Practice Management Tips
It’s Never Too Early for Physician Succession Planning
Six months before you want to retire is the wrong time to think about turning over the reins to your practice to a successor. Ideally, your succession plan is something that has been developed over time that will serve as a tool to help ensure your practice continues to thrive after your departure. Even if retirement is in the distant future, it’s never too early to start planning, because:
• Timing issues can be beyond your control. A health scare, a pandemic, or other external forces can have immediate impact on your practice.
• Grooming the right successor can take time and may require a lengthy apprenticeship period.
• Your succession plan is never set in stone, and can change course to accommodate your changing needs.
Read more about succession planning in this article from Physicians Practice.
HIPAA and COVID-19 Vaccine Status
Does asking for a practice team member’s or patient’s COVID-19 vaccine status violate HIPAA regulations? Not according to the recently issued guidance from the Office of Civil Rights, which notes that the HIPAA privacy rule does not prohibit:
• Businesses or individuals from asking whether their customers or clients have received a COVID-19 vaccine.
• Customers or clients of a business from disclosing whether they have received a COVID-19 vaccine.
• An employer from requiring a workforce member to disclose whether they have received a COVID-19 vaccine to the employer, clients, or other parties.
• A covered entity or business associate from requiring its workforce members to disclose to their employers or other parties whether the workforce members have received a COVID-19 vaccine.
Read more about HIPAA and COVID-19 vaccine status in this article from the HIPAA Journal and this overview from MGMA.
Remote Monitoring Devices and Apps for Allergy Practice Can Enhance Patient Engagement and Adherence
The availability and use of remote monitoring devices and applications (apps) has expanded exponentially during the COVID-19 pandemic. Education and self-management interventions for asthma and allergic conditions allow patients to play an active role in their care, and have been linked to improvements in medication adherence and asthma control, and decreases in unscheduled office visits.
Digital tools such as disposable rhinoscopes, digital otoscopes and Bluetooth spirometry can be used in the office, during a telehealth visit, at a remote care site or at the patient’s home. Benefits include:
• Patient satisfaction and convenience
• Standardization and quality improvement
• Teaching and replay options
• Information download to the electronic health record
• Additional practice revenue streams
Mobile health (mHealth) applications are widely available in a variety of formats (smartphones, tablets, computers, wearable technology) and are viewed positively by both patients and physicians. Apps offer symptom diaries, personalized action plans, medication reminders, goal setting/behavior change techniques and more.
More information on incorporating remote monitoring devices and mHealth apps into your practice can be found in the following resources:
• Digital Assessment Tools and Remote Monitoring Devices for Allergy Practice (AAAAI Virtual Practice Management Workshop presentation)
• mHealth and Allergy/Immunology (AAAAI article)
• Drive Patient Retention With Remote Patient Monitoring (Physicians Practice article)
• Remote Patient Monitoring: Building a New Outpatient Revenue Stream (Medical Group Management Association article)
Chart Note Do’s and Don’ts
The 21st Century Cures Act contained a provision requiring that physicians provide patient access to most types of medical notes. In the past, these notes were primarily filled with medical jargon and served as a way for healthcare team members to communicate about a patient’s care.
A recent small analysis of physician notes in electronic health records has found that some comments included could be stigmatizing and influence the care of the patient. Researchers identified major themes of both negative and positive language found in the chart note. Here are ways to ensure your notes remain clear and non-stigmatizing:
Avoid language that:
• Includes a large amount of medical jargon.
• Questions a patient’s credibility (e.g., the patient “claimed” something).
• Stereotypes by race, social or gender class.
• Expresses disapproval of a patient’s reasoning or self-care.
Include language that:
• Is straightforward and easy to understand by a non-medical professional.
• Acknowledges patient authority for their own decisions.
• Minimizes blame of the individual for their medical condition.
• Contains positive comments related to the patient and the physician’s view of the patient.
Did you miss the 2021 AAAAI Virtual Practice Management Workshop? You can still purchase and view recordings from all 22 sessions, including “Secrets of a Well-Run Allergy Practice,” which includes additional information on preparing effective chart notes.
Maintaining the Health and Wellness of Your Practice Team
When asked to identify the biggest source of stress in their life, 60% of Americans named their job, more than family responsibilities, personal health and economic concerns. Minimizing workplace stressors will lead to a healthier, happier and more productive team. Here are some ideas:
• Meet regularly with your team and ask if there are issues or concerns that need to be addressed. Even more importantly, listen to the team and take action to solve problems that have been identified.
• Recalibrate work hours. Allow some staff to work early and others to work later, which can result in expanded office hours for patients, a win-win situation. Can some of your team continue to work from home for part of the week? Physicians can conduct telemedicine visits, while staff can work on insurance verification. Be flexible, monitor regularly and don’t be afraid to make changes to meet the practice’s needs.
• Celebrate the team. Provide a catered lunch or breakfast. Celebrate birthdays and other special occasions. Say “thank you” often.
Want more ideas on how to cultivate a healthy practice team? Register for the 2021 Virtual Practice Management Workshop that will take place July 23-24. Registration closes July 18.
Talking to Your Patients About the COVID-19 Vaccine
While the number of adults and adolescents receiving the COVID-19 vaccine continues to climb, many people remain hesitant about it. Studies show that patients trust their personal physicians, and allergists are in a position to explain the intricacies of vaccine development, testing, efficacy and safety.
According to a recent Kaiser Family Foundation survey, these statements were most impactful in encouraging vaccine hesitant individuals to get vaccinated:
• Vaccines are nearly 100% effective at preventing hospitalization and death from COVID-19.
• Scientists have been working on the technology used in the new COVID-19 vaccines for 20 years.
• More than 100,000 people from diverse backgrounds took part in the vaccine trials.
• The vast majority of doctors who have been offered the vaccine have taken it.
• There is no cost to get the vaccine.
Visit the AAAAI COVID-19 resources page for other helpful resources on how to talk to your patients about the vaccine.
Planning for the Future of Telemedicine Post-Pandemic
More than a year into the COVID-19 pandemic, allergy practices have embraced telemedicine thanks in part to a relaxation of regulations during the public health emergency (PHE). The PHE is currently in effect until July 21 and the Biden Administration indicated it will most likely be extended through the end of 2021.
