Physicians Get Top Billing With EHRs

February 14, 2008

There are some unfortunate realities of today's healthcare system that work against providers, particularly smaller physician practices.

No compensation without integration

Rombach says the combination allows for better patient care and brings coding in line with the work physicians actually perform, so there’s no more guessing when it comes to coding. “We’re getting paid for what we actually do,” she says. It was hard with the old system to make sure the practice filled out all fields of the complicated HCFA-1500 claim form because there were so many disparate identifiers for patients, providers, and health plans. “Trying to make sure you had a clean claim, that was really a problem,” Rombach says. With an integrated practice management and EHR system, “You can basically see how the claim is going to be captured,” according to Rombach.

Girish Kumar Navani, president of Westborough, MA, vendor eClinicalWorks says that integration is an issue of managing one system versus having to manage two. “You save money on maintenance,” he says. “That’s the obvious one.” For a three-physician practice, eClinicalWorks charges about $3,000 more to get the entire system as opposed to just the EHR, a relatively small sum considering that an EHR alone could run $30,000 or more per physician depending on the features and services purchased.

Although the real advantages to an integrated system are related to workflow, there are also several less-obvious benefits, including ease of use for everyone in the office. For example, if a patient moves or changes phone numbers, updates made in the practice management system automatically are reflected in the EHR, so there’s no double data entry—and no chance of having conflicting information. At check-in, the doctor can see that the patient has arrived, as well as any new information provided by the patient. At check-out, the front desk can see, for example, that the physician wants the patient to return in two weeks, so it’s easy to schedule the follow-up visit and to remind the patient in advance of the next visit.

Since Block & Nation, P.A., a four-physician family practice in Winter Park, FL, added appointment reminders to its eClinicalWorks system in 2005, their no-show rate has dropped by 50%. Because the system automatically captures charges as the physician documents the encounter, the back office can get to work on sending out the bill right away. Insurance companies often need to see progress notes to justify charges. “You can open up the chart right when you’re on the claim and print it,” Navani says.

The integrated system definitely has improved revenue and cash flow for Family Physicians of Madison County. “My claims go out clean,” Rombach says, “and I have an exceptional A/R.” Only 29% of total accounts receivable are more than 30 days old, and of those patients with insurance, only 15% billed charges are considered past due. Some payers have timeliness-of-claim rules, essentially setting a statute of limitations on claims. If something turns up months after the fact, too bad. “They have people who get paid to throw claims in the trash,” says Rombach. “It’s important for me to know that I have a patient’s proper insurance information.”

Better systems equal better billing and better care

More significantly, thanks to their integrated system, physicians at Family Physicians of Madison County are spending more time on patient care, and the medical assistants are no longer hunting down lab results. “I need fewer staff to actually take care of the patient,” Rombach says. “It works toward well-rounded patient care.”

“Those are things that are costly to practices,” adds Jennifer Sirkawa, financial product marketing manager for Sage Software in Tampa, FL. The experience has been similar for Block & Nation since that practice migrated from an old practice management system and paper records three years ago to an integrated eClinicalWorks system. “Having the combination software definitely is better,” says one of the doctors, Bradley Block, MD. Previously, one staffer spent 75% of her time simply inputting data for superbills. “Vaccines and other ancillary charges were occasionally falling through the cracks,” Block reports.

A glance through a random stack of paper charts convinced Block that he and his partners were losing at least $400 per physician per month in unbilled ancillary services, which works out to $14,400 annually for the three physicians who were there prior to the EHR. Add to this fact that the part-time billing person was costing the practice close to $15,000 a year to handle mostly redundant tasks, and all of a sudden the EHR doesn’t seem so expensive. “That goes a

long way toward paying for the system,” Block says.

The doctors perform minor procedures in the office, such as skin biopsies. In looking over a paper chart that happened to be out on a desk, Block noticed that the practice never billed for a biopsy because someone pulled the abnormal result from the chart to call the patient and the record of the biopsy never made it to the superbill. By the time he discovered this, it was too late to submit a claim, so Block and his partners had to eat the cost. “Now, when I click on my EKG

or urinalysis, when I’m done with the visit, all the billing is ready,” Block says. “There’s no delay inputting the data… and we’re not losing charges.”

The office is operating much more efficiently, too. Within eight months of the eClinicalWorks installation, the practice reduced its labor costs by $5,500 a month by shrinking its front-office staff from four to three and cutting back to four medical assistants from the previous five. The biller who was wasting time on data entry was reassigned to more productive work. Multiple users can view the same information simultaneously, so the referral specialist doesn’t have to wait for the chart to be told to prepare a referral letter and make an appointment. In the first 15 months with the integrated software, Block & Nation saved $7,000 on office supplies, and the reduction in paper use also has cut copying and mailing expenses, Block reports. Records go out on CDs rather than in thick envelopes.

