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  • 2016-09-September

Success Is Never Perfect

5Minutes
By Paul Martin, PT, MPT, CBI, M&AMI

When I was a high school and college football player, I created elaborate plans for improved strength, speed, power, and ultimately improved sport performance. I worked hard implementing those plans by training almost every day. The actual workouts were never perfect, and the results were not always exactly as planned and graphed—but that was reality. The end result was a senior year in college where our team (the 1985 Gettysburg Bullets) and I displayed performance beyond our wildest dreams!

Plans and Reality

This reality also relates to business. In our experience, change in an organization does not always go as specifically outlined in a sterile plan as there are external factors out of our control that will impact execution. Success comes from the ability to know that you will get “off course” but can quickly redesign to get back “on course.”

Seek Success

Advice and strategy are lofty while action and execution are gritty. Seek success, not perfection. Accept that virtually nothing will be exactly as intended, but it will be better than before. Make midcourse corrections. Don’t be afraid to get your uniform dirty. No one ever won a football game with the crispest, cleanest, or brightest uniform.

Even in Adversity

We have worked with companies that have shown the discipline to work toward goals and work through adversity, and while they may be muddied, they showed million dollar–plus changes in their value. You’re next. Create a plan and follow your dreams.

paul_martin Paul Martin, PT, MPT, CBI, M&AMI, president of Martin Healthcare Advisors, is a nationally recognized expert on health care business development and succession planning. As a consultant, mentor, and speaker, Paul assists business owners with building value in their companies. He has authored The Ultimate Success Guide, numerous industry articles, and weekly Friday Morning Moments. He can be reached at pmartin@martinhealthcareadvisors.com.

Connie Ziccarelli, COO and principal

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Connie Ziccarelli owns Rehab Management Solutions located in Mt. Pleasant, Wisconsin, and has been in business since 1995. The business provides practice management solutions and has outpatient physical therapy clinic locations in several states with over 100 employees.

What movie has inspired you professionally/where is your most memorable vacation spot?

I have a real passion for movies, especially those with historical content and how those events shaped where our country is today. But I have a real soft spot for Legally Blonde. My daughter was in her formative years when that movie became popular, and it really spoke to me about the internal fortitude to achieve what you want to achieve, even if there are naysayers all around you. To me it is a true championship-spirit movie.

I have been fortunate to be able to travel quite extensively both professionally and personally. I enjoy learning about all cultures and customs (even just the differences in the regions of the United States). I want to return to the South of France—Monaco and Nice. Not only is it a beautiful area, but also the people were incredibly hospitable and proud to share their communities and gifts.

What do you like most/least about your job/what is the most important lesson you have learned?

I have been fortunate to work with physical therapists who are absolutely ardent about their profession and the patients they serve. The first time I walked into the physical therapy clinic I met two dynamic physical therapists who are experts in their field and passionate about entrepreneurial outpatient clinics. I knew that my business background would bring to life the philosophy that excellent business practices should parallel excellent medicine. The financial foundation I build with patients often lasts longer than the plan of care for therapy. Taking away the financial worry can help therapy treatments work more successfully for the patient, creating a customer for life. This marriage of practice management and clinical management led me on a journey that has exceeded anything I could have imagined. Serving on various committees with the American Physical Therapy Association (APTA) and Private Practice Section (PPS) and becoming the chair of the Administrators Council speaks volumes about the recognition and value of what I live each and every day.

One of the most important lessons I have learned through the years is to stay in front of any problem. Identify it, acknowledge it, discuss it, and find solutions to remedy it. If a problem grows legs, it can be a silent killer of morale and ultimately affect the bottom line of the business. Patients come to our clinics to return to a higher level of function and performance. My practice management team strives to take away the stress during their plan of care as it relates to financial worries; if we remember that each and every day we are all here to serve our patients, we will grow as individuals and as a company.

How would you describe your management style/how do you measure success?

My management style tends to be nurturing yet empowering. Keeping up with the latest trends and technology is key in our ever-evolving discipline of physical therapy. I take advantage of continuing education where my entire team can sit alongside me, ask questions, and learn. I feel this is the best way to demonstrate leading by example. In this way, I am fostering a sense of “worthwhileness” and a natural progression of pride in their work. I see success every day as I witness the extra mile my team members are willing to go for patients and the ownership they take of their positions. Transparency and information sharing has also led to a stronger sense of team. When my team is happy . . . I see success!

What have been your best learning experiences throughout your professional journey?