Multiple surveys show that patients are extremely satisfied with the convenience and quality of telehealth visits and want to continue them post-pandemic. While AAAAI and other medical organizations are advocating for permanent implementation of many of the relaxed rules, we don’t know which ones will stay and which will be rescinded.
As you’re planning for the future of telemedicine in your allergy practice, keep these considerations in mind:
• Focus on the problem you’re trying to solve rather than the technology, and then use work flow analysis to find the best solution. Read this Medical Group Management Association (MGMA) article on telehealth and COVID-19.
• While it’s good to recognize that a segment of your patient population may not have the technology to access telemedicine, don’t limit access for those patients that do. Whatever solution you use should be simple and easy to access. Access the AAAAI Telemedicine Toolkit.
• Your telemedicine solutions should meet the needs of you and your patients. These may have changed since the beginning of the pandemic and will likely continue to evolve over time. View this video to see what one allergist learned about telemedicine during the pandemic.
For the most up-to-date information on the future of telemedicine and its impact on your allergy practice, register for the AAAAI Virtual Practice Management Workshop, July 23-24.
Understanding the New Information Blocking Rules
New information blocking regulations developed as part of the 21st Century Cures Act went into effect on April 5, with the goal of facilitating better and more secure access to electronic health information (EHI). Our advocacy partner, Hart Health Strategies, has developed a detailed overview of the new regulations and their impact on allergy practice. Here are some key highlights:
• Information blocking refers to a practice that is likely to interfere with access, exchange or use of EHI. The rule applies to providers (hospitals/physicians), health IT developers and health information exchanges/networks.
• The types of data subject to the new regulations include patient medical and billing records, and other records used by physicians to make decisions about an individual’s health care. Specific data elements are defined in the United States Core Data for Interoperability (USCDI) v.1 standard.
• There is no requirement to make EHI information available proactively to individuals, but when it is requested the data should be provided in a timely manner.
Access the full Hart Health Strategies briefing document here, and access additional resources on the information blocking regulations here.
Successful Practice Transitions: Selling or Closing a Practice
The COVID-19 pandemic has caused many allergists to reassess their practice situation and consider selling or closing a practice.
If You’re Selling
Selling a practice takes a significant amount of planning, and it is important to assemble a team of experts—accountant, lawyer, appraiser, practice management consultant—to help the process go smoothly. Plan as far in advance as possible, and have a timeline for specific tasks.
The value of a practice is determined by tangible assets (equipment, accounts receivable) and “good will,” which can be subjective and is based on variables such as reputation, history and location, and patient base. While establishing the value of a practice can be tricky, here are some ways to boost your practice value:
• Eliminate as much practice debt as possible.
• Hold off on making major technology investments.
• Keep working (to keep revenue up).
• Maintain curb appeal by keeping your website, financial reports, and office aesthetics up to date.
• Maintain strong relationships with referring sources to demonstrate patient base consistency/growth.
If You’re Closing
Once you’re made the decision to close, plan for 3-6 months to complete the process, and establish a firm closing date. Consult with your legal and accounting teams to ensure your plan is complete.
• Review your vendor, service and managed care contracts for notice requirements.
• Notify patients, staff, and your insurance carriers as early as possible (at least 90 days prior to closing).
• Make arrangements for record storage and maintenance according to state regulations.
For more tips on transitioning your practice, view this presentation from the 2017 AAAAI Practice Management Workshop, and read the chapter “What is an A/I Practice Worth” from the AAAAI Practice Management Resource Guide.
For a practice closing checklist, email email@example.com.
Navigating the Job Market
Finding your first (or second, or third) job can be challenging, especially during a pandemic. As you explore options, make sure you have a clear vision of your priorities so that you find the best fit for you (and your family).
• Family/personal values: Do you want to be near family/friends? Will your spouse/partner be able to find a job? What type of lifestyle do you want/need?
• Type of practice: It used to be academics or private practice, but there are more options now. Telehealth, research, public policy, consulting, or a combination of roles is possible.
• Do your research: Visit practice websites to get a sense of their mission, culture and staff.
• Be flexible: COVID-19 has turned the job market upside down in some cases, but there are still jobs available. Consider your second or third location choices and be patient.
If you’re a fellow-in-training (FIT) looking for your first position post-fellowship:
• Start looking early (spring/summer during your first year of fellowship) and be proactive by reaching out to practices in your target areas. The recruiting process can take months.
• Have a CV/resume ready.
• Once you’ve made the connection, keep in touch with the practice and continue to show interest.
Here are some additional resources available from AAAAI:
• Chat with Practice Management Committee member Vivian Hernandez-Trujillo, MD, FAAAAI, about navigating the job market in the Practice Management Hub during the AAAAI Virtual Annual Meeting on Saturday, February 27 from 3:15 to 3:45 pm CST.
• Practice Management Basics for the New Allergist: What You Need to Know Before You Start Practice (This webinar recording is free for FIT and NAIA members. Simply email firstname.lastname@example.org for the coupon code.)
• View the 2019 FIT exit survey data. You can also find surveys from earlier years here.
Managing Your Pandemic Financial Assistance
Did your practice receive financial assistance through the Paycheck Protection Program (PPP) or the Provider Relief Fund (PRF) during the pandemic? Make sure you are aware of appropriate reporting requirements related to the PRF and new opportunities for funds from the PPP so you can plan accordingly.
The PPP was established to help practices cover payroll and other associated expenses, such as group healthcare payments. The initial application deadline was August 8, 2020, but the 2021 Consolidated Appropriations Act recently reopened applications, added additional funding, and made substantive changes to the program, including creating the ability for some borrowers to receive second draw loans if they meet certain requirements. Applications are being accepted on a first-come, first-served basis through March 31, 2021.
For PRFs allocated through the CARES Act, be aware that the reporting portal opened for registration only on January 15, 2021. Given the delay in full functionality, the February 15 deadline has been removed, and the Department of Health and Human Services (HHS) will provide a future announcement regarding updated timelines. Updated PRF FAQs can be found on the HHS site.
The 2020 AAAAI Virtual Practice Management Workshop webinar recordings include an overview of federal pandemic funding from our advocacy partners Hart Health Strategies, and are available free of charge to AAAAI members and their practice staff.
