Office Management



Office Management Final Marci Notes

Office Management Class #1 Monday, September 13, 2004

5 Major Chiropractic Personality Profiles

Looking at philosophy, science, art, and self perception

Type 1 - Referred to as chiro meds, chose the wrong profession, medical people trapped in a chiropractic college, philosophy is ridiculous and is eliminated, science is based on basic sciences, chiropractic should become part of medical profession, should all have a pre-med degree before chiropractic school or should go to medical school and then chiropractic college would be a residency, no art, perception is that the sooner chiropractic becomes part of medical profession the better off the profession will be

Type 2 - Chiropractic physicians and specialists, philosophy not real important, emphasis on basic sciences, clinical sciences deal with laboratory (UA, blood, etc.), art not as significant as group 3, art is based on physical therapy, heavy mixer approach, perception is that every chiropractor needs to be here

Type 3 - Functionalist, orthopedically oriented, clinical science, traditional manipulative technique courses, and dominant mindset in chiropractic, should adopt this model, safe place to be politically, culturally, and socially

Largest group - back doctors, musculoskeletal group - doctors of chiropractic

Type 4 - ChiropracTORS, do not forget where you come from, philosophy is very important, should be related to all classes, structuralists, non-allopathic, science based on clinical sciences (especially on chiropractic clinical sciences), art is very significant, less physical therapy, the sooner we get everyone to group 4 the better off the profession will be

Type 5 - super straights, philosophy is very important (write the text books),

eliminate basic sciences, art is very significant, most passionate about practicing chiropractic and making sure it is given to the masses (chiropractic to the world - religious about chiropractic), worship B.J. Palmer, tend to focus in on one specific area of the spine (upper cervical, sacrum, etc.)

Many times groups 1-2 are together, group 3 is separate, and groups 4-5 are together

ACA - Groups 1, 2, and many of 3

ICA - Groups 4, 5, and some of 3

National Association for Chiropractic Medicine - Group 1

Leading Causes of Death in America

Last year:

1. Heart disease

2. Cancer

3. Iatrogenesis or hospital/medical care

This year:

March 2004 - Death by Medicine - Gray Noll, Caroline Dean, Martin Feldman, etc. - Journal of Life Extension

Total number of deaths caused by conventional deaths is astounding - leading cause of death since this year - 783,936

magazine/mag2004/mar2004/awsi/death/01.html

Office Management Class #2 Friday, September 17, 2004

Practice Restraints

Those things/procedures/policies that do not allow your practice to grow

Sometimes it is things you are doing, and sometimes things that you are not doing

2 Main Constraints:

1. "Cash basis" - having a policy in your office where your patients pay cash up front for all office services - odds are against you to open up a cash practice

Personality types that can pull off a cash practice:

1. Deeply grounded in philosophy of chiropractic

2. Unbelievable ability to communicate chiropractic EFFECTIVELY

Problems with cash practice:

People today expect to use health insurance to pay for their care

Office Management Class #3 Monday, September 20, 2004

Cash Practice

Having patients submit payment as soon as services are rendered

Poor source for referrals

People cannot afford to pay up front

Credit

Accepting a patient's insurance coverage, taking it on assignment, and then wait to be reimbursed

Patients who have insurance expect to use it today

People do not have money so they use credit cards

Practice Restraints

1. Cash practice

2. Not performing a consultation, chiropractic examination, and a report of findings before you ever adjust

Should always perform a consultation, chiropractic exam, report of findings, and the first adjustment in this order

If you do the above in the correct order, patient compliance will be much higher

3. You need ironclad collection procedures and policies, especially if you are going to accept insurance

4. No prescheduling routine or policy

Should preschedule patients, especially those on condition-based care - prescheduling helps get patients in the commitment mind set

5. No sustaining care follow-up procedures

Sustaining care means what you do to a patient so that they receive chiropractic care for the rest of their life

Have to educate your patients about maintenance/preventive care

6. No practice or no self-promotion

$500/month - minimum amount to spend on marketing

7. Untrained staff

You will have to train your staff or have a practice management team train your staff

8. Office design and office layout

800-1000 square feet, starting out practice

9. HMOs, PPOs, and managed care organizations (MCOs)

Can be a restraint to be a part of a HMO or not to be a part of a HMO

10. No on-going chiropractic consultant management services

Should join a practice management consulting firm

Office Management Class #4 Wednesday, September 22, 2004

2 Types of Perspectives in the Office

1. Corporate/business perspective

2. Doctor/clinician perspective

Categories of Patients

Starts with patient's initial phone call to make an appointment to the end of their care

Categorize them according to what must be done based on the 2 office perspectives

1. Category I - personal injury/work compensation

Categorized them based on their paperwork - front desk, lawyer, work, etc. paperwork

2. Category II - major medical/health insurance

These people have some form of health insurance that covers chiropractic care and you have decided to accept their insurance

These patients want you to help them get reimbursed

3. Category III - cash

Patients, regardless of why they are coming in, are paying cash for their care

4. Category IV - Option 1 - Medicare

Should incorporate these patients into Category II

Medicare can be considered another type of health insurance

5. Category IV - Option 2 - HMO's

Both patient and doctor belong to the HMO

The chiropractor has agreed with the insurance company to accept a reduced fee

3 Models of Taking Care of Patients in a Chiropractic Office

1. Condition-base care

Example: patients tell you they have sciatica, whiplash, etc.

