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Coordination Gaps: What They Are & What To Do About Them
By: Chad M. Hemphill & Daryl J. Tegtmeier, CFP, Panoptic Wealth Advisors

Medical groups, whether large or small, deal with many of the same issues; billing and collections, human resources issues, managing risk, navigating leadership change, merging practices and coordination gaps. You may have been nodding your head as you read the previous sentence until the last two words made you pause. The term “coordination gaps” may not be familiar to you, but you probably have an intuitive idea about what it means because you have experienced their effects.

So, what is a coordination gap? A medical group is a business and like any business has a myriad of systems, procedures, departments, people and regulations that need to work together to optimize the performance of the overall practice. Each of these components may have been very well thought out and meticulously defined so that they operate optimally in their own silo. Bring them into the context of the entire practice, however, and things begin to break down. Sometimes this breakdown is caused by not thinking through how one component will interface with another. Sometimes it is caused by a lack of knowledge of how and why one component works by those that have designed another component. Sometimes it is caused by competing agendas between two components. Whatever the cause, what arises from these scenarios are coordination gaps.

So, as practice managers, when these situations arise, what do you do? You temporarily pull yourself up out of the individual issues to gain a higher perspective of the entire business. You identify the larger goal that the business is working to accomplish and then, with that context, work down into the individual components. Within each component you determine what needs to be modified or adjusted to allow the components to work together, optimally, to accomplish the goal. You have just closed down the coordination gaps.

Now, let’s take that same context, step out of the medical group and think about the coordination gaps that can exist for its owners by considering these questions. Does the medical group have more than one owner and do those owners have potentially competing agendas? What strategies are the owners pursuing to minimize exposure from taxes, both now and in the future and what trade-offs are those decisions causing them to make? Do the owners understand and take full advantage of the opportunities that exist to reward key employees? Do they have a strategy to effectively maximize the business value while also diversifying away from the business? Does one or more owner have interest in the building that houses the practice and have they thought through the issues this may cause? Does one of the doctors, by extension of his specialty, have a secondary business that produces a product to specifically help in the diagnosis or treatment of his patients and is he aware of the issues that could arise? Have the issues of risk that exist outside of malpractice been fully addressed and mitigated? Do one or more of the owners have plans to leave the business in the next few years and if so, have they worked through all of the exit planning issues? Have the owners put the business into the context of their overall life goals and objectives and how do they use this perspective to drive their business decisions? While most of these issues may have been thought through and addressed, if they were thought through in their individual silos, the unintended consequence of bringing them together are coordination gaps.

So, how can these coordination gaps be addressed? Much like a practice manager does inside the medical group, so a wealth planner does with the business questions asked above. They approach the situation by first stepping back from the individual issues and identifying the overall goals and objectives of the owners. Using that context, they dive into the individual issues and coordinate with other advisors (typically legal and tax) to help the owners make decisions about the medical group. When done in this way, the decisions made are not only consistent with the owners goals and objectives, but also in line with other owners; effectively closing the coordination gaps.

One final issue that you are acutely aware of, but that needs to be mentioned is the influence of government involvement in a healthcare business. The government is both the greatest protector of the individual’s rights (FDA oversight and industry regulation), while simultaneously one of the biggest clients of healthcare (Medicare and Medicaid); consequently, its influence can be felt in nearly every facet of a healthcare business. This realization is important because often government involvement can subtly cause coordination gaps to start where previously none existed. This requires both practice manager and the wealth planner to be constantly vigilant and attuned to look for these coordination gaps. When they see them beginning to appear, they can begin working to effectively minimize the risk to the business while simultaneously maximizing the opportunity.

Much like the practice manager operates for the medical group to close down the coordination gaps thereby assuring that it continues to operate at optimum levels, so the wealth planner acts on behalf of the ownership to assure that the coordination gaps are addressed and that their wealth plan is functioning as well as possible. By having you in the role of practice manager, your medical group has demonstrated its commitment to assuring they have the best advice and direction possible within the practice. Similarly, the owners of your medical group should commit to having a competent wealth planner to work on their behalf to assure they are receiving the best wealth planning advice and direction possible.

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Basic Controls Safeguard the Assets of Your Practice
By: Richard D. Krieger, CPA/CFF, CFE, CIA, Dir, Fraud Prevention Services, Anders Minkler & Diehl LLP

With the hectic schedule that physicians typically follow, many doctors are more than happy to turn over the financial details of their practice to their staff. In a practice without adequate internal controls, however, that decision could prove to be extremely costly.

Although every practice will vary to some degree, basic controls will go a long way towards ensuring that assets are properly accounted for and safeguarded against potential misappropriation. The following Top 12 Tips will assist practices of all sizes to maintain important internal controls that can keep a practice safe, running smoothly and profitable:

• Bond all appropriate practice employees.
• Use a bank lockbox for payer and patient deposits.
• Segregate job responsibilities; the person receiving cash should not be posting payments to patient accounts.
• Reconcile receipts to sign-in sheets and appointment books on a daily basis.
• Maintain pre-numbered patient charge tickets and account for the numerical sequence daily.
• Reconcile daily cash posting to the bank statement.
• Monitor contractual adjustments - look for unusual trends that don’t fit the pattern of the practice profile.
• Require physician approvals for all bad debt write-offs.
• Have a physician review and approve all vendor invoices and sign all checks.
• Forbid the use of a signature stamp.
• Periodically review endorsements of cancelled checks for any anomalies and investigate accordingly.
• Ensure proper computer password protection procedures are in place and properly enforced. Employees should only have access to those programs necessary for them to perform assigned job responsibilities.