COVID-19 Vaccine and Your Staff
Early this month, the CDC’s Advisory Committee on Immunization Practices recommended that healthcare workers be first in line for the initial doses of the COVID-19 vaccine. With an EUA already issued for the Pfizer-BioNTech vaccine and an EUA for the Moderna vaccine expected soon, your practice should already be planning for whether and how to vaccinate your team.
Each state is responsible for allocating the first vaccine doses, and your state public health department website is the best source of information for how to obtain the vaccine and when doses are expected to be available.
Will you require or merely encourage your practice team to receive the COVID-19 vaccination? This article from the Medical Group Management Association (MGMA) is a good overview of practical and legal considerations to help you make the best decision for your practice.
Visit the AAAAI COVID-19 resources page for the latest updates on vaccines, treatments, and other information affecting allergy practice.
Protect Your Practice From Cyber Attacks
The FBI and other federal agencies are warning of increased cyber attacks on hospitals and physician practices. In particular, cyber criminals have been sending emails with attachments and links that launch ransomware when clicked. Practices need to remain vigilant with emails from unexpected sources that include links and attachments, particularly those referencing COVID-19. Several resources are available to physician practices:
• American Medical Association (AMA) physician cybersecurity resources
• Department of Health and Human Services (HHS) Health Sector Cybersecurity Coordination Center
• Medical Group Management Association (MGMA) cybersecurity action steps
Practice Marketing Strategies During a Pandemic
While you are likely seeing a larger number of patients in the office than you were a few months ago, your practice may still not be at full capacity. Here are some strategies you can use to increase patient volume (both in person and via telehealth):
• Proactively reach out to reschedule visits that were cancelled in the early weeks of the pandemic, and include clear messaging about your COVID-19 safety protocols. Remind patients that you can see them using telemedicine if that is most convenient for them (the public health emergency has been extended until January 23, 2021).
• Keep your practice website up-to-date and prominently feature your COVID-19 safety protocols on the homepage.
• Create a video message on COVID-19 safety protocols for your practice website and send an email to all current patients with a link to the video.
• Develop regular social media posts that keep your practice in the minds of your patients and expand your practice’s visibility within the community.
• Consider purchasing advertising on Facebook, Google, Instagram and other social networking sites.
• Reach out to your referring physicians to see how they are doing and remind them that your office is open and accepting new patients.
The next 2020 Virtual Practice Management Workshop webinar will focus in part on pandemic marketing strategies and is scheduled for Thursday, October 22 from 7:30 to 9:00 pm CDT. Register for the webinar here.
Managing Your Practice Cash Flow During COVID-19
The ongoing pandemic is forcing practices to continue to look for strategic ways to ensure their financial health. During the recent 2020 Virtual Practice Management Workshop webinar titled Engineering Your Practice for the Continuing Crisis, panelists provided practical ideas in several areas.
• Critically assess your expenses and find places to make permanent or temporary cuts. Do you really need five phone lines? If you have multiple clinic sites, determine which are essential and which can be closed temporarily.
• Review standard supply orders. Is your pre-pandemic schedule still appropriate?
• If you have a mortgage, approach your lender to see if you can temporarily suspend payments without significant penalties. If you have leased clinic space, don’t be afraid to ask for contract modifications.
Meeting Patient Needs
• Be flexible. Offer early morning or early evening appointments, telehealth visits, or consider weekends if that is a need for your patients.
• Be creative with your schedule and give front desk personnel the ability to change appointment types as necessary. Maximizing your ability to see new patients will optimize practice income.
• Critically review your staffing levels and assignments and determine if you are right-sized. Cross train staff.
• Ask your nurse practitioners (NPs) to take on additional lower level nursing duties temporarily.
• Determine if some of your staff are willing to work fewer hours on a temporary basis.
Panelists agreed that the bottom line is to remain positive and be flexible and remember that the pandemic won’t last forever. You can access the full webinar recording here.
Navigating Staffing Challenges During COVID-19
Is your practice prepared to respond to unexpected staff or provider absences due to COVID-19? In addition to absences due to COVID-19 infection or exposure, many parents will now be faced with how to manage children who will be learning virtually instead of returning to school this fall. Here are some things to consider:
• Cross-train team members as fully as possible to allow for emergency coverage when necessary.
• For staff that are able to work remotely, make sure they are set up to do so. Clearly communicate expectations related to productivity and work hours.
• Manage patient volume by proactively messaging patients scheduled for in-office visits, and reschedule visits via telemedicine if necessary.
• Stay in contact with local temp agencies if some positions can be filled with a temporary worker.
For more ideas on staffing challenges and other COVID-19 issues, register for the next AAAAI Virtual Practice Management Workshop webinar, Engineering Your Practice for the Continuing Crisis, on Thursday, August 27 at 7:30 pm CDT.
Communicating With Your Patients Is Critical During COVID-19
Your patients continue to be bombarded with information on COVID-19 daily, and many may still be confused about how to safely manage their allergic disease in face of the continually changing information. They will look to you for guidance on how to minimize risk, and determine which information sources are credible and which are suspect. Here are a few ideas:
• Make sure all of your practice’s COVID-19 precautions and requirements are prominently displayed on the homepage of your website, and communicated via text, email or phone call before the patient’s appointment. This will help calm fears about the safety of visiting the office.
• Continue utilizing telemedicine visits for appointments when appropriate. This helps reduce the number of people in the office and reduce the volume of PPE needed for your staff. Some patients may prefer telemedicine visits to in-person visits and will appreciate having this option.
• Provide your patients with information from credible sources, such as the Centers for Disease Control and Prevention (CDC), World Health Organization (WHO) and AAAAI, and link to these resources from your practice website or provide any available handouts with the information.
Be sure to visit the AAAAI COVID-19 resources page for up-to-the-minute information, like our new patient handout on wearing a face covering or mask, which is available in English and Spanish.
Conducting Penicillin Testing With Telehealth
During the COVID-19 pandemic, allergists’ use of telemedicine has expanded significantly, and a large percentage expect to continue utilizing telemedicine even as patients return to the office. A new video lecture titled “Drug Allergy Assessment Using Telemedicine and Electronic Consultations” provides guidance on how to virtually evaluate drug allergy in both in-patient and outpatient settings. This allows for:
• Significant cost savings per patient, including both antibiotic cost and A/I physician time
• Limited in-patient traffic during the COVID-19 pandemic
• Continued de-labeling of penicillin allergy, to further antibiotic stewardship and reduce antimicrobial resistance
View the video lecture or visit the AAAAI penicillin allergy testing advocacy page for more information.