The #1 reason why people come in to get chiropractic care

90% of care

Chiropractic began as maintenance care in the first 50 years, but now in the past 50 years, chiropractic care has become condition-based care

#1 Problem in chiropractic

2. Preventative and Maintenance care

3. Wellness care

Office Management Class #5 Friday, September 24, 2004

Categorizing Patients

Need to categorize every patient that comes into the office

Can categorize each patient based on colored papers and folders or use color coded stickers

Gives you a heads up on the questions and answers for each patient and what paperwork needs to be filled out

Should start with patient's initial phone call

Patient's Initial Phone Call

Make a 5" x 7" card to have CA fill out when a new patient calls:

Name

Phone number and cell phone number Referral

Type of healthcare problem or maintenance care

Have you had chiropractic care in the past?

Do you have health insurance that covers chiropractic care that you would like to use in our office?

Would you like me to verify your coverage before you get here to save yourself time?

On back on card there is a questionnaire for the insurance company:

Do you cover this person?

What is their chiropractic coverage?

Are there any restrictions on diagnostics?

Have to watch the restrictions

Restrictions include:

Number of x-rays

Number of visits

Percentage that the insurance covers and the patient covers

Deductible - what is the deductible, is it per person, per family, etc., is the deductible per diagnosis, does it carry over from year to year if same diagnosis carries over

Name from the person you are talking to from the insurance company - extension to reach the person you talked to

Give patients a copy of their card within the first week - have patient verify their insurance coverage

Office Management Class #6 Monday, September 27, 2004

Initial Phone Call

Ask them if they have x-rays, MRI, CT, etc.?

Have them bring them in before consultation, when they have the consultation, or before 2nd visit

First Visit

Consultation

Exam

Second Visit

Report of findings

1st adjustment

Initial Phone Call

Considered the patient's first appointment

All about communication

Patients will base chiropractic care on past experiences

First Visit

Have patient say the first words to the new patient

Have the patient read the policies of your office and sign the confidentiality form

CA will then put the patient's file together

Pre-Consultation

CA needs to develop chemistry with the patient (to help the patient feel comfortable)

The CA will take the patient back to your office and perform a pre-consultation - 2 Reasons:

1. Categorize the patient (PI/work comp, Medicare, cash, etc.)

2. Explain how the category works in our office

Have the CA explain to the patient that if you accept them as a patient then we will further explain in detail his/her financial responsibilities

It is important that you do not put the patient in a treatment room or facility

Normal patient - wants the problem fixed yesterday, does not want to pay for it, and does not want to come back anymore

Consultation

So we can obtain a certain amount of information

Chronic vs. Acute

Determine severity of problem

Required to do one clinically and ethically

Main reason to perform a consultation/history: for you to develop chemistry with your patient

The consultation is the most important visit that you will have with a patient

Consider 2 things:

1. You

2. Environment

Spend extra money in your waiting room, front desk, and consultation room (neat, clean, professional, etc.)

Want to build "good guy" and "good gal" chemistry

Office Management Class #7 Wednesday, September 29, 2004

Consultation

Want to consider 2 things:

1. You - chemistry with your patient

Dress for Success by: John Malloy

Should dress and look like upper-level-corporate management

2. Your office

Do the consultation in a non-treatment room

Spend extra money in waiting room, front desk, and consultation room

The office should be conducive to growth

The statement you are trying to make is "talking"

Should be non-clinically (no charts, no blood and guts)

Should have a desk (helps set the stage that the person in charge sits behind a desk)

Fix the office up so that it looks like upper-corporate-level management

Make the office roomy (be concerned with patients being claustrophobic)

Have windows in the room

Put library in the room

Put up your diplomas (another place is somewhere out by the front desk so they can be viewed from the waiting room)

Office Management Class #8 Friday, October 1, 2004

Consultation

Conducive environment to create chemistry

Establish chemistry by learning and performing as a doctor who is a good listener

1. Quit writing during consult and history

2. Effectively communicate your listening nonverbally to patients

Personal space - approximately 3 feet at body

- The more often you overlap your space with another space, the better the chemistry

- Have to get close enough to invade space

- Establish physical contact (shake hands)

- Eye to eye contact and introduce self

- Use their name, but GET IT RIGHT

-- If unsure, ask them as maintaining contact, if got it right - "Close enough" is not good enough

- Write it phonetically in your file

- Close with who referred them ("I see Ben Jones referred you . . . How do you know him? When you see him again, tell him thanks for referring you to me, and when I see him next, I will thank him, too."

- Then sit down

- Look at chief complaint

-- "I see you are here for this . . . Let's talk about it."

-- Put down file and pen on top

-- Tell me about your ____. . . Let them talk

-- Can pull pen out to make quick note (medications, doctor's name, etc.), then put pen back down immediately

- When ready for them to stop talking, pick up pen

--"Let me see if I understand this" - then repeat back a summary of their problem

- "Did I leave anything out?"

- "Okay I think I've got it. Let's go examine your C/C."

