NP Practice Owners : Workplace Issues

NP Medical Home/Health Care Homes

Gretchen Moen — Thu, 08 Oct 2009 13:23:00 GMT

It has been a very busy fall for ECFC. In addition to general patient care and all the day-to-day administrative issues, we are faced with another task. The state of MN has mandated that all recipients of state-sponsored health insurance have access to and are members of a state-certified Health Care Home.

Eagan Child and Family Care is one of 15 recipients of a grant to attend the Institute or Family Centered Care Intensive Training session at the end of this month, in preparation for meeting the requirements to become a certified health care home. Our plan is to meet these requirements over the next 90 days. We are fortunate to have a DNP student who is helping us with this process as part of her doctoral project.

There are a number of agencies that offer some type of Medical Home or Health Care Home certification. Along with the State of MN, The National Committee for Quality Assurance (NCQA), The Joint Commission Accreditation on Ambulatory Care and Hospitals, Bureau of Primary Care/Health Resources and Service Administration, Medicare CMS Demonstration, and other state agencies. Some of these groups have fees associated with the process.

Criteria for certification for Health Care Home/Medical Home are slightly different, depending on which agency is involved, but there the basic requirements to measure performance are in these critical areas: patient access and communication, patient tracking and registry functions, care management, patient self-management, test tracking, referral tracking, performance reporting and improvement measures, electronic prescribing and advanced electronic communications. Within each of these areas there are components that are considered key and some that are highly recommended. Minnesota is developing a process to reimburse providers for care coordination services in an effort to defray the actual and potential costs of implementing and sustaining health care home services.

Care coordination, collaboration, patient centered care...these are the foundations of NP practice. I know the way we deliver our services is not going to change, more so the way we track and monitor the delivery of those services. I will keep you posted on our progress!

The Joys of EMR

Gretchen Moen — Mon, 31 Aug 2009 16:54:00 GMT

This past month we have been working toward dragging our office into the 21^st century. As I have mentioned in the past, the state of Minnesota required all healthcare providers to have electronic billing by July 15, 2009. In addition, EMR is an essential component to healthcare home designation. Hence, July and August have been somewhat more chaotic than usual.

In July, we were able to register for the "free" electronic billing option offered by the State of Minnesota. It works very well but requires us to double key all data, first in our practice management system then in the billing system. Someday we will be able to have a system that does both, but for now, free is good. Our EMR is also free and online. The advantage of an online system is that the data is stored off site so daily backup runs are not necessary. A second advantage is that clinicians can access the records from home as well as the office.

The first week we had EMR (August 1) we just entered the demographics and continued with paper charts. The next week we had all new patients on the EMR system and the old patients with paper charts and entering the newer notes in the system. That actually took us a couple of weeks to do.

At the end of last week we started scanning in documents from the old record. This looks like a bit of a challenge, especially with my special needs kids who have care plans updated every 60 days.

All in all, the front staff is excited about the move toward electronics, but the provider staff has their concerns. It's a bit cumbersome and can be uniquely tailored to the individual provider but not the practice as a whole. I have yet to discover all that it can do, so this may be a feature that I haven't found. For those of you who are of my generation and my computer comfort level, the support both online and via phone calls, is excellent!!

In the future we hope to have an EMR, billing and practice management system that is fully integrated and will communicate well with the outside world (hospitals, specialists, etc.). For now, it will take extra work on our part to manage the separate systems.

I shared with our patients the "exciting" news of our EMR. The response is mixed. Some see it as a step toward the future while others see it as a loss of our "small town" image. We will just have to keep serving tea!

Are You Ready to Start Your Own Practice?

Aaron Hartle — Thu, 13 Aug 2009 12:28:00 GMT

Should you open a practice? If so, what kind?

During these unstable economic times it is difficult to decide if now is the time to take the risk and open your own clinic. A stable job with a guaranteed hourly wage is tempting. Even if it means you are working for someone else and have to punch a time-card.

Still, in the back of your mind you might wonder . . . Can I do this on my own, will my own place pay off with a better salary, flexible hours, and the satisfaction of business ownership? Or will I struggle to make payments and go further in to debt? This worry is complicated by whatever health laws are going on at the government level (I have lost track of it lately, all I know is that there is a lot of confusion and a lot of anxiety regarding healthcare in America).

Through my experience I hope to give you an idea of what you can do to make it on your own.

I own two distinctly different clinics in Utah. My first clinic is Pace Clinic. It is a small retail-type clinic in the back of an independent pharmacy. It is an 11' x 11' room with a reception desk in front of it. Rent on 121 square feet is minimal. I have good traffic since the pharmacy customers have been coming to this pharmacy for years. I have little overhead and no debt with this clinic. At this clinic I accept insurance and have a special prompt-pay discount for those who are self-pay. It is convenient with walk-in only appointments.