Resuming Allergy Practice
As stay at home restrictions begin to ease and your patient volume increases, make sure your office has protocols in place to ensure the safety of staff, patients, and physicians.
The AAAAI COVID-19 Response Task Force has created a list of Suggestions or Considerations for Resuming Practices that includes staff safety protocols, practice space logistics, and a classification of low, medium and high-risk procedures. These suggestions presume that the actual infectious state of your patients is unknown and that asymptomatic or pre-symptomatic patients can spread the virus.
Taking Care of Yourself During COVID-19
This is a stressful time. You’re doing your best to keep your patients, staff, family and yourself safe and healthy. You’re using new tools, like telemedicine, in day to day practice. You’re working to ensure the economic impact of the pandemic on your practice and your staff is limited.
During this difficult time, it’s important to remember to take care of yourself, so that you can take care of others.
• Read the article Clinician Wellness During the COVID-19 Pandemic: Extraordinary Times and Unusual Challenges for the Allergist/Immunologist for specific strategies during this uncertain time.
• Watch this new video from the AAAAI wellness group.
• Consider using a mindfulness or meditation app regularly. Some options are:
o Art of Living – Online Happiness Program for Healthcare Workers
o Ten Percent Happier
• Check out the AAAAI physician wellness toolkit for a broader array of ideas and resources.
Visit the AAAAI COVID-19 resources page regularly for updated information to help you and your practice navigate the quickly changing situation.
Certain HIPAA Provision Not Enforced for Telemedicine Due to COVID-19
During the COVID-19 national emergency, certain provisions of HIPAA will not be enforced for covered healthcare providers utilizing telehealth services.
Read the announcement, and visit our COVID-19 resources page for further telemedicine resources.
Be Aware of In Vitro Allergy Testing Reimbursement Limitations
Recent review of payer policies on in vitro allergy testing reveals several limitations to using these tests in lieu of or in addition to skin testing. Be sure to document in the medical record why you are doing such testing instead of skin tests or in addition to skin tests. If the payer decides not to pay, the patient may come to you for reimbursement unless you have them sign an Advanced Beneficiary Notice. Also, you should be aware of the annual limits that insurers put on these tests (usually in the 20-25 test range, but sometimes up to 35).
Ease Prior Authorization Headaches
Navigating prior authorization (PA) requirements is complicated and time consuming. Here are a few ways to minimize the burden:
• Anticipate which medications trigger the highest percentage of PAs and have a plan in place. Can you substitute a generic or other medication that doesn’t require a PA?
• Maintain a series of templates for your most commonly used medications and procedures that require prior authorization so you don’t reinvent the wheel each time.
• Designate a staff person (or a small staff team) to focus on PA rules that can serve as a resource for everyone in the practice.
• Customize your EHR software to alert you when a PA may be required, and take advantage of electronic submission portals when they’re available.
The American Medical Association offers a prior authorization tool kit, including videos and a downloadable tip guide.
The 2020 AAAAI Practice Management Workshop, July 17-19 in Washington, DC, will feature a session on “Prior Authorizations and Other Practice Headaches: Tips and Tricks that Work.” Get more information here.
Is 2020 the Year to Implement Telemedicine in Your Practice?
Support for and interest in remote healthcare visits by patients across the entire age spectrum has increased significantly in the last year. Improved technologies, lower costs and increased reimbursement for telemedicine visits could mean now is the right time for your practice to consider implementing these services.
Interested, but not sure where to start? Check out our helpful resources.
• The AAAAI Telemedicine Toolkit offers guidance on a full range of issues including reimbursement, privacy considerations, documentation and more.
• The November/December issue of The Journal of Allergy and Clinical Immunology: In Practice is devoted to telemedicine and electronic applications in allergy and asthma.
• Register to attend the 2020 AAAAI Annual Meeting, March 13-16 in Philadelphia, which will feature several sessions on telemedicine and technology, including a hands-on training station.
Managing Penicillin Allergy Testing in Your Practice
One of the primary ways to combat antimicrobial resistance begins with penicillin. Approximately 10% of the U.S. population thinks they are allergic to penicillin, yet 9 out of 10 are not truly allergic when formally tested. This provides a significant opportunity for allergy practices, and the AAAAI has several resources to help you manage the penicillin testing process:
• Optimal coding strategies for penicillin allergy testing
• Sample protocols and documentation for challenge testing from the 2019 AAAAI Practice Management Workshop
• AAAAI Penicillin Toolbox
• Information on AAAAI advocacy efforts on penicillin testing, policy statements, and patient education resources
Is It Time to Stop Calling Your Patients?
How much time does your staff spend calling patients to remind them about appointments, provide lab results and verify insurance coverage, only to end up leaving voicemails and playing phone tag? If you’re looking for a more efficient (and effective) way to communicate, consider texting your patients. Recent studies show:
• 95% of your patients own cell phones, including 91% of adults 65 and older.
• 98% of texts are read, 95% of them within 3 minutes.
• Most Americans would rather receive a text than a phone call, and more than 30% of voicemail messages go unheard for three days or more.
Text messages can be used as reminders, to provide education after the visit, or to increase compliance and adherence. Texts can also be used to provide updates on unexpected schedule changes (for example, a blizzard forces you to close the office for the day). For more on effective patient communication strategies, read this blog post from Physicians Practice.
Getting Approvals for Immunoglobulin and Other Biologic Therapies
Obtaining insurance company approvals for immunoglobulin (IG) therapy is, for many physicians, among the most unpleasant aspects of patient care. Here are some tips for simplifying the process that have been shown to routinely result in gaining the required approvals.
Before You Start
It is crucially important to know the ground rules for IG therapy in PIDD both generally and in relation to the specific insurer. Particular payers often consider particular diagnosis codes to be supportive of the need for IG and other codes not. If you use the wrong code, there will be an immediate denial. Now that some payers are using preferred drug lists (PDLs) limiting the options with regard to brand, you must know the payer’s PDL as well. Usually, this information is available on the payer website or from the payer provider rep, but sometimes the payer keeps it a secret requiring the physician to make their best guess.