Maximum consult time should be 15 minutes

- Name is in his books in red (New patient)

- The time in book is the time the doctor will see them. So if appointment time is 3:00 then patient is told 2:30 so can get paperwork done

Office Management Class #9 Monday, October 4, 2004

How to get patient out of consult room and into exam room?

Move from personal to clinical

Take patient there

Have CA take them there

Patient in Exam Room

8 minute video about chiropractic

When patient leaves consult room - this is when you write notes (summary)

After video, patient gowns

2 challenges:

1. Develop a new chemistry

- From good guy/gal to good doctor

- Want patient to feel they made the right clinical choice

- They should feel your exam was different

2. Do a chiropractic exam that they cannot get elsewhere

- should be different

- Need a "third party" examination tool (thermograph, nervoscope, etc.) - it takes it out of your hands

- Full spine x-ray on everyone - one of the best chiropractic diagnostic tools - can help teach patients about the role of the spine, nervous system, etc.

- Cannot see pathology on full spine . . . But cannot tell pathology with palpation either - use full spine x-rays for other purposes (posture, education, etc.) - no one else does full spine films (they are different)

- The spine is an organ - need to see it in its entirety, not in pieces

Perform a talking exam

- NO pen

- Have a scribe write for you

- Always examine full spine, but start in the area of chief complaint (prone, supine, standing, seated)

- Check the spine (compression, rotation, motion, etc.) and relate areas of subluxation to Meric chart

Thermogram (this is different)

- Then for next 30 days, offer to scan family for free

- As performing, explain what you are doing and ask patient when last time they had it done

Address chief complaint, but there is a bigger issue - the entire spine

Exam should be 15 minutes tops

Finish

- Summarize exam in one sentence

Take x-rays

Bring patient back and dismiss

Office Management Class #10 Friday, October 8, 2004

First Visit

Have an opening and a closing script for consultation, entering and exiting the exam room, before and after x-rays, releasing the patient, etc.

Put patient on therapy if you need (do NOT adjust until after report of findings)

If you want to adjust on the first visit make it look like it is part of your examination (do NOT want patient to know that they are receiving an adjustment)

Chronicity

After OPPQRST, you must dig for chronicity - DO NOT MAKE A MOUNTAIN OUT OF A MOLE HILL - DO NOT MAKE A MOLE HILL OUT OF A MOUNTAIN

Want to make sure the patient is conscious of the problem

After patient explains the problem, "when is the last time you had anything like this?"

"What did you do about it?"

"How long did it last?"

"Any chiropractic care, medication, etc.?"

"Before last experience, when was the time before that?"

Etc.

Need to know all history (chronicity) because x-rays should show evidence of degeneration - if no chronicity, then spine should look like a new spine

This helps the patient understand that the problem is not going to be a quick fix

Perceived Value

Need to accomplish this with the patient

"What is in it for me?" - as far as the patient is concerned

It is why people come back to see you

When do the majority of people come to see the doctor? - when they cannot affectively treat the problem themselves

Need to know why patient is at your office

Have to be able to relate to patients what chiropractic does for them

Office Management Class #11 Monday, October 11, 2004

Perceived Value

Have to express this to the patient on the first visit

Have to know why you are in this profession and your chiropractic purpose

Need to make sure that the patient understands the purpose of chiropractic and his/her place with chiropractic care

Have to identify your patient's values because it will help them understand the value of chiropractic care

Need to close the consultation with the patient's values and how chiropractic care can help these values

Have patient tell you what they are not doing because he/she cannot (have to use the backdoor with perceived values) - make sure that it is important to him/her

End of consultation and the first visit

Report of Findings

Second visit

1. Start with a video - get patient on same page as you

2. Written final report

3. Oral final report

Perform in exam room (want everything in this room to explain chiropractic care - posters, models, etc.)

Do not change the procedure just change the technique

Answer the question of perceived value

Patient Evaluation Worksheet - do by hand

"Back Talk" videos

Special difficulties faced in stabilization/correction of spinal condition - #1 problem is patient waited too long

Patient comes in and watches video

After video is over, put the patients x-rays up on view box

Have patient read his/her report of findings (enough time to read twice) and look over x-rays

Chiropractor goes in and takes away report of findings from patient - review report of findings with patient

Exam room - make sure that it is large, flat table, diagnostic equipment, final report room (spines, x-rays that are marked, posters, etc.), countertop, view boxes, laminated charts so that you can write on them, television, computer, etc.

Fleet spine (Concept therapy, San Antonio, Texas?)

Visual Odyssey

Office Management Class #12 Wednesday, October 13, 2004

Final Report

Very important to have a written final report to give to the patient because it makes the patient feel that he/she is important and it helps keep you on track (you do not lose your train of thought)

Should be on second visit

2 Day Initial Visit (New patient):

1. Day one should consist of consultation, history, exam (chiropractic, physical, etc.), x-rays (if needed), instrumentation, and video

2. Day two should consist of video and final report

ALWAYS present to the patient what you think they need - where you start (not where you finish)

The ultimate choice is the patient's choice of what they want

Corrective/stabilization care - present to patient a care plan that will lend to "maximum" correction - want to get patient to "maximum" correction and "maximum" stabilization that his/her spine needs

4 Major Elements of Final Report (in this order):

1. Can you help me?

Puts patient's mind at ease immediately and gets he/she listening

2. What is wrong with me? - diagnosis

Give patient the technical terms and then give the patient the diagnosis on his/her terms

Your average final report should be presented at a ninth grade mentality

3. How long is it going to take? - treatment plan

4. What is going to cost (me)?

When describing to the patient what they need, break-up the spinal adjustments into parts (example: going to adjust your lumbars and pelvic, spinal adjustments on upper thoracic, and spinal adjustments on lower neck)

Want to give patient his/her treatment plan based on maximum correction - list all parts of treatment plan (therapy, spinal adjustments, vitamins, etc.)

