Starting a Practice

TMA Practice Consulting Ready to Help 

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Tex Med. 2013;109(2):21-25.

By Crystal Conde 
Associate Editor 

Setting up a medical practice is daunting. Physicians who make the decision to strike out on their own have to come up with the money to fund their businesses, find an office space, vet and hire capable staff, purchase the necessary technology and equipment, and devote time and resources to a host of other responsibilities.

When urologist Koushik Shaw, MD, and his medical partner, urogynecologist George Shashoua, MD, decided to open an Austin private practice in 2010, they sought professional assistance setting up their business from Texas Medical Association Practice Consulting.

"I received no formal training in medical school or residency on how to start my own practice and run it effectively," Dr. Shaw said. "In addition to that knowledge deficit, my partner and I didn't have time to devote to every step of the practice setup process."

Drs. Shaw and Shashoua relied on the expertise of a TMA practice consultant to help them screen potential employees, set up an information technology system, select an electronic health record (EHR) system, and determine how to handle billing and collections.

TMA Practice Consulting offers practice setup services in three phases. In phase one, TMA consultants meet with physicians and ask about their vision for the practice and their plans and preferences for managing the business. After the meeting, consultants develop a pro forma, a financial document that includes all setup costs and start-up expenses, monthly operating costs, and three-year cash flow projections.

TMA consultants then help physicians set up telephone and fax lines and voice mail service. They provide referrals to professional advisers such as bankers, health care attorneys, certified public accountants, realtors, and credentialing companies.

Phase two involves working with physicians to select equipment and necessary services. TMA consultants can either provide resources or request bids for insurance products, billing services, practice management software, medical equipment, office furniture, copier and fax machines, telephone systems, answering services, filing systems, and transcription services. This phase also includes an information technology consultation.

In phase three, consultants help physicians recruit and train staff and implement information technology.

Before starting a practice, Dr. Shaw worked at Austin Diagnostic Clinic for six years. Dr. Shashoua was part of a midsize obstetrical and gynecological practice in Round Rock for 13 years before going to work for Hospital Corporation of America in 2010. Practice ownership was a new endeavor for the physicians, but Dr. Shaw says the arrangement suits them.

"We opened our practice in early 2011, and in 2012 we moved from a 1,400-square-foot office to a 5,500-square-foot facility. We went from five employees on staff to 10. Our practice is thriving, and we're grateful to TMA Practice Consulting for giving us a roadmap for success," Dr. Shaw said.

Whether physicians need guidance setting up a practice, improving their coding and documentation, or ensuring their practices operate optimally and make money, they need to select a qualified consultant who's knowledgeable about the practice. (See "Good Advice About Consultants.")

"What I liked about TMA Practice Consulting was that I knew they'd look out for my best interest. Unlike some consulting firms, they weren't focused on improving their bottom line. I also spoke to physician colleagues who'd had good experiences with TMA Practice Consulting, and I felt confident in selecting them to set up the practice," Dr. Shaw said.

 Professional Help Pays Off 

At times, it's best to delegate business tasks to experts. A Texas pulmonologist, who requested anonymity, decided to hire a consultant after the Centers for Medicare & Medicaid Services notified him he'd been upcoding on some Medicare claims. The physician says the mistake was unintentional, and he realized he needed professional help to get his coding and documentation in line.

He hired TMA Practice Consulting to conduct a comprehensive coding and documentation review. The consultant reviewed the practice's documentation for accurate CPT coding; appropriate application of CPT and evaluation and management (E&M) coding guidelines; correct use of modifiers; encounter forms; claims; and corresponding explanations of benefits to help ensure accurate billing and reimbursement levels.

The consultant determined that the physician had been incorrectly documenting physical exams and had only a 30-percent accuracy rate for documentation. He received a formal, written report outlining opportunities for improvement, some of which included consistently listing diagnoses in order of importance and correcting conflicting information in some documentation.

After receiving the report, the physician took coding and documentation courses and followed his consultant's suggestions for improvement. Six months later, TMA Practice Consulting did a follow-up chart audit and found his documentation accuracy rate had improved to 80 percent.