It goes without saying that it will be easier to get an approval for a patient who clearly meets clinical and laboratory criteria for IG therapy. Before you start your letter, you should be familiar with your patient’s history, particularly significant events like an episode of meningitis or osteomyelitis and have relevant diagnostic labs compiled. You should also be clear about the IG product and mode of administration you want to use.
Writing the Letter
Start the letter by saying what you want, for example: “I am writing to request authorization for immunoglobulin supplementation therapy for the above referenced patient with a disorder of antibody production. I have recommended intravenous immunoglobulin therapy for this patient.”
Less is more! Keep the IG approval letter to one side of a page and use the same description of the patient’s history, for example: “This patient had a long history of recurrent bacterial respiratory tract infections. An immunologic evaluation demonstrated disorder of antibody production (laboratory studies attached). The specific diagnosis is listed below. Because his infections could not be controlled with the most aggressive conventional therapy, this patient needs immunoglobulin supplementation therapy.”
List the ICD-10 code and its description, the specific product name with its J code followed by the dose in grams and the infusion mode and interval. Here’s an example with each of these elements printed in bold on a separate line*:
D80.0 – X-Linked agammaglobulinemia, autosomal recessive agammaglobulinemia, hypogammaglobulinemia
Drug: Carimune J1566
Dose: 30 grams
Interval: every four weeks
Enclose copies of the diagnostic supporting lab studies with the letter.
A similar approach can be utilized for omalizumab for asthma, beginning the letter with a brief description of criteria (e.g., moderate to severe asthma), the last weight and IgE level and their dates, and closing with the dose (in vials and milligrams) and interval.
*This example uses a drug name and J code that is no longer on the market to avoid promoting a particular brand.
Take Control of Your EHR
As of 2017, 86% of office-based physicians had adopted an electronic health record (EHR). Since 2008, this has more than doubled, from 42% to 86%. While the promise of EHRs was to improve our access to patient data and streamline ordering and billing, increasing evidence suggests it is making our work day more difficult. A study published this past year found that the use of EHRs contributes significantly to physician stress and burnout, adding to our daily frustration level. Physicians also reported having inadequate time for documentation and spending large amounts of time working on EHRs at home. It is not too late to optimize your current EHR.
1. Ensure you are up to date on your version of your EHR. While upgrading may seem laborious and unnecessary, upgrades are usually better versions, often with additions recommended by providers. This also ensures ongoing interoperability with your practice management software and other IT tools.
2. Ensure adequate training after upgrades. The amount of training providers get on their EHR correlates with satisfaction levels. This is not only true during initial instillation but also for upgrades. Have a “provider champion” review the upgrade notes and share the info with all the providers.
3. Ensure your clinical workflow takes advantage of your EHR capabilities. Maximize the amount of information your front desk, then medical assistant or nurse can enter into the EHR before sending the patient chart to you. Document as much of the chart note as you can while the patient is still in the office, leaving less to have to go back to later.
4. Let individual providers adapt processes that work best for them. Not everyone has to do it the same way. Some providers may do better typing their notes into the EHR, some may prefer to dictate parts or all of their notes, and some may do better with a medical scribe.
Ongoing optimization can be crucial to keep your EHR working for you.
Percentage of office-based physicians using any electronic health record (EHR)/electronic medical record (EMR) system and physicians that have a certified EHR/EMR system, by U.S. state: National Electronic Health Records Survey, 2017 pdf icon[PDF – 371 KB]
Rebekah L Gardner, Emily Cooper, Jacqueline Haskell, Daniel A Harris, Sara Poplau, Philip J Kroth, Mark Linzer, Physician stress and burnout: the impact of health information technology, Journal of the American Medical Informatics Association, Volume 26, Issue 2, February 2019, Pages 106–114.
Monica Kate. 11 Ways Medical Practices Can Get More Out of Their EHR Systems. Accessed 28 July 2019
Hiring the Right Staff for Your Practice
Your patients’ perceptions of your allergy practice depend not just on the care provided by the physician, but also on their interactions with your practice staff, from the front desk to the MA to the nurse. How can you ensure you’re hiring (and keeping) high quality staff?
• Make sure the job description is up to date and potential employees are clear on expectations and responsibilities.
• Review applications carefully to ensure applicants have the right experience and training, and don’t be afraid to contact references.
• Ask open ended questions during the interview, and if possible, have the final candidate spend a couple of hours shadowing staff in the practice.
• Once hired, make sure the new employee gets a thorough orientation to the job and the practice.
For more insights on hiring the right staff for your practice, pre-order the recordings from the 2019 Practice Management Workshop, or read the chapter on Staffing and Human Resources Issues in the Practice Management Resource Guide.
Implementing the New USP 797 Standards in Your Practice
New USP Chapter 797 standards on sterile compounding were released June 1 and take effect December 1. Practices have the option of preparing extracts using an ISO Class 5 Primary Engineering Control (PEC) OR in a dedicated Allergenic Extracts Compounding Area (AECA). Additional personnel qualifications and training is also required to be in compliance.
The AAAAI website has a variety of resources to help your practice meet these standards, including:
• An overview of the new standards and requirements for allergy practice compounding areas
• Personnel qualifications, hygiene and training requirements
• A podcast episode with Andrew W. Murphy, MD, FAAAAI, where he breaks it all down and provides background, details about Chapter 797, and tips for implementation
The AAAAI Practice Management Workshop, July 12-14 in Cincinnati, will feature an expert session on implementing the new USP 797 standards in your practice, along with other important practice management topics. Online registration is open through July 1.
HIPAA for the Practicing Allergist
HIPAA is an acronym for the Health Insurance Portability and Accountability Act of 1996. “Privacy” and “Security” are not in the name HIPAA, but they present our biggest challenges.
The Office of Civil Rights revenue from HIPAA violations has doubled every year since 2012. Practices of all sizes are at risk, but smaller size practices are at higher risk. The practice or business can be fined for HIPAA violations even if a breach doesn’t occur. That is the case when a Business Associate does not comply with the HIPAA rules.
Business Associates (BAs) are individuals or entities who create, receive, maintain, or store private health information on behalf of a covered entity. Answering services, medical transcription, IT groups, billing companies, and shredding services are considered BAs.