Give patient his/her out of pocket expense (have to know insurance plan and have to calculate expense based on treatment plan - before patient says anything - "Your total cost is ___, this is how much your insurance is going to pay, this is your out of pocket expense, and this is how you can take care of it."

Then give patient options:

A. Maximum correction and stabilization

B. Relief care - only adjusting and therapies that are geared at relief

Most insurance policies are geared at relief care

Give them their out of pocket expense here too

Let them know that their problem will probably return

Also let them know that it requires little time and discipline

Also tell patient about maintenance care - this will keep them out of pain and prevent the problem from returning - let patient know that if they do not continue on maintenance care the next time they have a flare-up if it has not been to long then they can go on relief care but if it has been to long then have to go back to correction/stabilization care

Office Management Class #13 Friday, October 15, 2004

Final Report

You must differentiate between what care and treatment plan that each patient needs - patient must understand their care plan

A - Corrective/stabilization care - only time you do not offer this care is when they do not need it or they will not benefit from it

Maintenance/preventative schedule - 1x/month to 1x/6 months

Relief care - wait for pain to return and then come in for care

Once a patient decides on their care plan, accept it, do not say anything else, and leave the room

"Window of Opportunity" - determines the patient's corrective/stabilization care

Office Management Class #14 Monday, October 18, 2004

Midterm Project DUE: NOVEMBER 3

#1 Drawing

Full size poster board (any scale)

Fill up the poster board

Goal: Floor-plan (office design layout for what is feasible at this time in your life)

Look at cost factors

2 drawings

800-1000 square feet office space

Draw to scale - 30' x 40' (1200 square foot)

Label all rooms

On back of this poster board, list rooms (example: waiting room, front desk, and x-ray)

List contents of each room and an estimate of how much it costs (example: Waiting room - 6 chairs x $200 = $1200)

At end get a total amount of all rooms

Then another total - how much is build-out? (lease-hold improvements) - changes to the building - 50% of more is typically labor - look at carpet, lights, plumbing, etc. - Average cost is $25,000 - include subtotal for build-out

#2 Drawing

15' x 60' = 900'

Typically one hallway with rooms on one side

Do same instructions as above

One drawing per poster board

Pick your on scale

Capacity Evaluation

Saving you money

1. Evaluation of your office space

Do it by zones

Zone 1 (front of building) - waiting room, reception area, front desk

Zone 2 - treatment rooms, exam rooms

Zone 3 - x-ray, restrooms, offices, storage

One doctor or two - 125 visits per week - one CA

125-200 visits per week - two CAs

Patient Flow

1. Zone 1

Dead space - space that does not produce an income but space that is required

Waiting room

Hallways

Storage

Restrooms

Keep dead space to minimal square footage

Small waiting room - 5-6 chairs - rectangular

Hallways - one hallway, try to end hallway into a room

2. Zone 2

One adjusting room

Do not gown - but if you have to gown your patients then have dressing rooms

Therapies do not get performed in an adjusting room

Designate a room in your office that is a therapy room - therapy bay

If at all possible, get rid of your attended therapies (require active participation on your part or a staff member - example: ultrasound)

Office Management Class #15 Wednesday, October 20, 2004

Capacity Evaluation

Block scheduling - this is the time you want to be busy

Office Management Class #16 Friday, October 22, 2004

Capacity Evaluation

1. Block scheduling - put as many patients in a given time as possible

"Door Slam Time" - the time between when patients slam their door on their car when they get to the office and then when patients slam their door on their car when they leave the office

Block scheduling allows you to get into the zone - hard to get into the zone and then stay in the zone

"Present time consciousness" - getting into the zone

"Being in the zone" will stimulate patient referrals because patients feel excited about their visit and then refer other patients to you

Then when you have time periods between that is when you do other stuff

2. Paperwork

A. SOAP (Patient progress notes, daily patient notes, etc.)

Do not continue to ask patients how they subjectively feel every day

Take patient's subjective complaint and make it objective - eventually patient will stop talking about their symptomatology unless it gets worse

Objective findings

Treatment protocol

Office Management Class #17 Monday, October 25, 2004

Capacity Evaluation

Paperwork:

1. SOAP notes - consider doing a check-off list

2. Patient file

With initial visits patient file should go with patient

Once patient begins care the only thing that should go with patient is the daily progress note and a route slip (charges for the day, receipts for the day, next appointment)

3. Computer

Electronic billing (MD online)

4. CA check sheet

What you want your CA to do for the he patient's file - stays on patient's SOAP notes until completed (collection procedures, financial, insurance forms, final report appointment scheduled, lay lecture scheduled, etc.)