My second clinic is called Nucea Health and Fitness. It is a much larger facility (2,100 square feet) and is scheduled by appointment. Nucea includes a couple exam rooms, a room shared by a physical therapist and chiropractor, a massage room, a small OTC area, and even a gym with a full weight room, circuit line, treadmills, bikes, ellipticals, etc. I am very active and do triathlons, so Nucea was built with everything I needed to "stay in the game." It is my dream business.

One of these businesses gives me an income of over $120,000/year after all expenses,and the other has never shown a profit and is sucking finances from the other clinic. It is probably easy to guess that my little 121 square foot Pace Clinic is making me rich, while Nucea (designed for me) is costly and has yet to turn a profit.

So, the moral of the story is first, start small. Don't overspend or overbuild. Stay within a small budget. Grow with your business, rather than starting at the top. Secondly, direct your clinic to what people want, not what you want. I prefer working at Nucea because it is large, has a gym I work out at, I have my own office, etc. However, I made Pace Clinic affordable, convenient, and mom- and child-friendly. This is what my patients want and has turned this small one room clinic into a success.

--Aaron Hartle, FNP

* Note, the more successful Pace Clinic is for sale for which I guarantee at least a six figure income. If interested please call Aaron @ 801-491-2238 for details. I can also help start up your own clinic including ideas, location, credentialing, regulations, etc.

Preliminary Stats on NP-Owned Practices

Jill Rollet — Tue, 04 Aug 2009 16:18:00 GMT

I spent the morning going through the submissions to the 2009 NP Entrepreneur of the Year competition. I was struck by how many of the entries are from very new practices: Just over a quarter are a year old or newer.

Of course, we have a special judging category for new practices, which encouraged new owners to enter, so our submissions might not be representative of NP-owned practices as a whole. To confirm the my impression, I checked some stats with our 2009 National Salary and Workplace Survey.

We're still collecting data, but based on responses from almost 1,100 NPs from so far, it looks like 22% of NP-owned practices have been open for 1 year or less, and the median age of NP-owned practices is 3 years. That makes sense when you note that the number of NP-owned practices has been increasing. Compared with all NPs, the number of practice owners is small but growing, up a percentage point from 2 years ago to 4%, according to our survey so far. The exciting news is that more than 10% of respondents said they plan to open their own practice in the next 5 years.

So what about older practices? One respondent listed a 25-year-old practice, and 15% indicate that their practices are 10 years old or older.

Finally, according to the survey so far, 57% of NP practice owners say they are very satisfied with their jobs. And they should be: The median annual salary for NP practice owners appears to be more than $109,000.

If you haven't yet, be sure to fill out the survey at http://nurse-practitioners.advanceweb.com/Article/Nurse-Practitioner-Salary-Survey.aspx. The more responses we get, the more reliable the data!

Avoiding Burnout

Aaron Hartle — Mon, 15 Jun 2009 18:16:00 GMT

Seventeen months ago when I opened Pace Clinic I was excited to be out on my own. No more working for somebody, I could set my own hours, come and go as I please, and do my own thing. I have thoroughly enjoyed working for myself.

However, even though I no longer have (a) boss, I still work for now thousands of bosses (my clients). Sure, I can leave early when I want, come in late, or take an extended lunch break, but now that I have an established clinic in the community, my patients expect me to be at the clinic. I won't get fired for not being at work, but I may loose business, which leads to a loss of revenue, then maybe a loss of the clinic.

So, "just hire some help" you say, but that is much more difficult than it seems. Unless you have a lot of discretionary income, starting up a clinic is expensive. Many start out solo since to hire another practitioner can cost quite a bit of money.

In addition to this, most nurse practitioners in Utah where I work are not credentialed with insurance companies. They work for and bill under the doctor. So if I want to hire a practitioner, I have to get her credentialed, which takes several months to finally be on all the insurance panels.

Now what? I just do what many other NP's do, I work too much. I believe that anyone that works over 40 hours per week is overdoing it.

When I started the clinic I worked 64 hours a week just to keep things going. I am now down to about 50 hours per week and still think it is too much. Since I started, I have hit a couple of "burn-out" stages that I have had to make it through and have learned a couple of coping mechanisms. Here are some that helped.