HIPAA requires that BAs must now:
• develop policies and procedures for HIPAA, as well as train staff
• conduct risk analysis
• be subject to federal inspections
• monitor covered entities where a Business Associate Agreement exists and have Business Associate Agreements with sub-contractors
• be subject to the HIPAA Breach Notification Rule
In 2019 the major issue is communicating with patients and providers utilizing emails and text messaging while complying with the HIPAA rules.
To learn more, attend the 2019 Practice Management Workshop, July 12-14 in Cincinnati, Ohio.
Be Aware of Insurer Skin Testing Limits
Insurers are beginning to limit the number of skin tests a patient may have over a period of years (the time varies with insurer). If your new patient has had previous testing, you may not get paid. Be sure to familiarize yourself with the limitations of your most prevalent insurers so you are not surprised! The AAAAI Office of Practice Management is working with insurers to make sure that these limitations are reasonable. For example, there should be no skin test restrictions when a patient is changing allergists.
Click here for more information on additional AAAAI advocacy activities.
Looking for other great practice management ideas? Register for the 2019 AAAAI Practice Management Workshop, July 12-14 in Cincinnati, Ohio.
Don’t Be Afraid to Negotiate Your Employment Contract
Whether you’re starting your first job after fellowship or are well into your allergy career, you can successfully negotiate (or renegotiate) your employment contract. Here’s how to start:
• Read up on negotiation strategies and practice your pitch.
• Research the market value for allergists in your area so that you have an idea of what you can reasonably expect.
• Remember that base salary is only part of your overall compensation package, which can include benefits like health, malpractice and life insurance, paid time off, CME days/CME allowance, relocation or moving allowances, and more.
The AAAAI Practice Management Resource Guide has more specific information on contract negotiation strategies, and this post on the KevinMD blog includes some great ideas for how to determine your market value.
Early career allergists can learn contract negotiation strategies from seasoned employment attorney Penny Phillips, JD, at the 2019 AAAAI Practice Management Workshop, July 12-14 in Cincinnati, Ohio.
Many insurers are requiring proof of reversibility of airway obstruction for the approval of biologics. By the time the patient needs biologics, however, documenting reversibility may be difficult.
Remember to be sure that this test is performed at some point early in the course of asthma, if appropriate, so you have documentation when the time arrives. The AAAAI Office of Practice Management is corresponding with these insurers about the practicality of this requirement.
Successful Practice Transitions
With increasing mandates and complexities of practice, many physicians are either selling or closing a practice or joining larger entities in order to reduce financial and administrative burdens. Here are some things to consider if you’re:
Selling your practice
- Plan as far in advance as possible, and have a timeline for specific tasks.
- Assemble a team of experts – accountant, lawyer, appraiser – to help the sale go smoothly.
- Eliminate as much practice debt as possible, and hold off on making major technology investments.
Closing your practice
- Review your vendor, service and managed care contracts for notice requirements.
- Notify patients, staff and your insurance carriers as early as possible (at least 90 days prior to closing).
- Make arrangements for record storage and maintenance according to state regulations.
For more tips on transitioning your practice, view this presentation from the 2017 AAAAI Practice Management Workshop.
Start the New Year Off on the Right Financial Foot
Get yourself and your practice off to a good start in the new year by taking some time to think about your financial goals now.
Physicians start their first real job relatively late in life, and many have little or no financial experience and a significant debt load. It’s never too early (or too late) to get yourself on the track to fiscal fitness:
• Live below your means. Aim to save 15% of your gross income every month and set up a sensible household budget that covers your needs and wants. Consider buying a smaller house or less expensive vehicle until you are financially well-off.
• Build an emergency fund, then prioritize paying down debt (higher interest rate loans first).
• Whenever possible, use low cost, index mutual funds to invest.
• Diversify your investments to include an appropriate allocation of stocks and bonds, and make sure you are investing appropriately for your age and risk tolerance.
• Never try to time the market. Rather, periodically rebalance your portfolio to ensure that your desired asset allocation is maintained.
• Maximize your tax efficiency. Take advantage of tax-deferred plans like 401(k), 403(b), IRAs, 529s and HSA accounts. These allow your investments to grow tax-free.
For Your Practice
• Do you have patients with high deductible health plans (HDHPs)? Consider utilizing a credit card on file to automatically collect payment at time of service, or use them for monthly budget payment plans.
• Review your payer contracts and update your fee schedule annually. Keep a master list of your payers and their allowed charges to help you identify potential problems early.
For more financial tips, view these presentations from previous AAAAI Practice Management Workshops:
Revenue Cycle Management: From Appointment to Payment and Beyond
Personal Finances and Investing for the Physician: A Boglehead’s Approach
Studies show that a high performing medical practice with a strong culture:
Do You Know Your Practice Culture?
• Can adapt more easily to changes in the marketplace
• Has employees who are more engaged, productive and aligned with the practice mission
• Benefits from lower employee turnover and less stress and burnout among physicians and staff
All of these factors contribute to higher patient satisfaction and a better bottom line for the practice. For more information on how to assess and improve your practice culture, view these slides from the 2016 AAAAI Practice Management Workshop.
Is Your Practice Prepared for an Audit?
Today, it’s a matter of when, not if, your practice will be audited. While audits can be nerve-wracking, there are things you can do now to ensure your practice is prepared for the inevitable.
• Keep meticulous records of your expenditures. File them on a regular basis (preferably monthly) and store them by calendar year. This will make it easy for you to assemble documentation quickly for the auditor.
• Create a checklist for your financial activities, from front desk collections to tax filing procedures. Make sure the staff responsible for these activities follow the checklist, and train new staff in your procedures as part of your onboarding system.
• Keep personal and business accounts separate.
For more practical details, listen to A Step by Step Guide to Surviving Practice Financial Audits from the 2018 AAAAI Practice Management Workshop.
Disaster-Proof Your Practice
Extreme weather events such as hurricanes, tornados, floods and wildfires are occurring at an increased rate. Is your practice positioned to weather the storm? Here are some lessons learned by Coastal Allergy & Asthma in Savannah, Georgia after Hurricane Matthew:
• Have a written disaster plan/procedure and make sure your staff is familiar with it. When emergencies arise, initiate your plan to ensure the safety and well-being of practice staff and patients.
• Closely review your business interruption insurance policy to make sure it will cover your operating expenses in the case of an unexpected shut down. It is also important to know what events trigger the insurance. As Coastal Allergy & Asthma found out, a mandatory evacuation order for an impending hurricane was not enough.