5. Handouts

Summary about what you want the patient to know (Backtalk systems)

6. Process all incoming paperwork the same day - day in and day out (within 24 hours)

"MARGINAL NOTES - Please accept these marginal notes as an immediate response to your questions. I believe in this case you are interested in speed, rather than formality."

Income

1. Personal Injury

Personal injury - can be from a variety of different ways (auto accidents, injury at home, etc.)

99% are auto accidents

Mostly MVAs

State statutes determine who is responsible for paying and when

2 Scenarios:

1. No-fault state

Legally when it comes to liability there is no fault

2. Fault state

Legally at fault - if you sustain an injury, you may be entitled to a financial settlement

A.k.a. Non-no-fault

The state that the accident occurs in dictates the settlement

There are some states (usually bordering each other) that have made an agreement to honor each other's laws

2. Work compensation - someone injured on the job

Office Management Class #18 Wednesday, October 27, 2004

Accident

Jason (Hummer) hit Rhonda (Jaguar)

Rhonda's insurance:

- Car - Country Company

- Health - Blue Cross/Blue Shield

- Spouse - Cigna

Jason's insurance:

- Car - Snake Farm

- Health - United Health Insurance

- Spouse - Etna

Rhonda is responsible for 100% of her bill with you

RULE: ALWAYS BILL A MEDPAY AND A MAJOR MEDICAL (when available)

If in a non-no-fault state every one has ability to purchase "medical payment" on their car insurance

Medical payment portion on automobile insurance pays for your entire healthcare if you are in an accident

Med-payments are always based on contract and not on fault

Will take the bill and print out twice and take claim form and mail to both auto insurance for med-pay and to major medical insurance - equally responsible for making payment on this bill

Paid based on UC/RN

Usual and customary (UC) - based on what is a usual and customary fee geographically (used to be based on what is usual and customary for your practice)

Reasonable and necessary - diagnosis and treatment have to be compatible

Med-pay is always reimbursed based on UC/RN

Med-pay always pays 100%

Participating vs. Non-Participating

Non-participating - you take care of people with a particular insurance but you are NOT part of the club

Participating - you belong to the club of a particular insurance

Example: Blue Cross/Blue Shield

Participating - $0 deductible, then either 80/20, 70/30, or 50/50 - insurance company sends the larger percentage and patient is responsible for the other amount - BUT only the ALLOWED is paid not necessarily what you charge

Non-Participating - there is a deductible and you get a percentage of the full amount (?)

Office Management Class #19 Friday, October 29, 2004

Non-No-Fault

Always bill med pay and a major medical simultaneously

Med-pay pays 100% of chief complaint - but there may be a limit

If insurance payments total are greater than the expenses, the doctor must write a check to the patient

Is not double billing to send to both companies because the laws state that if the person pays the premium, they are entitled to the benefit (example: 3 life insurance policies on spouse - if spouse dies you can receive money from all 3 companies - because paid the premium)

To determine state statutes:

1. Look up on web

2. Call insurance commission

3. Call a local DC

4. Call PI attorney

If no med pay purchased, there is zero coverage

Health insurance will pay according to the purchased plan (deductible, co-pay, number of visits, etc.)

Spouse's Insurance

Spouse's insurance - sometimes is elective - other times it is a true benefit (no choice)

- Coordination of benefits coverage - co-insurance

- May cover things that primary insurance does not cover

In a fault state, the hitter's insurance is liable

- Typically wait until patient is released

- Want to make payments as a settlement

Office Management Class #20 Monday, November 1, 2004

Non-No-Fault

Rhonda - Country Company - Blue Cross/Blue Shield- Cigna

Jason - Snake Farm - United Health - Etna

Always bill med pay of the car you are in

Bill Country Company (med pay) and Blue Cross/Blue Shield (major medical)

Also send bill to Snake Farm "liability"

Most people have $1,000, $2,000, or $5,000 med pay

United Health Care and Etna is not responsible for Rhonda

Rhonda has no med pay, bill major medical and check-out co-insurance so that you can try and get 100% of what you billed (no law about this - between you and your patient)

Rhonda has no insurance - collect cash from Rhonda or wait for Snake Farm - if Jason uninsured collect from cash from Rhonda

Jason comes in for care - bill med pay and major medical insurance (Snake Farm and United Health Care)

Med pay is based on contract and not based on faults

May need to bill co-insurance - Etna

Diva is passenger in Rhonda's car - has Geico auto insurance, Prudential health insurance, husband has Mercy plan

Med Pay follows the car - bill Country Company and Prudential - Mercy may pick-up the rest of the bill

Diva still has a liability claim against Jason and Snake Farm and a liability claim against Rhonda and Country Company

Rhonda has no Med pay - have to prove - Diva now has right to use her Med pay

If there is exhaustion of Rhonda's benefits by Diva - get proof of exhaustion and then send to Diva's insurance and ask for her Med pay benefits - called stacking - stack one Med Pay benefits on top of each other)

Office Management Class #21 Friday, November 5, 2004

Rhonda

Country Company - car insurance

Blue cross/Blue shield - major medical

Cigna - spouse's insurance

Diva (passenger in Rhonda's car)

