. Usually, this is best accomplished by recognizing and addressing systems issues. What systemic changes can be made to better support the clinician at the point of care and to prevent similar mistakes or adverse outcomes? No one truly benefits from a malpractice suit, not even the plaintiff if they win. They incurred some sort of loss to become a plaintiff in the first place, and would surely rather choose not to, if they could do it all over again.

Not all adverse events result in death, disability, or other major/chronic issues. However, the goal of risk mitigation is to reduce the overall trend of adverse events in total. Even issues deemed to be minor or insignificant (3).

The Swiss cheese model (4) is not germane to the healthcare industry. It can be applied to any industry where singular issues, when compounded with other seemingly singular issues, create a sum (adverse event) greater than their parts. Picture it as slicing a block of Swiss cheese, and laying the slices atop each other. It’s practically inevitable – something will eventually slip through every slice.

Be assured that the partnership between CARE and OmniSure provides you with a plethora of knowledge, experience, and expertise to help your practice identify potential holes, if you will, in your risk management plan. Contact us today for more information.

References

  • https://omnisure.wistia.com/medias/51g19jcybx
  • https://mckinneylaw.iu.edu/ihlr/pdf/vol16p21.pdf
  • http://files.constantcontact.com/68ac21ab401/4cb9c5c5-ba86-4ba8-ae9c-041f1b78f673.pdf
  • https://www.youtube.com/watch?v=JRCMxfBULB4

The Benefits of a Solid Risk Management Plan

It’s imperative to be proactive in healthcare. Not only in caring for your patients and staff, but also to stay ahead of any inherent risks to your business. A solid risk management plan reduces your liability in the first place, and acts to minimize litigation (should it happen). This protects not only your financial standing and assets, but also your firm’s market share, accreditation, reimbursement levels, brand value, and community standing.

One major benefit of instituting a risk management plan is that it improves patient outcomes too. A heightened awareness of processes, especially documentation, instills a sense of professionalism across your entire team, including both healthcare workers and office staff. This in turn reduces errors, which improves patient satisfaction and strengthens your reputation in the community. It also increases your bottom line by reducing expenses.

Risk management, at a basic level, is the responsibility of everyone employed at your business. But since everyone already has a full plate of responsibilities, their role is usually more reactive (to specific events) than proactive (looking at the big picture). You also need an expert on your team. Depending on the size of your practice, it might make sense to hire a risk manager. However, more often than not, your budget simply doesn’t have the room to take on a full-time salaried position. Partnering with a third-party risk management firm might be the perfect compromise.

Speaking of third parties, a level of risk is both assumed and mitigated whenever you contract with third parties. Not just for malpractice management, but for any services. Consider basics, such as records management and document shredding services. These may seem like simple tasks, but everything related to healthcare records needs to be considered under the watchful umbrella of compliance. Data sharing, storage, and destruction all fall under that umbrella.

Contact us today if you have questions about risk management and outsourcing those types of responsibilities. We would love to put our collective experience to work for you.