• Make sure you have a back-up generator in case of power failure and know how to start it manually.
• After the disaster, carefully inspect your property for potential damage.
Get more disaster preparedness tips and a sample plan here.
Does Cyber Insurance Make Sense for My Practice?
Allergy practices are experiencing escalating day-to-day operating expenses, but one expense we may no longer want to delay is the purchase of cyber insurance. In a 2017 survey by the American Medical Association and Accenture, 83% of physicians reported experiencing some sort of cyber attack. An accidental or deliberate patient data breach can cost your practice over $100,000 plus penalties.
What does one need to look for in a cyber policy? There are key categories that seem to be standardized in each cyber policy, but a comprehensive policy will cover losses resulting from patient data being stolen, exposed or improperly shared. It will cover breaches from deliberate actions, such as hacking or ransomware, as well as accidents (such as a lost laptop containing unencrypted patient data). You’ll want to sit down with your insurance broker and compare policies side by side to determine which option is the most cost effective for your practice.
Looking for more practice tips? Order the recordings from the 2018 Practice Management Workshop. Topics include billing, coding, financial benchmarking and more.
Maximize Your Revenue by Avoiding Common Billing Blunders
Conducting an annual audit of your practice’s revenue cycle management processes will help you avoid costly errors that can negatively impact your collections. Make sure to:
• Determine the patient’s benefits prior to the appointment (when possible) and collect co-payments at the time of the visit (always).
• Review all insurance payment guidelines at least every 6 months to ensure you are submitting appropriate and timely documentation for claims. This will decrease denials and staff time required to file appeals.
• Code each patient encounter appropriately, to the highest level of service supported by documentation.
AAAAI coding consultant Teresa Thompson and Tessie Adams will be reviewing these tips and more at the 2018 AAAAI Practice Management Workshop in Salt Lake City during their session “Beyond Correct Coding: Getting Paid for What You Do and Avoiding Billing Blunders.” Can’t make it out to Salt Lake City for the workshop? Preorder the recordings here.
Implementing Telemedicine into Your Practice
Have you seen a decline in growth in your practice? Telemedicine may help increase that growth with some considerations.
• Decide what the best work flow may be for your practice, whether it’s practicing telemedicine one day a week, in between in-person consultations or something else.
• If you implement telemedicine it must be secure and compliant with state and federal regulations.
• It is important to confirm that medical liability coverage includes a provision for telemedicine services.
• You don’t want to water down your current level of care so ensure your live interactive video visits with patients be at the same standard of care, professionalism and ethics as your in-person consultations.
For more tips on incorporating telemedicine into your practice, register for the 2018 Practice Management Workshop, July 20-22 in Salt Lake City, Utah.
Navigating the Solo Allergy Practice
Although the majority of fellows-in-training and young physicians join existing single specialty and multispecialty groups as well as academic institutes, a number of new grads are either considering or have already started solo practices. If you are in solo practice or considering solo practice, these tips are for you.
1. The stability and survival of a medical practice depends on its financial success. And the financial success depends on having a steady flow of patients, providing excellent patient care, good management and controlling the overhead while delivering the best care. Recruiting patients in solo practice is highly dependent on the physician’s reputation, which is in contrast to group practices where the flow of patients is greatly influenced by the reputation of the group or senior partners. To this end:
- Make sure your patients are having a great experience when they visit your office from scheduling to billing and collection.
- Learn appropriate scheduling to avoid having patients wait in the exam rooms or waiting room more than 10 minutes to see you.
- Listen and address patients’ concerns.
- Explain why you are doing any investigations or testing.
- Involve your patients in the decision making regarding treatment options and remember: satisfied patients are the best free advertisement for your practice.
2. When seeing a patient, communicate with the primary care provider even if the patient was not referred to see you.
3. Don’t speak negatively about other physicians. Not only it is unprofessional, but patients will not respect you or your medical opinion.
4. Hiring an experienced practice manager may not be financially feasible in first 5 to 7 years of practice and in some instances might discourage you from learning how to manage a practice. Consider hiring an assistant manager or attending the annual AAAAI Practice Management Workshop. The workshop will provide you with tools to understand all aspects of hiring, training and retaining staff, as well as scheduling, billing and understanding financial benchmarks. You also have the opportunity to network with a large group of allergy/immunology physicians and office managers with a wide range of expertise.
Utilizing Nurse Practitioners and Physician Assistants in an Allergy Practice
Are you considering hiring a nurse practitioner (NP) and/or physician assistant (PA) in your practice? Adding an NP or PA can:
• Expand physician schedule capacity
• Generate additional practice revenue
• Allow quicker access for acute visit patients
At Allergy, Asthma & Immunology Center of Alaska, one NP and one PA support five allergists at one location, according to Melinda Rathkopf, MD, FAAAAI. “Our NP and PA do routine follow-up visits (like annual immunotherapy visits), not new patient visits. They often have more availability to see acute visits quickly and are the first to respond to shot room reactions. They are an invaluable addition to our clinic and allow the allergists to focus on more complex patients.”
To ensure a good fit for your practice, you’ll want to assess if the NP or PA candidate shares your practice philosophy and is able to collaborate and adapt to your style of medicine.
For more tips on incorporating an NP or PA into your practice, view this presentation from the 2016 AAAAI Practice Management Workshop or register for the 2018 workshop, July 20-22 in Salt Lake City, Utah.
Given the current and future healthcare climate, physician health and wellness is and will remain a significant issue. Here are some tips for the individual physician to help improve wellness and reduce burnout:
• Take care of yourself. Physicians are often involved in taking care of family members, including spouses and children, in addition to treating patients. Maintaining adequate sleep, nutrition and exercise is important, as is making sure to address your own physical and emotional issues by regularly seeing healthcare providers.
• Find a sanctuary outside of medicine. Take up a hobby or volunteer for a cause you believe in to help alleviate the daily stresses of practice.
• Take your scheduled vacation time to destress and allow a “recharge” of energy. Many physicians do not fully use their allotted vacation times.
• Take small breaks during the work day, including breaks from electronic devices.
• Focus on the positive aspects of work as well as family and personal issues, and maintain a sense of humor regarding these topics.
Remember, as healthier allergists/immunologists, we can be even better advocates for our patients and our wonderful specialty.