First of all remember, anyone can do about anything for a little while. At first, it may simply take a lot of hours to get a clinic up and going, but remember, being overworked is probably necessary, and should be temporary. Focus on the long term benefits.
Exercise daily. That has been a good outlet for me and helps open my mind for the day. It also helps burn off pent-up frustration from the business, patients, etc.
Eat right. You need all the energy you can to start up a business. It is not easy.
Have fun. Turn on a radio in your office and dance for a minute after a stressful patient or watch a funny Youtube video then get back to work.
Have a lot of friends. I love spending time with friends, so I treat my patients like friends - well, sort of. We don't go hang out, but when they come in to the clinic, we chat, talk about exciting events since the last visit, etc. Due to time pressures, we don't do it for long, but the patient enjoys the feeling that I care about them, and I like the outlet to take my mind off work if only for two or three minutes.
Remember you spouse and kids. You probably can't take off work for every little thing, but if your child has a school play or a field trip, then go. If your spouse has a special appointment, take off and watch the kids so he or she can go. If you feel you are fulfilling your responsibilities in the home, you will feel better at work.
Finally, remember, you can't do it all. Ask for help, take one day at a time, remember your own limitations, and don't sell yourself short to your new practice.

Aaron Hartle, FNP
Owner of Pace Clinic (Springville, Utah) and Nucea Health & Fitness (Lindon, Utah)

Swine Flu Disaster!

Gretchen Moen — Wed, 06 May 2009 20:09:00 GMT

Do you have your disaster plan ready?? The avian flu spurred organizations to evaluate their disaster plans and to revise or add provisions in response to a national biohazard or infectious disease disaster.

Our county health department has been holding meetings for care providers to assist them in developing individual disaster plans as well as plans for working together in the event of a health care crisis or national disaster. Well, the H1N1 flu situation kicked it into high gear these past two weeks and some of us were not adequately prepared.

I like to think I am on top of most things but, alas, there are times when I drop the ball... What would you need to consider when you develop your disaster plan? One disadvantage we have is that the HVAC for the building is all interconnected. Each suite has their own control panel but the duct work and pipes all connect at some point in the ceiling and basement. The dentist offices would close but our patients would need to have access to us. What to do?

What kind of patients would you be able to help during a disaster? Our office would not be able to care for highly contaminated or infectious individuals but we could be a vaccination station or call center.
Who would man the office? Do you or your staff have children at home? What would happen if the schools or day cares were closed? Would your staff be willing to work in a potentially hazardous situation? How would you make that decision?
What type of personal protective gear do you need? Can you afford to buy the necessary gear?
What would happen to your equipment, supplies and records? Storage of HIPPA-sensitive material? Storage of temperature sensitive medications or vaccines?
What about simple "disasters": power out for more that 4 hours, phones out, computers down, locked out, patient or staff safety... we could go on and on.

Oh the advantage of having a smaller clinic! The health department sent e-mails with sample protocols for anyone who did not have a plan in place. We modified them slightly and had them ready within a couple of hours. The county nurse stopped in and issued N95 masks, instructed the staff, and reviewed our protocols. There were no committees to approve or disapprove of the written plan, no need for a timed roll out and very little lost time for education and implementation.

There are days I long to hire a person who can do the OSHA, BLS, HIPPA, RED FLAG, SAFETY, COLA and all the plans, rules and education requirements we need to review every year..... someday. For now, we are ready for H1N1, maybe H1N2.

Don't Get Sued!

Aaron Hartle — Wed, 15 Apr 2009 11:43:00 GMT

During my 2 years attending graduate school in the University of Utah Family Nurse Practitioner program I remember hearing the phrase about being sued, "it's not a matter of IF but WHEN." This has always worried me, especially now that I am a business owner.

I have good medical liability insurance, but the thought of being sued is scary. A suit can lead to loss of income, increased stress, lack of sleep, and higher insurance rates, among many other worries. In the 4 years of being a nurse practitioner, I have never been sued (knock on wood). The following is a list I try to adhere to, which helps reduce the chances of getting sued.