Two examples readily come to mind. One was the creation, early on, of a dedicated, aggressive approach to managed care and credentialing. I placed a lot of emphasis on building relationships with payer representatives including traveling for face-to-face meetings. Growing and maintaining healthy and strong relations has paid off in big dividends as we explain physical therapy to the payer community. Another learning experience that helped me reach way beyond my comfort zone was in 1995, when I became an active member of the APTA/PPS. Membership led me to various positions including member of the Payer Relations Committee, secretary, vice chair, and two terms on the PPS Annual Conference Program Committee. I am honored to currently be serving another three-year term as chairperson of the Administrators Council.

What are you optimistic about for the future of private practice?

PPS is an amazing ready-resource and network of support for like-minded PTs to benefit from the “been there, done that” experiences. I am optimistic in regard to the strengthening of the involvement, especially through PPS, in the legislative arena. No one knows our issues better than we do. It is incumbent on us to make our elected officials aware and educated on our issues and the impact that their decisions inflict on their constituents/our patients. Vigilance is a key word as our marketplace gets tighter and mergers could make us as outdated as the floppy disc. I am also optimistic about our future as we become a nation desiring a fit lifestyle and more sophistication with aging and maintaining performance and movement. More emphasis is being placed on wellness, and we have always been the champions of living well! We continue to be a nation that will always have room for the entrepreneurial spirit.

What are your goals for the next year?

We are looking at ways to meet needs in our communities in the areas of after-school sports/athletic performance, providing services as industrial rehab specialists, developing and implementing postdischarge wellness programs and truly listening to our patients to learn what other voids are out there for us to fill. Combining these cash-based programs with maintaining strong third-party payer relations should set us up for continued success. And of course we will maintain our goal in three areas: to look for low-cost, revenue-producing opportunities, to service our communities better than ever, and to have a little fun along the way!

What is your life motto?

I always tell my team to listen with an intelligence of heart and mind. Also . . . Shoot for the moon! At the very least, you’ll land on a star!

The Value of Feedback

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Centers for Medicare & Medicaid Services seeks to implement merit-based incentive payment system.

By Alpha Lillstrom Cheng, JD, MA
September 9, 2016

The Private Practice Section’s (PPS) federal policy efforts focus on advocating for and supporting the passage of bills that impact private practice physical therapy. However, the passage of legislation is not the end of the road for policy development. After a bill is signed into law by the President, the intent and direction of the law needs to be determined and implemented by an agency in the executive branch. The Department of Health and Human Services (HHS) and its Centers for Medicare & Medicaid Services (CMS) are tasked with drafting, proposing, and finalizing regulations that put meat on the bones of health care laws. Through a process known as “notice of proposed rulemaking” (NPRM), CMS releases draft regulations to the public and requests feedback and comments from stakeholders. Based on the summary, analysis, and draft comments developed by your lobbying team, PPS routinely weighs in on these proposals on behalf of the membership.

Scheduling the Next Visit

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Ensure your patients follow through with treatment with one simple task.

By Brian J. Gallagher, PT

Just about two years ago, I realized that the basic metrics being used when benchmarking a performance in a physical therapy outpatient setting were drastically changing. Prior to that an outpatient orthopedic physical therapy practice would be able to sustain its weekly visits so long as 10 percent of those weekly visits were new patient visits. However, because of the changes in our health care system we must now have 12 percent to 15 percent of our weekly visits as new patient visits. In addition to that, there is an increased financial responsibility being placed on our patients through higher copays and deductibles, thus resulting in fewer visits per week causing the potential for greater noncompliance with their prescribed plan of care. Compounding that with flat or decreasing reimbursement per visit, today’s practice owners must be innovative in their approach to their administrative operations. Because, let’s face it, there is only so much one can do on the clinical side of the practice to reduce operating expenses and increase efficiency without negatively affecting your patient care experience.

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So, when owners are looking to increase patient visits, they must look at their clinical delivery system. Simply put, if your physical therapists are not 85 percent efficient according to their schedule, maximizing their productivity per visit, and getting raving feedback in writing from both their patient and your referral sources, then you have found a good place to start. Assuming that you have successfully implemented a management-by-statistics system of measuring your staff’s productivity so that you know each week which of your clinicians are hitting these targets, then you can turn your attention toward the administrative operating systems.