Reference: Nanda A, Wasan A, Sussman J. Provider Health and Wellness. J Allergy Clin Immunol Pract 2017; 5: 1543-8.
Sexual harassment allegations have made the news repeatedly in the last few months. The AAAAI has added a sample anti-harassment statement and policy here for your consideration, but remember to always consult legal counsel in your own state before adopting any new policies and procedures in your practice.
Sample Anti-Harassment Statement and Policy
Looking for more ways to improve your practice? Select recordings from the 2017 Practice Management Workshop are available for purchase in the AAAAI Continuing Education Center. Registration for the 2018 Practice Management Workshop, July 20-22 in Salt Lake City, Utah, will open March 1.
Use Social Media to Engage with your Patients and your Community
A recent Google Think survey found over 76% of patients were getting their healthcare information online. Make sure your practice website is up-to-date and engaging, and then leverage other social media platforms to engage with your patients and your community.
• Facebook: Establish a Facebook page for your practice and post information regularly (weekly, at a minimum, is best). Ask patients to “like” your practice page. Keep your personal Facebook page separate and don’t accept “friend” requests from patients.
• Twitter: Why Tweet? It’s a real time network with more than 328 million monthly active users. Use Twitter to communicate simple messages like pollen counts, shot hours and office hour changes. Build up a network of followers and connect with other allergists on Twitter.
• YouTube: This video sharing site can help you market your practice. Post short videos on key allergy topics, procedures (patch testing, etc.), or to answer common patient questions. You don’t need expensive equipment. You can use your smartphone to record and upload the video.
Find more tips on our Social Media 101 page, or Take a look at the slides from the 2017 Practice Management Workshop session on new practice marketing techniques. (Only AAAAI members can access this document.)
Do You Need an Employee Handbook?
An employee handbook is needed whether you are a solo physician, practicing in a single specialty or part of a multispecialty group. It is the document that will provide your employees with the proper guidelines and rules that govern your practice and will allow you to reward or discipline an employee when needed. Fair employee treatment cultivates loyal employees. The employee handbook should include the following:
1. Mission and vision of the practice. It’s important to invest in developing a mission and vision that reflects your goals and beliefs and fits your practice style. Great mission and vision statements will motivate your staff.
2. Job titles and descriptions for all categories of the office staff.
3. The office hours of the practice.
4. What constitutes part-time and full-time employment and what benefits each are entitled to receive.
5. An outline of all benefits (medical and dental insurance, life insurance, CME allowance, PTO) and how to qualify for them.
6. A description of what actions result in disciplinary actions, as well as steps for disciplinary actions.
7. Rules about use of cell phones during office hours and personal use of office computers.
8. A statement and mandatory education on the Health Insurance Portability and Accountability Act (HIPAA) including the consequences of HIPAA violations.
9. Your sexual harassment policy, including your complaint or investigation procedure.
Employees must read the handbook and sign an acknowledgment that they read it. The signed acknowledgement should be page kept in each employee’s file.
Looking for more ways to improve your practice? Select recordings from the 2017 Practice Management Workshop are available for purchase in the AAAAI Continuing Education Center. Registration for the 2018 Practice Management Workshop, July 20-22 in Salt Lake City, Utah, will open in March.
Is your practice experiencing declining reimbursements? Here are some tips consultant Ron Howrigon shared during the 2017 Practice Management Workshop:
Negotiating Managed Care Contracts
• Negotiation is a process, not an event. Your first plan generally won’t survive the first round; be prepared to adapt, adjust and overcome.
• Set goals for your negotiation. Reimbursement rates are essential, but contract language can be just as important. Set your opening position, identify areas open for negotiation and be clear on your walk away points.
• Knowledge, analysis and planning are essential for a successful negotiation. To strengthen your position, make sure you:
- Create a master fee schedule of each payer’s reimbursement level.
- Know your payer mix. How hard do you want to negotiate with a company that is only responsible for 6% of your payments?
- Know your contracts. Create a contract summary form that includes the fee schedule, effective dates, contract point outliers, etc. for each payer.
This session and other select recordings from the 2017 Practice Management Workshop are available for purchase in the AAAAI Continuing Education Center. Mark your calendar for the 2018 Practice Management Workshop, July 20-22, in Salt Lake City, Utah.
Reducing Physician Burnout
Physician burnout can be caused by excessive workload, poor work-life balance and lack of control. Here are some tips from the American Medical Association (AMA) Steps Forward Campaign to reduce physician burnout:
1. Daily huddle with your team: Spend 5 to 10 minutes each day talking to your nurses and other office staff to plan how your day might go. Discuss the scheduled patients who might need more time with the provider or need any labs, tests and records to be retrieved or done before seeing the provider.
2. Have a documentation team: Nearly half of providers say they spend too much time on clerical tasks. Have your nurses help you enter clinical data. Train them to get better on their technology skills. Increasing the number of your support staff might actually save you more money. Consider hiring a medical assistant to serve as your scribe and as your nursing assistant.
3. Better prescription management: When prescribing a medication, consider prescribing a 90 day supply of medicines with 2-4 refills and try to be consistent in doing this. It will reduce the number of calls into your office for refills and other prescription changes. If a patient calls asking for refills, then you and your staff know immediately that a patient has not been to your office in a while and needs a follow up appointment.
Visit the AAAAI Continuing Education Center to order the recordings from the 2017 AAAAI Practice Management Workshop, which includes the topic "Practice Transformation: Reducing Burnout and Rediscovering the Joy in Practice."
Handling Biologics in Your Practice
Here are a few tips from the 2017 Practice Management Workshop presentation on How to Handle Biologics in Your Practice:
1. Determine the number of patients that your practice has on biologics. It might be time to assign or hire a person on your staff to solely manage the handling, billing and administration of biologics.
2. Keep a detailed inventory and tracking log, and update it every day. The log should include patient names and insurance and specialty pharmacy information, payment information, dosage, and vials and milligrams used.
3. Do not forget about disaster management. In light of the most recent weather-related disasters, do not forget about having disaster insurance on your inventory of biologics and allergy extracts and vials. Even a simple prolonged power outage can destroy thousands of dollars’ worth of biologics, extracts and medicines.
To learn more tips, the AAAAI is offering select recordings of the 2017 Practice Management Workshop for purchase at the AAAAI Continuing Education Center.
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