Dynamic Chiropractic - February 9, 1998, Volume 16, Issue 04|
Solutions to Preventing Practice Pollution
by Gerald T. Lalla, DC, and Diane Lalla, CA.
It doesn't take 20/20 vision to see that we practice in the age of documentation. As repulsive as that might be for many health care providers, if we expect patients, third-party providers and regulatory agencies to understand and agree with our diagnoses, treatment plans and procedures, we have to provide adequate documentation. Those who attempt to take shortcuts or refuse to establish and maintain universally accepted office procedure systems (that easily and efficiently collect and provide copies of patient records) make themselves prone to problems with insurance companies, health maintenance organizations, boards of examiners, governmental agencies and patients. As important as it is to provide excellent diagnostic and treatment services to our patients, the age is upon us where third-party persons are going to make life difficult for practitioners who fail to provide the documentation they require. Even though there are some office procedure and technique teachers who teach and/or sell systems that attempt to support their philosophies, many do not hold up when they are scrutinized by insurance claims handlers, boards of examiners, peer review and/or record review organizations.
In this and forthcoming articles, we will be reviewing practice management problems and simple, inexpensive solutions that not only offer the opportunity for more than adequate documentation, but office procedures that make diagnosing and dispensing care both cost effective and efficient. In essence, we will be discussing principles of risk management from the perspective of reducing your risk of having problems with patients, boards of examiners, insurance companies, malpractice and IMEs (independent medical/chiropractic examiners) and records reviewers. What we share is based on 30+ years in private practice, teaching undergraduates and postgraduates in chiropractic colleges, and consulting for many law firms and health insurance companies in the U.S.
You Are Not a BusWe accept the fact that chiropractic care can help everyone, but not everyone should be your patient. Every practitioner should eventually recognize their special calling or anointing in the type of conditions and personalities they are best suited to care for. You should make up your mind what you want to do in practice and achieve in life. This is very important, as you cannot be everything to everybody. Even though chiropractic care is good for everyone, there are certain people, personalities and conditions that we as individuals are not called or anointed to care for. The practitioner who doesn't look for their practice personality profile is going to be like a bus that picks up anything and anybody that comes their way. They will pick up and carry around problem patients and the problems generated by those patients in their practice, with insurance companies and with boards of examiners, all of which are avoidable.
Establishing Your Profile -- Your Niche -- Your Likes and DislikesThe key is to find out those conditions you like to take care of and those you don't like to take care of (acute/chronic); what you're really good at and what you're not so good at (maintenance, rehabilitation, metabolic, etc.); the types of personalities you are comfortable with and those you are not comfortable with (aggressive, passive, passive/aggressive, choleric, sanguine, melancholic or phlegmatic); and the type of financial relationships you're comfortable with (cash, accounts debatable, insurance, HMOs, etc.).
There Is No Need to Accept Lack or Failure in Your LifeYou were not created by mistake or without a divine destiny. You have a special anointing (niche) or calling. In God's creation of you, he has provided opportunities for more than adequate numbers of people who need your special anointing. Unlimited numbers of people do exist who need what you have to offer now, and there are untold numbers of people who are going through situations that will cause them to need your care tomorrow and throughout your entire future. There is never a lack of people who need your specialized products, services and ideas. If there is an interruption in the flow of patients into our offices, we have to look in the mirror for the cause, as we are the ones who attract and/or interfere with their attraction to our offices. This is relative to our failure to establish a professional practice profile of who we are, who we are best suited to relate to, and the basis on which we care for them.
You Control Your DestinyYou are the one who should decide the types of conditions and personalities you're best suited for, not some other person, school, treatment technique, philosophy or practice management teacher. Nor should volume of patients seen per day be the thing that validates you. We should be validated by filling our present place in accordance with our individual divine destiny. Once you make up your mind as to what you like and want, those decisions should be followed through in your office procedures. That begins on the telephone.