Be Nice. Very few people sue their friends. This doesn't mean you have to buddy up with each of your patients, but just be kind and show compassion. Patients know when you are in a hurry with them, annoyed at something, or treating them like a paycheck. If you show them that you genuinely care about them, they will feel it.
Be Honest. If you make a mistake, promptly admit it. We are human and will make mistakes. If you lie to a patient or try to cover something up, they can tell. However, if you always tell the truth, they will understand.
Be Open. Sometimes I'll tell a patient, "I don't know" or "I'm not sure and need some help on this." Don't try to be a specialist in areas you really aren't.
Be a Team Player. When you are unsure of a diagnosis or procedure, don't be afraid to ask help. Have a network of other practitioners to call on if you have a question. Don't be afraid to call and consult with a specialist. Hire a physician consultant to refer patients to. Never get caught doing things you are unsure doing. If you feel nervous treating a condition, doing a procedure, or prescribing a certain medication, then don't. Refer the patient or consult with someone until you feel proficient at the task. Several practitioners have a rule that they will see a patient a three times. If they are comfortable with the condition they will continue treatment, if they are unsure about the diagnosis, treatment, etc. they will refer them on. Don't let a patient's true diagnosis go undiscovered.
Be Wary of any Drug Treatment. If you are not familiar or proficient with a medication that a patient needs, don't prescribe it until you are comfortable with treating the patient with that medication.
Be Present. If you are distracted, tired, or mentally in Hawaii, don't treat a patient or do a procedure that can turn out bad. The best way to prevent injury or problems is to be physically, mentally, and emotionally prepared.
Obtain Informed Consent. If you ever do a procedure that could have a negative outcome, obtain consent from the patient and explain completely the procedure, expected outcome, potential risks, and alternatives to the proposed care.
Chart Well. If you are nervous when an insurance company asks to review a chart, you probably could do better. Take a couple extra minutes after each patient to quickly prepare the chart. Don't wait until the end of the day when you have forgotten to add in essential information. Chart what you do when you do it and you should be fine.

These are eight of the steps I take to reduce my own liability. Will they prevent a suit against me or my clinic? NO, but they will help me sleep well tonight and even in the advent that I ever get sued.

Financial Hard Times

Gretchen Moen — Thu, 09 Apr 2009 11:30:00 GMT

February was a tough month for ECFC. Our patient visits were down and our receipts even lower. We typically see a decline in receipts the first couple of months of the new year as patients are recovering from the holidays, have new insurances and new deductibles or now have no insurance at all. Our office staff were on edge about their positions, my partners were concerned we may have to close and my mind was racing with ideas to increase revenue as well as patient visits.

There have been a few changes in the health care landscape of Eagan since I opened (here) in 2005. A CVS Minute Clinic opened a half mile up the street and a new "health system" primary care clinic opened in the downtown area (about 5 minutes away). These clinics provide stiff competition to our small NP practice. Minute CLinic was able to negotiate with MN insurance companies to waive patient copays for visits to the clinic. I am contracturally obligated to collect copays for patient visits. Insurance payments have decreased as the copay amounts have increased. To the general population, that means I get more in my pocket, when in fact, the insurance company pays less and the patient is now making up the difference. Of course, all that applies after the insurance company disallows and reductions have been applied to the billed encounter. Hence, I cannot financially afford to waive copayments - even if I was not obligated to collect them. In addition, MN requires electronic insurance billing by July 1, 2009. We need to invest in a billing system.

So, what to do what to do? Financial stability seems to be an ongoing challenge for us. My partners and I sat down and looked at the budget and talked about where we could trim even further. None of us are taking a salary so a cut in our pay wasnt an option. We looked at our supplies and found ways to decrease our expenses by switching suppliers when there were advertised specials on our regular supplies. In one instance we were able to save nearly a thousand dollars by switching our supplier for our strep tests. We talked with our staff and asked them to try to keep their hours within their appointment (32 hours, 15 hours, etc) and have told our MD she needed to stick within her 10 hour a week schedule. We have an appointment to speak with the landlord about a modest decrease in rent for the next year and we have trimmed our reception staff.

My job is to find ways to bring in more patients. I have asked my staff to go outside and start tripping people but.... We decided to put up a banner that states "your neighborhood quick clinic" and a sign that says "new patients welcome". Our location is great, on the corner of two main thoroughfares and just across from a day care and a large church so the signs will be visible. I am making the rounds of the local school health classes, womens groups and grocery store health fares. We have added a third evening clinic to compete with the local Minute Clinic and we are collecting emails to start an online news letter. One of our families is helping to get testimonials added to our website and we are planning a Spring Health Fair and BBQ open house.

It is still hard to understand how the emergency rooms can be packed with patients who do not have emergencies and our primary clinics are seeing patient visits decline each month. I have a family who called on two separate occasions for advice on a non-urgent medical problem. Each time there were appointments readily available, each time the family said they appreciated our advise and would call if they felt they needed to be seen and BOTH times they went to the local emergency department for care DURING office hours. When asked why they drove to the ED and waited to be seen vs coming to the clinic, they said they really didnt know why, they like the clinic and they just did it. In this case, the copay for the ED was far more than the copay for the office visit.