A solution that works in virtually every office where it has been implemented is one that ties together the administrative staff and the clinical staff so that a cooperative effort is being launched to maximize clinical efficiency and patient care compliance with almost no additional cost to the practice. How many times have we seen a patient be prescribed three times a week or two times a week by their therapist only to result in the patient at the front desk negotiating a one time a week schedule instead? They will cite either time or money or scheduling as their justification for not wanting to follow through with what the therapist had just instructed them to do for their physical therapy scheduling. The solution is for the therapist to write out a “physical therapy frequency order slip” and hand it to the patient at the end of their evaluation for them to take up to the front desk for scheduling. This action is no different than when a doctor writes an order for the patient to follow. scheduling-the-next-visit-03When the physical therapist writes an order and gives it to the patient, it increases the significance of that recommendation purely because it’s in writing and results in greater patient follow-through and compliance. This allows the patient, the front desk staff, and the therapist to be on the same page and adhere to what is the best recommended plan of care for the patient. And, if the front desk schedules out the entire plan of care at that time, patient compliance also increases.

What does your front desk actually say when scheduling the patient out following their evaluation? This is another area that can improve carryover of the plan of care. They should never ask the patient when would they like to come in but rather say, “So what days and times don’t work for you?” With this method you will save time when scheduling and get greater patient compliance with their schedule. Try it. You’ll be surprised how such a small simple change can have such a large effect.

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Brian J. Gallagher, PT, is the chief executive officer of MEG Business Management, LLC, in Severna Park, Maryland. With more than 24 years’ experience in the field of rehabilitation and 19 years in business, he specializes in physical therapy practice management and executive coaching nationwide. He can be reached at brian@megbusiness.com.

The Cycle Never Ends

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A big picture look at Revenue Cycle management and touches on the interconnected nature of the first point of patient contact through a paid claim.

By Eric Cardin, PT, MS

Revenue cycle management, a relatively mild term in the world of business jargon. It’s a simple yet important idea to look at the “management” of revenue. Physical therapy practice can be an emotionally and personally rewarding profession, but the obstacles between treatment and payment can be daunting. The term cycle implies a defined series of events or a routine that repeats itself, a cycle or pattern that is overtly and covertly tied together and the nature of which holds the key to successful management.

Visits x Charges x Accounts Receivable = Revenue (Income minus Expenses)
Simple, right? See a patient, charge for it, collect that money, pay the bills. Have something left over. Many businesses, including physical therapists in private practice, struggle or even fail by not digging deeper into what drives the factors in this basic equation for revenue cycle management.

Visits are revenue. No matter what metric you use, when you get to the bottom of the paper, visits drive the bus. Getting the patient in the door is an obvious first step but keeping them coming and growing the practice is the first and most important step. After all, there is no revenue cycle without revenue.

From the moment of first contact (phone intake, walk in, scheduling a neighbor for an evaluation on your phone—thank you, cloud-based electronic medical record (EMR)—while standing in line at the grocery store), the revenue cycle starts. So much of our ability to efficiently bill and collect revenue and manage cash flow is dependent on how well we collect information up front. “Clean” demographic information is the first obstacle we face in getting paid on time. Depending on the volume of your office, the ancillary staff you may or may not have, and the collection method, there are several “fail points.” Handwriting problems, typing errors, missed steps, and general lack of organization can and will delay a claim. It is very important to get the information from your client and get it into your billing/scheduling software in a quick and accurate manner. If you look at your turnaround time (time to get paid from the point you send out claim), you should be able to discern what the average is and also take note of what claims are rejected and why. Take note of the common errors and implement simple policy changes to reduce the rate of rejection. Your cash flow will thank you for it.

After you’ve efficiently and accurately collected demographic information and processed it without error, you still have some hurdles to overcome. Was there a referral in place? Was the patient authorized and/or do they have active insurance that will cover them during their entire episode of care? There are a few ways to go about this. One, you leave it to the consumer. It is their responsibility to know their coverage. Or two, you collect the necessary information at intake and you “trust, but verify.” There is usually a personal cost (doing it yourself) or actual payroll expense (paying someone to do it) in the time it takes to make sure all the referrals and authorizations are in order, but for a solo therapist with a full (30 to 40 hour) schedule of patients, for example, the effects on the bottom line are worth the up-front effort.

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Customer Service
The unifying theme in the first factor of “Visits = Revenue” is the ability to collect information. The tie that binds the components together is a positive customer service experience. A pleasant phone call or face-to-face encounter that leaves your client with the feeling that you are helping them get registered, authorized, referred, and ready for what is usually their first physical therapy experience will go a long way to establish your office as the destination of choice for physical therapy. It is wise to remember that the most important marketing opportunity you have is the patient who is already in front of you. Creating an environment that helps the client heal and doing so in a way that creates a feeling that everyone in the office is helping them on their journey will only serve to grow your patient base and your bottom line.

