PRACTICE POINTERS

To keep your practice humming, get the right help

Knowledgeable consultants can tune your office systems—including computer and coding—giving you more time to see patients. Here's how to find the right ones.

By Gail Garfinkel Weiss
Senior Editor

Some physicians or administrators think that they should be able to handle everything that the practice needs," says Will Latham of Latham Consulting Group in Charlotte. "But nobody can do it all. There are times when it makes sense to bring in someone from the outside."

When do you sound an SOS? "Any change for the negative is certainly a reason to call someone in," says Kenneth Bowden of Berkshire Professional Management in Pittsfield, MA.

More specifically:
• If collections or income start to fall.

• If insurance claims are being rejected and reimbursement delayed.

• If staff turnover seems high or the staff seems dissatisfied.

• If patients seem dissatisfied or are taking their business elsewhere.

• If internal disagreements threaten the stability of your practice or group.

But a

thriving

practice can benefit from expert intervention, too. A practice management consultant can help you deal with:

Financial issues. How should group members divide earnings? How can you control expenses? How do you calculate bonus distribution? How can you improve your billing, coding, collections, compliance plans, or fee schedule?

Human resource issues. How much should you pay staffers? What is the right staff size for your practice? How do you conduct a performance review? How do you find and keep good staffers? What benefits should you offer? How can you get staffers to work more efficiently?

Managed care issues. Should you join an HMO or PPO? Are you getting all the reimbursement you're entitled to? "Your collections might be lower than they should be because staffers are accepting disallowances from the insurance companies at face value," says David Scroggins of Clayton L. Scroggins Associates in Cincinnati. "But it's possible that some of those rejections can be challenged."

Or you might need help with reviewing or negotiating a managed care contract. Julia J. Hook of OakRidge Consultants in Tustin, CA, notes: "It's always better to get help than to enter into an agreement and find out eight months later—as happened with a group of doctors I worked for in Washington, DC—that you signed a contract that didn't have rates in it. Those doctors had no idea what they were supposed to be getting paid."

Growing practices might benefit from advice on coding, financial planning, tax planning, marketing, recruiting new physicians or midlevel providers, merging with another practice, or adding satellite offices or ancillary services. A growing practice also means conflicting opinions among its physicians. "Call a consultant when an independent opinion is needed," suggests Bruce Bosquet of Medical-Dental Consultants in Cranston, RI.

What to look for—and be wary of

"You'll get the biggest bang for your buck with someone who's had successful experience in your specialty and in the issues you're dealing with," says Will Latham.

Chemistry is important, too. "You need a good working relationship with your consultant because you'll be working as a team," says Julia Hook. "To get things done, the consultant will need some of your time and energy and understanding, so if you don't have good rapport with that person right away you should probably keep interviewing."

Hook advises interviewing a couple of people at least. "Ask each one how many clients he handles," she says. "How many people in his firm? How long has the firm existed? Will there be coverage when he goes on vacation? How many associates will be helping him? How will everyone's contribution be reflected in the bill?" (See "Hiring a consultant: Key questions to ask".)

National Association of Healthcare Consultants' President Gary Borucki, who's a principal with Rehmann Robson in Lansing, MI, offers this interviewing tip: "Rather than saying, 'This is what I need,' ask consultants what they do; they're more likely to list the things they do well."

Be sure to check references. "Ask consultants for the last three doctors they've worked for, then call those doctors and ask how the consultant managed the project," Hook recommends. "Were they happy with the results? Do they feel they got good value for their money?"

Don't bite if potential consultants try to sell you something other than their services or talent, experts advise. "If a consultant is peddling insurance, investment opportunities, or computer hardware or software, you have to be concerned about what his real motivation is," Borucki warns.

And don't be quick to hire a consultant who insists, "I've got just the solution for you." In Latham's view, "These people are usually coming up with some sort of canned approach that may not be relevant to your situation."