On a ligher note, we had the busiest day since we opened on Monday. You can never tell with health care. Our new financial advisor asked about our "fixed" costs and I had to laugh... fixed...rent, two leases and a loan payment. Fixed revenue? That is an even bigger laugh..... and so it goes.

Keeping you posted....

ON a side note, my thoughts about retail health: I am a primary care provider who has felt the impact of retail health in a very different way that most of my NP collegues. Retail health clinics are necessary because health care in general has seemed to move away from serving the public toward serving themselves. What I mean is, kids dont want to miss school, people cant miss work and disease doesnt go to sleep at night. There will always be a place for retail health in the "fix it now and fix it fast" world of today. I am torn between the opportunities available for NPs in the retail health sector and the restrictions they put on NP practice. It is a two edged sword.

Essential Office Technology

Joseph Marra — Thu, 02 Apr 2009 12:43:00 GMT

Computers can be a very worthwhile investment. Many day-to-day operations can be managed by this technology. Web sites are a great example of cost effective advertisements that pay for themselves. My web site http://www.urgentcarecenter.us/ introduces the staff, showcases the business, gives directions to our locations, and allows for communication between patients, and potential patients.

We also use our computers to submit our billing, generate letters to patients, transcription, e-mail, scheduling, and of course communication between "Advance" and myself.

I have not experienced the benefits of electronic records at this point, however will explore this logical step in advancement in the near future. This can potentially save you hundreds of dollars if not thousands over the long haul. Considering that my staff makes up over 30 new charts per week, which costs incurred includes staffing time, paper, the folder itself, stickers, and patient time to fill out these forms, is simply not cost effective in today's world.

You pay for the lump sum of money on the front end of the investment for electronic records. It is absolutely worth it!

I am currently limited to time to do the research on the different software that is available, however will be making time in the near future.

We are currently implementing software that my staff and I can dictate into that allows my transcriptionist to transcribe from any location that has a computer with an Internet connection.

An answering service is utilized 24/7 in my practice, that allows patient access in emergency situations to contact me for advice. My answering service calls my cell or my home phone to relay the message. A cell phone is invaluable doing this work.

It is difficult to imagine that just a few years ago that our technology did not even support pagers, cell phones, computers, etc... You can live without these things, however they sure make your life simpler in many regards. Then again, having this constant connection to you can get very frustrating after a day of many calls coupled with a very busy day! Keeping up with the competition has always been an art in business, and I don't see this changing any time soon.

The Replacements

Gretchen Moen — Mon, 16 Mar 2009 19:42:00 GMT

This past week I had the pleasure of spending the day lecturing for one of the FNP programs in town. The experience was not a new one for me, but it was different in that I was "it" for the whole class day. I enjoyed myself very much, and my feedback has been positive to date. As I prepared for this posting I thought about this experience and how it pertains to business ownership.

Our clinic has a three-pronged mission: providing high quality health care services, serving as a resource to our community and promoting our profession. As one of two NP clinics in the area, we feel it is our duty to provide learning opportunities for health care professionals of the future.

Many of my colleagues are feeling the strain of financial pressures in their various practice settings. Instead of receiving straight salaries for work product, the trend is to compensate based on performance, which usually translates to sheer number of patients per day. Given the intense pressure to care for increasing numbers of patients, clinics and other health care systems are reducing or eliminating student opportunities. The argument is that students "take time" that could otherwise be spent seeing patients. Consequently there are fewer clinical sites available and far fewer students completing their training, especially in primary care.

Having control of my schedule and the general clinic schedule allows me the freedom to work students into the day without compromising patient care. Communication with the support staff as well as providers is essential. When the appointment time is flexible for the patient, we try to schedule visits to coincide with specific student requirements. Our patients are well aware of our educational advocacy and often express their excitement in "helping out" a budding health care professional.

What's in it for you?

Students challenge your process. They ask questions and want sound explanations for everything you do. Students force you to stay current with the latest research, evidence-based guidelines, practice trends and all the other aspects of practice one never has time to pursue. In a small practice, students are very valuable for filling the gaps with answering telephones or returning patient calls as the need arises. Students can also become future employees.

In some areas, clinics who train students are eligible for stipends through health care education funding.

I want to encourage you to design your practice to foster NP growth. Include student placement in your business model. Remember that you were once a student, too. Every single day I have a student, I learn something new or appreciate something special about my practice, my patients or myself. Today was another of those days.