Payer Mix
Once you’ve seen the patient you’ve got more hurdles to jump through. What’s your payer mix, what are their coverage rules, what codes do they accept, and which ones pay well? The next factor in the equation for cycle management, “Charges,” is another important factor. Payer mix (what percentages of which insurers are paying you) should be a huge part of your due diligence prior to getting started. If you find yourself inundated with patients that have a low reimbursement rate, you might find it hard to stay in the black. Payer mix can be quite varied, and can change even from one town to the next. It is important to investigate who your patients may be, where they will come from, and who is insuring them before you decide where to practice. After you’ve made that decision, it is a good idea to routinely sample your payer mix and take note of where your bread is being buttered. Once you understand that, you can tailor your demographic collection and charge habits to maximize your revenue. As you understand payer mix, you will also find that it is important to stay on top of credentialing, continuing education (regarding coding/charges), and global changes to reimbursement. Visits x Charges = Revenue. If you have a multitherapist practice, get in the habit of sharing who pays what and what is well reimbursed and what is not. Even if they are not the practice owner, you will be surprised that they often do care that they are reimbursed appropriately. The cycle continues with or without you and your attention to detail is key. The only thing you stand to lose is money!

Accounts Receivable
Now that you’ve created a positive customer service environment and efficiently and accurately collected patient demographics while understanding insurance rules and gotten the client better without going over the allotted visits—it’s time to collect your revenue. Visits x Charges x Accounts Receivable. It is important to note that this equation we use to describe the revenue cycle uses multipliers, not addition. This is done with the intention of creating an understanding that success or failure will move exponentially. Small mistakes or small victories will carry over quickly. If you are seeing a hundred patients a week or a thousand, then that is your multiple. One mistake repeated 100 times. Or one success repeated over and over. It is all connected and all part of the revenue cycle.

Accounts Receivable (AR) is a basic component of any business that allows their “product” to be taken or used with a promise of payment. Physical therapists in private practice face the delightful challenge of having varied payment methods, contractual adjustments to our fees, and limited ability to make changes. Again, there are options. Cash-only payment at time of service sounds appealing when you delve deep into third-party reimbursement, but for those of us not ready for that option we must soldier on and get on our AR. Since we know we’ve already collected accurate demographics and used our expensive billing software to send out “clean” claims, we can just sit back and watch the bank account swell. Right? Think again. The struggle is real and the cycle waits for no one.

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Again, the tie that binds is customer service. Helping your client understand their benefit before they start physical therapy can seriously and positively affect your AR. Kindly let each patient know what their personal financial responsibility will be (copay) or could be (estimate their deductible) for their time in physical therapy and routinely remind them that their copayment, coinsurance, deductible, etc., is due, or will be due. Accept all forms of payment, remove all obstacles to “I forgot my [insert payment method here].” Create controls in the system to keep balances low and keep your consumer informed. Soft chasing them the same day in the front office is much easier and much more cost effective than bringing it up 90 to 120 days later. Start at the first point of contact with creating an understanding that you provide a service and that service has a cost. Too often we fall into the trap of the “helper/healer,” but have you ever tried to pay the utilities with good feelings?

Once the claims are out and awaiting payment, watch your rejections and Explanation of Benefits. Much of the payment process is automated and this has been to our benefit, but computers still can make errors and somewhere along the line someone is processing your claims who maybe—just maybe—isn’t having the best day and they just might let a charge slip through unpaid. If you are not managing this part of the cycle, there are plenty of ways to lose money. Pay attention to individual filing limits, coding rules, and coverage limitations. Bill your services as soon as you can, follow up as quickly as possible, and send out statements weekly (or more frequently if you can) to keep the cycle going and your cash flow strong. Bill the claim, correct the claim, rebill the claim. Keep the statements rolling.

Finally, you’ve collected demographics, charged appropriately, followed up on outstanding claims, and hopefully watched your bottom line grow. Revenue cycle management is constant. It begins with the first point of contact with every patient and ends with prompt and accurate payment. Tight controls, simple policies and procedures, and attention to detail should result in timely payment. Each practice should take a look at least quarterly at the components of the cycle. As time passes your data set grows, and you can see cause and effect and sharpen the parts of the cycle that lead to prompt, accurate payment.

Eric Cardin, PT, MS, is the executive director of South County Physical Therapy, Inc., which has six locations in western Massachusetts. He can be reached at ecardin@sc-pt.com.

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