To avoid this, Hook suggests asking, "How much of your work will be template material that you've already developed for other practices and will tailor to ours, and how much will be original material, developed just for our practice?"

Working effectively with the person you choose

When ophthalmologist Peter Menger took over a practice in Glendale, NY, in 1990, a consultant spent two days analyzing the practice. "He rolled up his sleeves, dug in, and produced a 10-page report with specific advice and commentary. To this day, I refer to that report."

Indeed, Ken Bowden prefers to do a practice survey for all of his new clients. "It can be a very narrow survey, or soup-to-nuts, depending on the client's needs," he says. "Even a brief survey might reveal a great deal."

For example, Bowden was called in by a pediatrician who couldn't understand why his patient base was eroding. "The first thing I noticed when I entered the office was an orange shag carpet," he recalls. "I thought I'd been time-warped back to the 1960s, and I wouldn't have been surprised if patients assumed that this doctor wasn't up to date."

Because practice management consultants don't come cheap—fees range from $60 to $300 per hour, depending on the nature of the job and the size of the practice—Julia Hook suggests that you and your consultant agree up front what the deliverables are: "What are the five bullet-point things you hope to accomplish by hiring this consultant?"

Then agree on a time line: "When does the consultant think he's going to be able to achieve all this? How quickly can he start on your project? Once he does start, will he diligently finish it or will he go off to another project and come back later? What's the estimated date of completion?" Don't be reluctant, Hook says, to ask consultants about their fees and method of payment. And expect to give the consultant a retainer.

In addition to a practice survey, most consultants draw up a financial statement to identify where problems exist. Gary Borucki produces monthly financial statements for his regular clients. He and other consultants also draw up contracts with their clients. These agreements, Julia Hook says, should contain a confidentiality clause.

"Sometimes people are calling just to look for verification that they're on track," says Karen Zupko of KarenZupko & Associates in Chicago. But doctors who hire consultants need to be open to criticism and bad news. "You have to tell consultants everything—not just selected bits of information," Borucki insists. Be sure to ask a lot of questions, too. "Probably the biggest dissatisfaction clients have is, 'He didn't tell me X, Y, or Z.' Well, if you didn't ask, maybe the consultant didn't know that was an issue."

Doctors resistant to change and those unwilling to take advice are probably wasting their money by hiring a consultant, Zupko says. She also warns against engaging a consultant to rubber-stamp what you planned to do anyhow.

Bowden agrees. "I don't know how many times I've gone to a meeting with a doctor or a group of doctors," he says, "and it starts out with, 'Well, Ken, you're not going to want to hear this, but we've already done X.' In doing so, they might have broken something that I can't fix. Or maybe I could have offered a better approach or demonstrated why X wasn't a good idea."

Getting the staff's cooperation is a must when you bring a consultant on board—a difficult task during good times and an almost impossible one during lean times when job security is at issue. "It's important to stress that the consultant is there to help staff with their jobs, not to do away with those jobs," says Borucki. He also cautions against pointing fingers. "I think you need to indicate that we need some outside help, rather than accusing anyone of not doing their job."

Other advisers a practice might need

Most practice management consultants advise in a number of areas—or at least their firms do. Gary Borucki and Bruce Bosquet are CPAs, for example, and Ken Bowden is a certified financial planner. But you should go elsewhere for legal advice. "You'll need a lawyer who's got some health care experience," Scroggins notes.

Ditto for insurance agents and computer consultants. The latter, according to computer adviser Rosemarie Nelson of Syracuse, can do more than help physicians evaluate their hardware and software needs. "A good consultant can help a practice find the right vendor and advise on how to best use the vendor relationship," she adds. "For instance, does the practice have a schedule of services? Have they arranged for the vendor to examine and update the system at regular intervals? Does the practice use the system completely?"

Wayne Hooks, office manager for Independent Physicians, a three-doctor practice in Nichols, SC, swears by the practice's computer consultant. "Too many doctors put in computers and think they're through with the process, but the problem is that everything changes," he says. "There's nothing left of the system we installed in 1993."