Today one of our PNP students was evaluating two brothers for strep throat. English is not the family's first language. The eldest is 5 "and a half" years old, and the younger one is 4 years old. When they arrived I asked them why they came to visit me and the older brother said, "I have something in my throat that hurts but it's not strep throat." Throughout the visit the older brother continued his chatter; he couldn't wait to be 6 (years old) because then he would be King; he'd been to the dentist recently and described his experience by saying he didn't like "adult" dentists because they were mean and that "next time" he was going to see a "kid" dentist; he loved his brother and his brother copied him all the time but that he didn't want to copy his brother all the time; and he ended with: "my brother....we are a lot alike and like the same things but he is different because he is two shades lighter than me." The student was trying hard to stay focused and concentrate on the task at hand but couldn't help but laugh at this child's soliloquy... In the end, both the boys had strep throat!

The entire visit took 20 minutes, tops, but the lessons learned will last a lifetime.

Preparing for Emergency Absence

Gretchen Moen — Thu, 19 Feb 2009 14:58:00 GMT

The past few weeks have been quite busy and somewhat chaotic for Eagan Child and Family. Following my absence to care for my father, we suffered another unexpected blow: my partner's mother passed away. Shortly thereafter, our administrator took ill and it seemed like there was no one around to "mind the store." I thought it might be timely to discuss what to do when you "suddenly" cannot run the business.

Do you have a contingency plan outlining how your patients will be handled if you are unable to care for them temporarily? Is there adequate internal staff to help, or do you need to find some to step in? What about administrative tasks?

In the short term, patients are usually able to accommodate your absence by rescheduling preventive care, working with a substitute provider or going to urgent care. If absences happen too often or for long periods of time, the business will suffer. Those extended times are when you need to be creative and provide some services to your patients in anticipation of your return.

Here are a few of the ways I have managed changes in provider time:

shortened office hours and kept an assistant to staff the telephones
used picture phones for assessment and assistance by other specialists
met patients in locations outside of the office
had students work with certified NPs to manage a clinic day
enlisted "volunteer providers" to cover key shifts
diverted patients to other providers in the area and called ahead to alert the providers
kept in contact as much as possible by calling patients at home to check in or asking the office staff to update key patients during provider absences

Clinical services aside, I was not prepared for the management of administrative activities that occur on a daily, weekly or monthly basis. In the recent case of our family emergencies, there wasn't time to gather all the information, write a list of what is pending, assign responsibilities or come up with any plan for other pre-emptive activities to help those who were running clinic. In the end we missed a few scheduled payments and scrambled to get payroll done. Rent went out late. I spent quite a bit of time on the telephone explaining the situation and asking for considerations. Not a good feeling.

I recommend having an administrative operations manual with information that would be useful if you are unavailable for more than 7 to 10days. Here are a few of the items I would include:

E-mail: someone assigned to check administrative e-mail from patients, vendors, regulatory bodies, etc.
Snail Mail: assign someone to open and distribute bills, payments, notices, medical records, junk mail
Patient flow: patient flow is managed daily to decrease the likelihood of potential blocks, inappropriate scheduling, poor planning, time management
Payroll: timecards, how to run payroll and who will be signing checks
Accounts Payable: payment schedules, checks. paying the "float"
Accounts Receivable: including insurance payments, patient payments, billing questions
Pending: audits, taxes, insurance reviews, contracts, malpractice payments, credentialing processes
Students: who will be mentoring the students, or do you need to contact the schools and work to reassign the student
Physical maintenance: telephone, internet, IT, and building management contacts, plumber, electrician, pest control

I am glad the past few weeks are behind us, but I am still dealing with some of the issues that arose from patients and business relationships during our untimely absences. We have started an administrative manual that we hope to complete soon. I am proud of my staff and partner for "keeping it together" as well as they did, and I have learned a valuable lesson in emergency preparation!

How to Get Credentialed

Aaron Hartle — Wed, 21 Jan 2009 12:42:00 GMT

If you plan on opening an independent practice, one of the most important things on your "to-do list" if you plan on billing insurance is to get credentialed. This is a long and arduous process taking from around 60 days to several months depending on the insurance company.

The sooner you can get started, the better off you will be. I'll walk you through what you'll need to become credentialed and how to get started.

What you need:

1. A business address: As soon as you have one, start the credentialing process, even if you will not be starting your practice right away.

2. Tax ID #: These are easily obtained from your local government web site.

3. NPI #: apply online at https://nppes.cms.hhs.gov/NPPES/StaticForward.do?forward=static.npistart

4. State license, DEA number, business license

5. CLIA waived certificate: If you plan on drawing labs or doing in-office tests. For information go to: www.cms.hhs.gov/CLIA/downloads/HowObtainCertificateofWaiver.pdf

6. Professional liability insurance: Generally $1 million / $3 million is required.

7. Education history, transcripts, and professional memberships and certifications.

8. Three or four good professional reference.

9. Go online to http://www.caqh.com/ to register to be credentialed with several different companies.

10. Call the credentialing departments of the rest of the insurance companies you wish to bill and get started. You can find the numbers on each of the insurance companies web sites.