He plans to have TMA Practice Consulting do a coding and documentation review annually. TMA Practice Consulting can perform audits on a monthly, annual, or quarterly basis. Comprehensive coding and documentation reviews are approved for 20 AMA PRA Category 1 Credits™.  

The physician says that since hiring TMA Practice Consulting he's more confident in his coding and documentation. He encourages physicians struggling with coding and documentation to hire a consultant for assistance and peace of mind.

TMA Practice Consulting also offers an on-site coding and documentation training program for practices that need help understanding documentation guidelines or identifying inappropriate or inaccurate coding and weaknesses in medical record documentation. The two-hour session, customized to the practice specialty, covers a review of 1995 and 1997 E&M documentation guidelines, time-based coding, modifiers, and audit triggers, among other topics. It is approved for up to 2 AMA PRA Category 1 Credits™.

In addition, TMA Practice Consulting can conduct an operations assessment for a medical practice. The service features a comprehensive, on-site diagnostic review of the medical practice. Consultants interview the physicians and staff, observe work and patient flow, and collect information and reports relevant to daily operations.

Houston family physician Roberto Alvarez, MD, hired TMA Practice Consulting to conduct an operations assessment of his practice in 2009. At the time, he and his partner, David Nelson, MD, and their two nurse practitioners were seeing 125 to 150 patients a day but weren't seeing the profits. A TMA practice consultant spent three days at the practice offices and found an outdated records management system, delayed payments from insurance companies that cost the physicians money, and staffing problems that hindered the practice from operating smoothly and profitably.

The consultant recommended an EHR system to replace an outdated paper-based system and suggested the practice begin procedures for collecting payment from insurance companies within 45 days.

With the help of TMA Practice Consulting, Dr. Alvarez says, his practice revenue increased at least 20 percent within the first four months following the operations assessment.

The operations assessment includes: 

  • Accounts receivable analysis;
  • Review of billing and collections processes;
  • Patient flow analysis;
  • Internal controls review;
  • Managed care process analysis;
  • Review of medical records systems;
  • Review of practice management software;
  • Overhead analysis;
  • Human resources and personnel concerns; and
  • Clinical staff operations.  

Upon completing the assessment, the consultant presents a brief summary of the findings. Within 30 business days, the practice receives a written report, complete with a full analysis and specific recommendations.

Dr. Alvarez says the operations assessment opened his eyes to the importance of having a role in the business side of the practice.

"We as physicians tend to negate the fact that we are businesspeople. This is a business, and we need to be an integral part of it. I've become more in touch with what's going on in the practice since TMA Practice Consulting came in," he said.

TMA Practice Consulting services are available for a fee. To schedule an operations assessment, coding and documentation review, practice setup, or other service, call (800) 523-8776, or email TMA Practice Consulting. Additional information is on the TMA website

Crystal Conde can be reached by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by email. 

SIDEBAR 

Good Advice About Consultants 

TMA Practice Consulting offers this guidance on working with any consultant: 

Q: What questions should physicians ask before hiring a consultant? 

A: Heather Bettridge, director of TMA Practice Management Education, says physicians should ask when the consultant last worked in a medical practice. If it has been a while, ask how the consultant stays abreast of changes and current issues in practice management. Find out if the consultant worked on a comparable project in a similar environment; has a support team to provide additional expertise; has direct practice management experience, certifications, or credentials; and has a vested interest in any products or services. Always ask for and check references from past clients.

Q: What should a physician look for in a consultant?    

A: Ms. Bettridge says consultants need a strong understanding of the medical industry. With applicable skills and hands-on experience, a consultant should be able to ask the right questions, assess the situation in depth, and identify potential solutions to satisfy the needs, limitations, and goals for the practice. A good consultant will either provide the tools to stabilize the practice or will move the practice toward the next step.

 Q: What are common signs that a practice needs a consultant?  

A: Peggy Pringle, associate vice president of TMA's Practice Management Services Department, says that if physicians feel things aren't right or staff turnover is high, it's time to hire a consultant. Ms. Bettridge adds that if a practice's revenues or charges drop dramatically from one year to the next, or if cash deposits stop completely, physicians should bring in a consultant. Other signs that it's time to hire a consultant include failure of the practice manager to regularly generate financial reports and excessively high overhead expenses.

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