Not only does his group's computer consultant oversee the practice's evolving computer system—which includes outpatient records, billing software, financial software, Internet access, and lab links—he's on site almost immediately if any part of the system falters. "If you rely on a large company," Hooks says, "you get a different technician each time. Our consultant knows our system and can get us up and running so we can function."

The vagaries of coding have defeated even the most savvy doctors and office managers. Which is why you might want to get advice from a certified professional coder. One such, Fred Chafin of McVey Associates in Novato, CA, points out, "In my experience, 60 percent of physician encounters are undercoded. That's partly because most physicians don't take the time to learn the system and partly because they're intimidated by the repercussions of overcoding."

Chafin did some work for a 16-physician urology practice in which the most frequently billed code was 99211—a nursing code. "That miscue was costing the practice about $1.5 million a year," Chafin says.

Do you need a whole stable of consultants to keep your practice on track? Not necessarily, says Guy Gillespie, a practice management consultant who's also a technology adviser. "I think the distinctions between some of these roles have begun to blur," he notes. "CPAs are doing audits to see that a practice is in compliance with Medicare and Medicaid regulations. Those are things that a lawyer might have done previously. Often, a doctor's best bet is to make greater use of the talent at the consulting firm he already has a relationship with."

Rosemarie Nelson feels that a practice is better served by several consultants with specific expertise. "That's costly if you keep them on a retainer," she concedes, "but it's not so expensive to hire consultants for specific tasks. A coding consultant is a good example. Initially, you bring her in to help you understand how to code. Then you say, 'I want you to come back every six months to do a code review and tell us whether we're slipping.' So I think it can be cost-contained and well worth the effort."

Shopping for a consultant

Start your search locally by asking colleagues for names of people they've used and been satisfied with. Your state medical association may be able to identify consultants with experience in your specialty. Nationwide, the Medical Group Management Association (www.mgma.com ) or medical societies like the American Academy of Family Physicians (www.aafp.org ) can provide direction and advice—but neither gives out names or phone numbers.

The National Association of Healthcare Consultants has a directory on its Web site (www.healthcon.org ), as do the American Association of Healthcare Consultants (www.aahc.net ) and the Society of Medical-Dental Management Consultants (www.smdmc.org ).

To determine whether a practice management consultant is certified (certified consultants must pass an examination and meet annual continuing education requirements), contact the Institute of Certified Healthcare Business Consultants (800-447-1684; www.ichbc.org).

Hiring a consultant: Key questions to ask

If you want an adviser to direct a specific project, Julia J. Hook of OakRidge Consultants in Tustin, CA, says, he or she should provide a written proposal that includes the project's goals, time frames, expected outcomes, and estimated fees. Hook also recommends that you ask the following questions:

1. How long have you been a consultant?

2. What areas of consulting do you specialize in?

3. What kinds of projects have you done that were similar to ours?

4. How many other consultants do you work with? Are these consultants full time with your company?

5. Will you be directly involved in our project, or do you plan to delegate it to lower-level consultants within your firm?

6. When can you start our project and how much time can you devote to it each week?

7. What can we expect in the way of preliminary results and when can we expect them?

8. How would you begin to handle our strategic needs? What can we do to ensure your success here?

9. If our practice is very busy, but we seem to be working harder and making less, how would you go about assessing our efficiency?

10. Would we have to sign a contract to work with you? What are the terms of this agreement?

11. How much of the work that you do for us will be previously developed "boilerplate" material rather than material developed specifically for our practice?

12. Who owns the rights to any new material that results from our project?

13. When working with your firm, what assurance do we have that our information will remain confidential and exclusive to our practice?

14. Do you have errors and omissions insurance? General liability?

15. We would like references. Would you be willing to let us contact your last two or three clients?

Gail Weiss. Practice Pointers: To keep your practice humming, get the right help.

Medical Economics

2002;3:32.