Be patient, remember the processes takes weeks to months. As soon as a company sends you an application or contract, quickly fill it out and send it back. If you don't hear from insurance companies for awhile, call the credentialing office or provider relations number and follow up.

Good Luck!

The Interviewing Process

Joseph Marra — Wed, 14 Jan 2009 17:15:00 GMT

Well, I have been at my new office now for over a month, and yesterday's schedule had 38 people on! Yes, it is really taking off. I have advertised again, and I'm thankful for the responses. I will be interviewing three new prospects at the end of the week.

It really is difficult to see patients and manage a a busy practice at the same time. I plan on hiring some individuals to take up some of the slack. I still intend to practice on occasion; however, I am unable to continue this pace!

I have also just hired two ultrasound techs. One's specialty is in cardiovascular medicine, and the other is in general medicine. I will be hiring a women's health NP to care for my female population.

This venture has just exploded with opened doors and opportunities. If you believe in the premise that "Thought becomes reality" then, the sky is the limit. I feel strongly that medicine needs to transition into having several specialties under one roof. People enjoy convenience, and practitioners should welcome the continuity of care. I have also hired a hypnotherapist as well who also is a Reiki master. She is doing wonderful things for smoking cessation and stress management. Patients are always asking of "natural" ways of healing, therefore I offer these alternative services as well.

I will continue with the updates each time I blog for those who are interested.

Expanding Your Business

Joseph Marra — Mon, 08 Dec 2008 19:55:00 GMT

I have been looking for a larger building for my business to continue to grow and have been unsuccessful. I have been looking for 8 months through the local papers and checking online, and I have even hired a realtor.

Looking in an area that is close to my current location has left me empty handed. I had closed my mind to other possibilities, such as a separate practice, in a new location. As you may know, I had two practices at one time and after difficulties with colleagues, I had to close the less busy practice.

However, I have since hired three NPs instead of doctors and have just been presented an opportunity to take over another practice, in another town. At first I thought it would be prudent to purchase another building that would accommodate my current practice, as I have significantly outgrown the building. Once I opened my mind to the possibility of another location, I then had to come to terms with such things as staffing, computers, signs, advertising, etc...

Well it just so happens that it was an all in one deal!!! So I had no alternative but to jump on this opportunity. The lessons learned with my earlier adventure of two practices have become invaluable. I will focus on my primary practice expansion later.

Business can be a gamble at times, but when you have a strong model and stick to what works, things just explode!

I currently employ a Psych NP, an Adult NP, and a Family NP that will be picking up the slack at my Altoona office while I am off with this new adventure. I also intend to hire a Woman's Health NP in the near future.

I must tell you that I am there Tues. and Thurs. starting two weeks ago, and my schedule is booked. Once I follow my model and get things up to speed, I will be hiring more providers to "Answer the call."

The freedom of independent practice is indescribable. As I am writing this blog, I got a fax with the number of patients on the schedule for tomorrow = 27. We do take walk-ins so I will be taking my roller blades along.(LOL)

Since this will only be my third week, I will keep you posted in the next few blogs for successes and pitfalls as things progress.

Calling All Pennsylvania NPs!

Joseph Marra — Thu, 20 Nov 2008 14:02:00 GMT

Pennsylvania NP regulations are up for legislative review. Letters are encouraged to be sent to the board of nursing by 12/8/08. I wrote one personally that you can read below, and I got several physicians, dentists, NPs, other colleagues, patients, and even representatives to send letters. Please show your support! If you are an NP from another state that is already independent, please write, showing that NP independence is really safe and affordable, and the quality of care provided is equal to our colleagues.

Send your letters to Ann Steffanic, Board Administrator, Pennsylvania State Board Of Nursing, P.O. Box 2649, Harrisburg, PA 17105-2649.

Here's my letter:

November 16, 2008

Dear Ann,

My name is Joseph Marra Jr. and I am a CRNP that owns and operates the "Urgent Care Center" in central PA. I have been independent now since opening my practice February 14, 2006. I would like to take time to write in my perspective, just a few limitations that are imposed to CRNP's by the current regulations. First, many NP's have a limitation in prescriptive authority. Second is the limitation with collaboration with physicians. Third is the inability to prescribe home health and hospice due to certain language or interpretation within the regulations. Fourth is the limitation of admitting privileges into hospitals, just to name a few.

