Office efficiency: Small changes mean a lot

August 6, 2009
John Jesitus

John Jesitus is a medical writer based in Westminster, CO.

Tips for an efficient, harmonious office range from staying on top of patients' deductibles to taking regular four-day weekends, an expert says.

Aiken, S.C. - Small adjustments to one's office routine can reap significant savings, says a busy South Carolina dermatologist who has been refining her procedures since 1981.

To simplify the check-in process, Margaret H. Fitch, M.D., Aiken Dermatology And Skin Cancer Clinic, Aiken, S.C., emphasizes updating as much patient information as possible over the phone before the patient arrives - or with new patients, upon first phone contact.

"I find it's key to get that initial information - their address, their phone number and their insurance. Insurance is important because I do not participate with several carriers," Dr. Fitch says.

Staff members must inform patients of this fact up-front "or else they'll show up, and they're upset that you're not in their network," she says.

She also recommends providing telephone reminders two days before appointments because it helps to minimize one's no-show rate.

p>"It's a reminder only. We must consistently point out to our patients that we are not babysitters - if they make the appointment, it's their responsibility to keep the appointment."

To that end, she emphasizes the importance of getting a copy of one's no-show policy acknowledged and signed at check-in.

In this area, Dr. Fitch's document says she charges $25 for a first missed appointment without notice, $50 for second, and after a third she suggests patients seek treatment elsewhere. However, she says, "We understand emergencies and broken-down cars. So I always waive the fee" for a patient's first no-show and charge $25 for the second.

Along with pulling files the night before the appointments for which they're needed, Dr. Fitch says dermatologists should attach the necessary superbills and referral letters.

"In South Carolina, you cannot charge a consultation fee without a written referral. You can't just ask the patient, ’who referred you?’-

Also the day before the appointment, she says, "Always check the deductible. Our receptionist finds out exactly how much each patient's deductible is and how much the patient has met already." This way, patients can't argue about their payment amounts after their appointments, Dr. Fitch says.

When the patient arrives, "Copy his or her address-bearing photo ID. We've been doing this for 10 years, because there have been instances where patients without insurance show up with someone else's insurance card," claiming to be the person named on the card.

"Another reason for copying the photo ID is that in my state, if you don't have a physical address on the driver's license and the patient defaults, you cannot send them to collections" with a post office box number. To coax addresses out of patients in a neutral manner, Dr. Fitch recommends asking them where the EMTs would go if the patient has a medical emergency.

"Always obtain a cell phone number and e-mail address," she adds. "I find it very important to have that e-mail address." With it, Dr. Fitch can share information such as test results if the patient doesn't respond to repeated phone calls requesting an in-person appointment.

""I can print it out and document for the record that I have notified the patient."

Also in these situations, "if we left three phone messages and 14 days have passed, we always send the patient a certified letter" containing the test results.

Regarding patient visits, Dr. Fitch says that assembling surgical trays with patients' names the day before their appointments helps surgeries run on time.

Her staff also draws lidocaine/bicarbonate syringes approximately twice weekly. To bring them to room temperature before injection, "The nurses carry them in their pockets. If you're going to do a biopsy (or a second biopsy at the same visit), you don't want to run out to central supply to pick up that syringe."

She also recommends assembling biopsy trays twice weekly.

To keep track of each day's schedule, Dr. Fitch uses color-coded check-off sheets. "We put a printout on the bulletin board in the nurses' station."

By using different colors for each type of patient (new, returning, surgical or cosmetic), "I can glance at it first thing in the morning and know what I'll be doing that morning." During the visit itself, Dr. Fitch says her patients greatly appreciate that she draws blood in the office rather than sending them across town for this service.

She also recommends holding surgery trays with patients' names on them for two to three days after their visits in case a specimen gets misplaced, and inserting wire mesh strainers over sink drains so small surgical instruments can't get lost there.

"Use a template to document all visits," Dr. Fitch adds. This form should include a section to record what time the patient enters and leaves the exam room, she says.

"We've all had that patient who comes in with only one problem, but you're in there forever." Bullet items alone might record only one or two anatomical areas examined, "So you can't fully document the level of care provided to the patient. But you can justify the level by the amount of time spent with the patient."

To simplify the checkout process, she suggests constructing an insurance table comparing all participating carriers' allowables. It's important for staff members to be able to find this information at a glance, Dr. Fitch explains.

Furthermore, she says, "When I get a new contract that an insurer wants me to sign, I look at what they say they're going to pay, and I can easily compare this to what I'm already being paid by other carriers."

Regarding other paperwork, she advises faxing all referral letters to eliminate postage. "It doesn't sound like much, but if you're sending a bunch, it adds up."

When patients book a follow-up appointment, Dr. Fitch adds, "Always hand them a physical appointment card." On the rare occasions when a patient shows up without an appointment recorded in the office's booking software, their showing the receptionist this card quickly clarifies any confusion, she says.

As for employee training, Dr. Fitch says having an employee manual is crucial. "Nothing's tougher than training a new medical assistant. They come in knowing nothing about skin." Even if they've worked for other physicians before, she says, "skin is so different, they don't have a clue. I also caution you not to hire a medical assistant who has worked for another dermatologist."Dr. Fitch says both times she has done this, it proved extremely difficult to shift the assistant from the way the previous dermatologist did things to the way she wanted them done.

Conversely, she says closing the office for a four-day weekend once a month - adjusting her hours accordingly to compensate during the rest of the month " has proven very worthwhile for her and her staff.

Somewhat similarly, Dr. Fitch schedules a 20-minute interval every afternoon so staff members can complete chart work without having to stay after closing time.

""I've found that many of these small efficiency items can add up to a happier work environment for the physician, staff and patients," she says.DT

Dr. Fitch reports no relevant financial interests.

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