Accounts receivable on insurance-paid claims older than 90 days rarely tops $1,000, since the practice doesn’t have to wait for staff to enter charges manually or hold bills until there are enough from each payer to send out “batch” claims. The old practice management software didn’t even produce HIPAA-compliant transactions, so there were additional delays and expenses to send the claims through a clearinghouse for conversion. Now, the practice collects insurance

reimbursements in half the time it previously did.

EHRs let you go with the flow

Above all, with integrated EHR systems, workflow simply is smoother, making for safer care and a better experience for patients, physicians, and staffers alike. “It’s quieter in the office,” Block reports. “Now we don’t hear ‘chart up’ every two minutes,” he says. “I can track data faster on the computer,” Block notes. “Here, on one screen, I’ve got three years worth of data.” And that record will only get richer with time. With one particular patient, he clicked on the page showing the man’s vitals and noticed that the patient’s weight had been trending up for the previous three years. That basic historical information in hand, Block started asking questions and was able to determine in a matter of minutes that the 40-something man had been suffering from erectile dysfunction.

Without easy access to historical information, it might have been impossible to get the patient to talk about such a sensitive topic in the short amount of time the doctor had with him. For patients with chronic conditions like diabetes or an enlarged prostate, being able to view trends in lab results is invaluable. Intergy, the

Sage product, includes a health management module to help the physicians with disease management, reminding doctors, for example, to schedule regular eye and foot exams for diabetics. Physicians can set the frequency of reminders based on guidelines, and the practice can document if a patient declined the test and

include a reason. Patients might skip the eye exam because their insurance excludes vision care.

Version 4 of Intergy, set for release later this winter, will improve upon this, according to Sirkawa. “Health management will be tied to practice management,”

she says. The computer will remind the front office if a patient is overdue for a check-up, physical, or test, leading to more revenue and better care without burdening the physicians.

Rombach, the Illinois practice manager, knows that time is money, and having the problem list visible to the physician right away saves both. “When the patient is in the room, those are dollars ticking away,” Rombach says.

It also is a matter of patient safety for Family Physicians of Madison County, since there is no draw station on site; patients have to go to nearby Quest Diagnostics and Laboratory Corporation of America facilities for most testing. Fortunately, the practice’s EHR is connected to both companies, so the lab gets the diagnosis code immediately and is ready whenever the patient arrives, and results get electronically reported back to the practice and into the patient’s record. This way, the practice knows the patient has actually gone to the lab for the test—and has the information to act upon.

Th ere are some things that are not fully electronic, however. When Block & Nation switched to the integrated system in 2004, direct ePrescribing into pharmacy information systems was not widely available in central Florida—and federal law still prohibits prescriptions for narcotics and other controlled substances without a paper trail—so the practice opted for an electronic fax system. Even that smoothed the workflow. “We used to have lines of nurses at the fax machines,”

Block says. Now, all faxes come into and go out of a computer, and the fax system is linked to the e-mail network embedded in the EHR, so it’s easy to rout messages to the proper people.

Block says he frequently sends messages to nurses to request patient-specific information such as test results from local hospitals. “A couple of minutes later, I get a knock on my door to know the report is in,” he says. Sometimes there is no knock on the door, because the system includes a virtual private network (VPN) for secure, remote access. “I can do work from home if I want to,” Block says. He no longer stays at the office until 9:30pm some nights to go over paper files, and he can pull up patient information from his home computer when he’s on call at Winter Park Memorial Hospital or at Florida Hospital in nearby Orlando.

This winter, Block’s practice may add a secure portal to what right now is a rudimentary website, potentially giving patients the ability to request refills, schedule routine physicals, and view test results over the Internet. Reimbursable Web visits for existing patients may be a component of that. Block says patients also will be able to update personal information such as addresses, phone numbers, and insurance data. An add-on program called Instant Medical History from Columbia, SC-based Primetime Medical Software will give patients the option of entering medication lists, allergies, and symptoms from home rather than filling out the

dreaded clipboard each time they come to the office.

Patients benefit from the convenience factor, while office staff and clinicians can be sure they have the most current information for safety’s sake. “I get paged all day long,” Block says. He expects the portal to reduce the number of times nurses have to ask him to sign off on results before calling patients, potentially reducing overtime expenses and taking some of the stress off weary nurses. “We get better flow and better patient satisfaction.”

Neil Versel is a freelance healthcare journalist.

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