The current prescription authority limits us as well as our pt.'s. Many pt.'s must return every month even when they are stable within a disease process and medication regime, due to the inability to write for refills. This is not only an inconvenience for the pt. but increases healthcare dollars as well. Also several of my pt.s that have chronic pain from histories such as MVA, work r/t injuries, vertebral compression fractures etc. require monthly prescriptions for chronic pain medications, and we are limited to only 72 hours of medication administration. Many pt.'s come in as new pt.'s whose physician has retired or moved out of the area and had already been prescribed pain medications for years for chronic pain, and Adderall for ADHD, and I have to send them away due to my limitation. Another issue with prescription authority is the limitation with writing for suboxone. I work for Pyramid Healthcare, in addition to my own practice and have discussed with the DEA the rationale behind why we as CRNP's cannot write for a Schedule III drug? They responded; "The limitation is from the State Board of Nursing not us". I would be glad to go to the classes required for this extra education in prescriptive authority, but cannot with the current regulations. So many individuals would benefit from being on a maintenance dose of suboxone and ad to their community, as well as re-enter into the work force. This is such an under rated program, that it is disheartening to me. As a profession we compete for jobs and since we have limitations, we are often times looked over due to another individual with full prescriptive authority, even though we may be just as qualified and work for less money. Limiting our prescription ability simply limits access to quality care.

The second limitation that I would like to address would be the access to collaborating physicians. First of all I don't personally feel that this should be a requirement any longer. CRNP's have proven themselves time and time again, as safe and effective practitioners, with study after study. It has also worked in many other states, so why not in this state. Also it is difficult to obtain a physicians collaboration. They usually fear litigation on someone that they have never even seen. Also, if you must collaborate with the physician, and they tell you, you must address the situation a certain way that you don't feel safe or necessary, the pt., as well as the CRNP's license are at risk. Then there is the matter of paying the physician for their collaboration. This increases healthcare dollars as well. In my own family practice I have been not only trusted to make independent decisions but have been consulted by my physician peers for certain things. We as a profession know our strengths as well as our limitations. If the pt. needs something above what we were trained to do, we simply refer to the ER or a specialist, depending on the severity of the condition.

Third, I have had several pt.s that see me for family medicine due to the inability to get in with a PCP, from living in an underserved area. I offer the lowest prices in town, with a basic visit at only $40 per visit, and I use the $4 prescription plan at the local pharmacies as well as giving out free samples. But when NP's are limited to such things as home health, especially when pt.'s really require debilitating in home care, there is no where else to send them. I find it almost inhumane the way medicine is right now. I can provide the service to the pt., however am unable due to a regulation, and therefore a reimbursement issue. I of course don't turn these pt.'s away, but they get to a point where they can no longer make it to the office, and left with lack of proper care in the homes. Family members are left taking care of these pt.s that have a very high acuity. I implore you to take a serious look at our current regulations for our citizen's sake.

The fourth and last point that I will address in this letter, is that of the inability to admit to hospitals. When you think of total access to care, you must also think of continuity of care. When you have seen a pt. for years and know what meds. they have been taking for certain ailments and aware of the illnesses that have developed, but they have to be admitted under another practitioner, the quality of care is less in my opinion. Although hospitalists are worth their weight in gold, some family medicine practitioners continue to see their own pt.'s. My pt.'s continually express a dislike in this matter. I of course have no option but to reply; "My hands are tied". I understand that some hospitals allow for admitting privileges under other physicians. However, the pt. must be seen by that physician within a certain time frame. The decision made by the physician, may not be considered wrong, but not always the exact choice that HCP or pt. would choose.

In Summary, with limited access to primary care well documented, and less and less physicians going into this specialty, it stands to reason that someone must take over this responsibility. NP's are quite capable of taking care of this population. We are well trained, and several studies have shown that at the end of the study, NP's provide equal care to that of physicians and sometimes even better. I can forward you these studies if you would like. NP's make solid decisions and know their limitations as well. After practicing for over five years and being independent for almost three, I can tell you that this office functions quite efficiently with little to no complaints. In fact I will have some of my pt.'s send you their interpretation of the care that I, and my colleagues provide. I will offer my Urgent Care Center as a model if you would like. Take a day and actually come to my office, see how it runs, and ask the pt.'s what there perception of the quality of care is that they receive. I commend Governor Rendell, for his part in making changes that benefit this profession and ultimately our communities.

Thank you for your consideration in this matter, and should you have any questions, please don't hesitate to contact me at the above number. I would be honored to answer any questions you or the board would have, in the possible revisions to our regulations.

Sincerely,

Joseph F. Marra CRNP