Geico - car insurance

Prudential - major medical

Mercy - spouse's insurance

Bill Rhonda's med pay and Diva's major medical

Rhonda's med pay is primary and Diva's med pay is secondary if there is not enough money to cover Diva's injuries

Jason (Caused accident)

Snake Farm - car insurance

United Health Care - major medical

Aetna - spouse's insurance

RULE

Bill med pay and major medical

Stacking

Excess Coverage

Med pay and major medical that are covering any one of the above people do not want to be responsible

Each one of these companies is trying to get state statutes that makes one company the major company and pays the majority of the bill and then the other company is secondary and pays the balance

Jason as Patient

Bill Snake Farm (med pay) and United Health care (major medical)

Bill spouse's information to Aetna

Lisa (passenger in Jason's car)

Allstate - auto insurance

Health link - major medical

Carpenters 618 Union - spouse's information

Bill Snake Farm (med pay) and Health link

Med pay follows the car

Lisa has liability claim - can sue Snake Farm - has 2 claims, a med pay claim and a liability claim from Snake Farm

Office Management Class #22 Monday, November 8, 2004

Uninsured Motorist

If Jason was uninsured and she had uninsured motorist coverage then she can get liability from her insurance based on this coverage (might have to sue her insurance company to get money)

Coverage that you should have

Med pay

Liability

Collision-comprehension

Uninsured motorist

Under-insured motorist coverage

Under-Insured Motorist

Rhonda hit by Jason

Rhonda seriously injured so collects from Jason

But then Rhonda's insurance would pick up the rest of the coverage

No-Fault State

There is no-fault

Jason hits Rhonda - legally when it comes to liability Jason is NOT at fault

In a no-fault state, med pay is referred to as PIP (personal injury protection)

State that the accident occurs in determines how the case is settled

There is NO other coverage

*No-fault is ONE coverage only UNLESS Rhonda's care meets the threshold amount [threshold amount is that dollar amount (as determined by state statute) that Rhonda's care must amount to before claiming liability]

Example: If threshold amount was $5000 - once Rhonda's care meets $5000 then Rhonda can claim a liability against Jason's insurance

Every state tries to get a higher threshold

Unless you meet that threshold you do NOT have a liability claim

Work Compensation

Worker's compensation insurance coverage is a policy that employer's buy to give health care services to their employee's who are hurt on the job (covers treatment, liability, disability/impairment)

3 Possibilities that happen when it comes to reimbursement for the patient:

1. Best scenario - patient has the right to choose the treating physician - provided usual/customary

2. Employer has the right to chose the treating doctor that the patient goes to - have to have a written document

3. Insurance company has the right to choose the treating doctor

Once a patient has a work comp claim they have nothing else UNLESS the patient was driving while working (taxi driver, bus driver, truck driver, etc.) - if hurt on the job while driving then they have a work comp claim, a med pay claim, and a liability claim

NOP - no-out-of-pocket expense - in Missouri cannot charge the patient the balance of the bill that is not paid by the insurance company - have to write the amount off

Office Management Class #23 Wednesday, November 10, 2004

How to get paid with Major Medical?

In and out of network - if you are in-network, you are a participating provider (you have signed a contract that you will participate with the agreements within the contract)

If you participate, you will be promised referrals because your name will be added to the directory

In-network saves the consumer money when he/she goes to a participating provider

Minimal to no deductible when patient goes to a participating provider - the insurance company ONLY pays the allowable charges (example: charge $75 for a service, Blue Cross-Blue Shield decides that the service is only worth $40 - so Blue Cross only pays 80% of the $40 and the patient pays the balance on the $40 - NOT on $75)

Out-of-network means a non-participating provider can charge the patient the full fee for a service - the patient must meet his/her deductible first - deductible will be higher with out-of-network than in-network

Office Management Class #24 Monday, November 15, 2004

Final Report

Need to know patient's insurance coverage and how much his/her payment is for total treatment plan

Always recommend what you think the patient needs and document it - keep in patient's file - whether or not patient follows your treatment plan will be based on his/her out-of-pocket expense

Cash

Key to a cash practice:

1. Pre=payment with massive discount (50% reduction in fee if you pay cash)

Office Management Class #25 Wednesday, November 17, 2004

Cash (Category 3)

Large percentage of practice will be cash (more than 1/3)

Key to cash and making it work is having patients feel they got a deal

Give patients a mechanism of pre-payment - make the patient pay up front - have to discount services to get patient to pre-pay

Has to be done in one breath (do not hesitate)

Some consulting firms are telling doctors to discount services by up to 50%

Have to give patients cut-off time they can pay it

Office Management Class #26 Friday, November 19, 2004

Cash

Do not make cash practice 100% - can pick and choose

Free - The lower the socioeconomic class the better "free" works

5 Socioeconomic classes:

Lower income Families

1. Lower

2. Lower middle

3. Middle

4. Upper middle

5. High

Based on:

1. Income

2. Education

3. Housing

These 3 things determine the status of the class you are living in

Buying/Leasing Office Space

Scenarios:

1. Triple Net Lease

3 parts:

1. Rent - how much? - determined by so much money/square foot

1200-square feet x $15 = $18,000 per year or $1500/month

2. Maintenance

Each month or quarter there will be a bill from landlord for maintenance of property (landscaping, trash, parking, outdoor lighting, minor repairs, etc.) - usually $1-2 per square foot

3. Insurance and tax

Usually $1-2 per square foot

2. Straight Lease

Office Management Class #27 Monday, November 22, 2004

Leasing Office Space

1. Triple Net Lease

A. Rent (based on square feet)

B. Maintenance for upkeep (lawn, trash, parking lot, etc.)

1. Standard per square foot - usually $1-2

2. Itemized cost every month for each service and then divided between each space

C. Taxes and insurance

Insurance premium - so much per square foot or itemized list - $2-4 per square foot

2. Straight Lease

Will include all of the above

Items that should be mandatory in lease

Leases are written for the advantage of the landlord

1. First right of refusal or first right to continue the lease

Landlord will usually make you take a 3 year lease

Will also request your spouse to sign

Before you sign the lease need to negotiate what is going to happen at the end of the lease

When renew lease want to be able to get the same deal - make sure you negotiate BEFORE you sign the lease

6 months before the lease is over the landlord has to contact you about renewal

RENEGOTIATE the cost AND the first right of refusal in another 3 years or right to renew for the same amount

**RULE: NO OPEN END LEASE

2. Lease hold improvements

Who is going to pay for them and how much?

90% of renters will pay for this

3. Right to sublease with landlord permission

Gives you the right to market the place if you decide to move

When you sublease the renter pays you

4. Right to vacate premises as is

Can remove any personal property that you want as long as you repair any damages

5. Death Clause

Most state laws have a death clause

Right to continue the contract for your spouse and/or family if they so chose

Gives the spouse/family protection to decide what to do

Tell your spouse/family to get another doctor in your space immediately

6. Parking considerations

Zoning and building codes determine how many parking spaces are allotted per building

Landlord issue that needs to be handled before the lease is signed

7. Visibility

Can people see your office?

If you are not visible to the public (people driving by) be prepared to spend $$$ on advertising

8. Maintenance

In your contract make sure it states that you are only responsible for a percentage of the building space (base it on your square footage) - so that if the other spaces are not being rented out you are not responsible for the total amount

High users - people who use a lot of water, electricity, etc. - make sure you are only responsible for your space

Leasing Equipment

Most of us will lease equipment

Leasing is always more expensive to buying

When you lease, there are a couple of options:

1. No down payment

2. Usually there is a down payment - usually one lease payment

After lease ends:

1. Give equipment back

2. Buy equipment - usually 10% of cost - standard lease talk

Has to have a buyout (make it $1)

3. Can continue to lease the equipment for only one monthly payment per year and then you own the equipment after a certain time period

Office Management Class #28 Monday, November 29, 2004

Leasing Equipment

3 Choices after lease:

1. Give it back

2. Buy equipment (does not have to be 10%)

3. Continue to lease (usually one monthly payment one time per year)

Lease factor is a converted percentage

Lease factor x cost of equipment = monthly payment

Monthly payment x number of months = Total cost paid for equipment

If you miss a payment, the leasing company will come and take it back

When you lease equipment there will be a coupon book - usually when initially lease equipment you have to make 2 payments (usually the first and last months payments)

New Patient Acquisition

#1 problem of going into practice was because new patient acquisition

Rules:

1. The more people you know the more new patients you will get

2. The more money you are willing to spend on marketing the more patients you will get

3 Sources of new patients:

1. Present patients (best source)

2. Past patients

3. All of the others (people who have never been to see you)

Plans for new patients:

1. Need 500 patients for referrals

Takes about 5 years to get this many patients

2. How do I meet 500 new people in 1 month?

Need to meet 20-25 people per day for 6 days a week

Be well-dressed

Introduce yourself - "I want you as a new patient"

Go into small businesses

Ask for owner

Introduce yourself

Always ask about them

Hand written note to all of the people you have met

Office Management Class #29 Wednesday, December 1, 2004

New Practices

Need to meet 500 people within a month - start with small businesses

Just introduce yourself - nothing to buy and nothing to sell

Add these people to the mailing list

Mailing List

When start practice write a mailing list including everyone you know - send something about chiropractic every month

Add all of the people you meet

Add new patients

Can add and remove people as you want

Clean-up mailing list periodically

Community Survey

Go door to door - residential

In next week or two do a drop mailing to that area

$500 minimum every month for first year - does not include mailing

Office Management Class #30 Friday, December 3, 2004

Starting a Practice

Make it routine to introduce yourself to new businesses in your community

Take an "office package" with you that talks about you and your office

Send a note "glad to meet you"

If the person says they already get chiropractic care from Dr. X

- If you know that person very well, then go ahead and say "I do know him and he is an excellent doctor"

Do NOT say that if you do not know the doctor or wonder about their professional ethics (the person may be testing you - may not really like their doctor . . . seeing if you are friends, family, etc.)

- Then say if your doctor is ever unavailable then feel free to come in and I would be happy to send my notations back to your doctor and then he can see what I did

- Do NOT say anything negative/bad

- If the doctor is terrible just say that "I have not met him, but I am glad you are getting chiropractic care"

If you do see another doctor's patient then - can only do so much without records or x-rays - do what is legally, ethically, and clinically right - do not put into system unless you participate in their insurance - only accept cash at the time of visit

If in community without many businesses go to smaller surrounding towns (within 15-20 miles) and canvas them

How to move patient from condition-based care to wellness care?