Taking Shortcuts Increases Your Risk of ProblemsMany practitioners are more treatment-oriented than diagnostic-oriented. They tend to take shortcuts in the history and examination, and inadequate case histories and examinations prevail. These short cuts contribute to misdiagnosis, incorrect diagnosis, malpractice, poor treatment planning and insufficient documentation, all of which are unnecessary and avoidable. Plan Good Work and Consistently Work Your Plan
Even though we are by and large a profession of treaters and fixers, we serve our patients and profession well if and when we consistently base what we do on proper consultation, examination and diagnostic testing. To make that process much simpler, faster and effective, we have a staff person who is responsible for telephone appointments. Part of her responsibilities are to take the prospective new patient's name, address, telephone number(s), major complaint, and (depending on the availability of the doctor) telling the prospective patient that she will either interrupt the doctor or that Dr. X will call that person back. A mutually agreeable time is established for the doctor to do a telephone consultation, which we'll discuss in more detail later in this article.
In our practice we have a "new patient telephone intake form" which not only allows the appointment coordinator to collect the patient's name, address, age, date of birth, telephone number(s) and major health concern for telephoning us, but allows the staff doctor(s) to take the patient's case history over the telephone. This form contains the usual categories of health problems that people typically call a chiropractor's office with the services provided, and the fees. Using it as a guide to follow and collect information during the telephone consultation is quick and simple with profound results. It allows you to document the prospective patient's symptoms, health history, family history and medications quickly and efficiently, which helps us determine if their condition is relevant to what we are called to care for. It also allows us to identify if an appointment should be given for an examination and what possible diagnostic tests might be indicated, based on what they've told us and on our usual and customary procedures regarding similar conditions.
Enter the Information into a Computer
If we feel that we should become involved with the patient and an appointment is given, the information collected over the telephone is entered into a computer (each office in our clinic has a laptop computer which all doctors and massage therapists use) that contains standardized documents for new patient consultation; initial examination; six different documents for reevaluations; one document for initial examination of those coming in for metabolic-related concerns, and several options for daily chart or SOAP notes.
Inform Before You PerformIf I feel an appointment is called for, I tell the prospective patient so and transfer their call to our appointment coordinator, who sets the appointment and also tells the patient the cost of the examination and our fee policy. Other than conditions related to automobile accidents, all services are rendered on a cash basis.
Patient Acknowledgment/Sign Off FormWe utilize a form that lists all the potential services we offer in our clinic and check the services the patient has agreed to have performed. We explain those services, inform the patient that the tests may be considered to be investigational, and that they may not be found to be reimbursable by their insurance, Medicare, etc. We then have them date and sign that form as a confirmation that we informed them of the services, and that they understand and agree to what is stated on the form. All clinics are required to have Medicare patients sign such a form, but we've found that it's a good idea to have all patients sign such a form.
If the patient has an acute problem that we feel our schedule can accommodate that day, we get them in, then do the examination and other diagnostic tests called for. If the patient has a problem(s) that is not acute, then the examination fee is quoted, our payment policy discussed, and a mutual agreement regarding the payment for said services is established. If that appointment is made five or more days in advance, a member of our staff mails or faxes literature to the patient regarding our approach to conditions similar to theirs, and the "new patient entrance questionnaire" with instructions for them to complete the questionnaire and bring it with them on the day of their appointment.
We have our own website (http://www.greatphysician.com) for patient access. If the entrance forms are not mailed prior to the initial examination, the appointment is set for 30 minutes before their scheduled time to see the doctor. The doctor reviews the information gathered over the phone and moves quickly on to the examination. Doing so allows adequate time for the new patient to fill out the new patient entrance questionnaire and other questionnaires that you may deem necessary. The result is that you have saved you and your staff a great deal of time by doing a telephone intake consultation to determine if the prospective patient fits your niche, then discussing fees and payment policy, which eliminates a lot of talk, time and potential problems. The patient will have basically decided if you're the type of doctor they're looking for. They know what you believe should done on the first visit and what the costs of initial services will be. Whatever your established fee policy, they know what they'll be expected to pay. This eliminates all kinds of unnecessary problems that many offices struggle with.
In our next article in this series, we will look at the essentials of an effective consultation.
Gerald T. Lalla, DC