Lifelong care

And how to do you get them to bring in their family?

Utilize a mandatory new patient orientation class within 1-2 weeks of onset of care

Do not educate about innate, BJ Palmer, subluxation, etc. during exam, final report, etc. --> patients are focused on their situation

Group classes --> bring spouses too

This is where you talk to them about why they should receive lifetime care and bring their families in too

Treatment plan can be on their terms (relief, maintenance, preventative, etc.)

Talk about chiropractic care as a way of life - put message out and support it with nonverbal, verbal communication, office posters, etc.

They need to understand why they should come in and get checked/adjusted every week/month no matter what else is going on in life

Office Management Class #31 Monday, December 6, 2004

Condition Based Care to Wellness Care

Mandatory new patient lecture:

1. Before you see them before consultation

2. Within 2 weeks of initial visit

During final report:

Begin with "Can I help you" - tell them if you can help them and then reiterate what they have looked like - tell them you are going to give them your final report in two steps - today and next week - let CA know that your patient needs to be scheduled for 2nd part of report (new patient lecture)

Give patient a colorful bright sheet with patient's name and date of new patient orientation - "Patient's name is scheduled for new patient orientation meeting on Date. This is a mandatory meeting for new patients. Failure to attend this meeting will terminate your care at this office. X-rays, records, etc. will be available to any doctor of your choosing immediately."

When patient asks about the importance of this lecture - tell them you are going into greater detail about chiropractic and how it can help them

Take classes about this lecture to help you

Chose a room that has all of your education material in it

Start lecture on time

Lecture will be about chiropractic, how people get sick, and how people get well

Open lecture with a welcome and your goal - "I want you, your family, children, and friends to get chiropractic care for the rest of your lives."

End lecture with "If you understand what you learned here tonight, then bring your spouse and/or children in by DATE to be checked. If you come in before this date then I will check your family for free. If I decide they need care then there are family plans available."

With new patient make sure you preschedule all of their appointments so they know and you know

Next patient visit follow-up the patient will probably ask you about the lecture - after their testimonial tell patient to take you up on your offer - if patient is not interested then drop up

If your patient does not mention the lecture then thank them again for coming in and say that you hope they learned more from the lecture and to take you up on your offer

New Patient Advertising

Community survey that is on-going - visit every new business that opens within the next 5-10 years

"Free" will work depending on socioeconomic level that you live in

Difference between marketing of goods and marketing of services

Must consider the socioeconomic class you are marketing to

3 Approaches for advertising a professional practice:

1. Image advertising - those things that you would do in the community that puts your name in the good in front of the community (sponsorships - little league, buy a space on a calendar, food drives, nice sign on your office, etc.)

2. Educational advertising - teach people about chiropractic - (pamphlets, handouts, "ask the doctor" in the weekly newspaper, lectures, etc.)

3. Call to action advertising - basically says "try me" - new patient days, free x-rays, free consultation, etc.- have to have a cutoff date and keep date as short as possible

Key to this advertising is NOT to mix them - when you mix them you dilute the message

Yellow pages - will have to experiment - the cost has increased and HMOs and PPOs have taken over - depends on socioeconomic class

"Get well" card - allows you to come into the office and get a consultation, exam, and x-rays if needed at no charge - if you do not need help then give it to someone who needs help - give the value, cutoff date, name, and phone number to call, etc. - typically send to your patients

Office Management Class #32 Wednesday, December 8, 2004

Associates vs. Independent Contractors

Associate typically refers to a person who is an employee

Independent contractor is a sole private practitioner who is doing nothing more than working at an office as an independent doctor - the owner of the office is the landlord

Both terms matter because of the IRS

IRS would prefer you be an associate because if you are an associate your employer has to withhold part of your earnings and responsible for sending these withholdings to the IRS (social security)

If you are an independent contractor you are responsible for paying your own taxes, social security, etc.

IRS says independent contractor criteria are:

- There must be sufficient lack of control over the independent doctor (ID) (cannot set hours, tell independent doctor what to do, etc.)

- Worker that is the ID has an independent profession (should start own business by name)

- There is no supervise of the actions of the ID

- No right to fire you (DO have the right not to renew the ID contract)

- No fixed set hours (ID sets own hours)

- ID should have own federal tax and social security number

- ID must have own liability and health insurance

- ID must have own checking account

- ID is responsible for obtaining own license, renewals, seminars, travel, etc.

- ID receives no training supervision from employer

- ID can hire anyone he/she wants to, to work for him/her

- ID cannot have a continuing relationship with employer (must have a monthly or quarterly contract)

- ID can work multiple jobs without employer's permission

- ID does not have to submit reports to employer

- ID cannot have an investment in the facility (if ID owns any part of business then it is considered a partnership)

- ID must be able to make a profit or suffer a loss (ID cannot have a guaranteed paycheck)

- ID must advertise and promote own practice

- ID cannot claim attachment to the facility (must have own advertisements, own letterhead, own billing, etc.)

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