Ultimately, the physicians have to take responsibility for managing their practice. Implementing some basic controls can offer peace of mind that your assets are being adequately protected.

A Certified Fraud Examiner (CFE), Rick is the Director of Fraud Prevention Services at AMD. He is also a CPA and work extensively with privately-owned businesses on audit, accounting and other financial management matters. He is a member of the AMD Health Care Services Group and consults with physicians and other healthcare organizations on fraud prevention and detection, and related internal controls. Rick can be reached at 314-655-5540 or rkrieger@amdcpa.com.

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Run, Don’t Walk, To Your Next Meeting
By: Claire Keeling

Sandy arrived in the boardroom five minutes late. She had her agenda in her hand and had gone onto the company’s shared drive to review the minutes from the last meeting. As she sat down into an empty chair, she realized that they were reviewing the minutes from the last meeting. This really irritated Sandy, when others came to the meeting unprepared and wasted her time needing a review. Two hours later, Sandy was tired, unmotivated, and frustrated, as she walked out of the meeting. “I’d rather stick a fork in my eyeball, than sit through another one of those,” she thought, already dreading the next meeting.

Sound familiar? Ineffective meetings have become the norm because individuals haven’t been taught the skills needed to run a successful meeting. By understanding these easy meeting mistakes, you can help your team turn your next meeting into something staff members will enjoy attending and look forward to. Below are four strategies to overcome bad meeting mistakes.

Meeting mistake #1: No clear purpose or desired outcome. One step towards holding an effective meeting is to be very clear at the onset as to the purpose and outcomes of the meeting. Are you meeting to make a decision, generate ideas, offer status reports, communicate something or make plans? By sharing this information with your attendees, others can come prepared and ready to get to work.

Meeting mistake #2: No agenda. Items that might be included on an agenda include:

• Date
• Purpose
• Desired outcomes
• Review of decisions to be made/decision making process
• Time frame
• Summarize decisions
• Review “parking lot items”
• Review next steps

Whether you’re having an internal staff or team meeting or an external meeting with a client or group, the use of an agenda is a crucial component of a successfully run meeting.

Meeting mistake #3: Holding the wrong type of meeting. Staff members will burn out quickly if your 5-15 minute daily huddle turns into a 45-minute complain-fest every day. Understanding the different types of meeting and purpose is crucial. Here are the four main types:

• Daily Check-In - this type of meeting is best standing up, needs to be 5-15 minutes long, it’s purpose is to ensure that items don’t fall through the cracks and can eliminate unnecessary email chains about schedule coordination
• Weekly Tactical - regularly held meeting focusing on tactical issues of immediate concern, 45-90 minutes long
• Monthly Ad Hoc Strategic - usually project based, length depends on the topics being considered, two hours scheduled per topic is pretty normal to ensure open ended conversations and debate
• Retreat - can last one half day or run one or two days, focus is typically a review of trends and team development

Meeting mistake #4: No clear decision making process. Knowing why you’re meeting and what type of decision will be made, if at all during the meeting, is essential. Here are some types of decisions:

• Tell and Sell - Leader makes decision ahead of time and uses the meeting to tell and sell the group on the idea
• Input/Feedback - Gather input or feedback and then leader decides
• Recommendations - Group develops recommendations (does research, writes proposal) and then leader decides
• Group - Group decides by consensus (everybody in the room can live with the decision and will support it)
• Subgroup - Group identifies parameters and sub group decides

Claire is an experienced productivity consultant, national speaker, trainer and coach. She diagnoses productivity priorities to address within an organization and teams up with individuals and groups to help guide change and foster a culture of learning. She encourages personal development activities and solutions that motivate individuals to work smarter and help reduce stress.

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Why EHR? Why Now?
By: Sandy Pagones & Jeremy Milarsky, Primaris

For all of the discussion about it, electronic-health-record (EHR) technology has followed a bell curve when it comes to people actually using it, like any new product on the market. Obviously, many healthcare providers have come out as innovators and early adopters - they have already implemented systems, gaining experience and expertise through challenging (but ultimately rewarding) change.

Few physicians who have gone electronic would go back to paper. Patients prefer physicians who use EHR systems2. The operating benefits of the technology have been well-proven1,3.

In sum, adoption has now spread to the early majority. Physicians who have not yet adopted EHR systems are at a crossroads - move ahead with the masses, or continue to lag with the skeptics. But even for those skeptics, there are ample reasons why now is the ideal time to take this technology seriously and move forward.

• Financial Incentives: Never before (and likely never again) has there been such generous federal monetary incentives for implementing a new technology. Each provider stands to earn up to $44,000 over the next five years - or up to $64,000 over the next seven years if serving a high Medicaid population - for adopting and learning to effectively use an EHR system. Additionally, in Missouri, a “bridge loan” program has been established to assist with funding the purchase of an EHR system. Other financial incentives that align with EHR adoption are still in place, but scheduled to be phased out in the near future, including the federal Physician Quality Reporting Initiative (which affects Medicare reimbursements) and various managed care incentives. Finally, adopting now allows a provider to earn the “carrot” and avoid the “stick” - the penalties for late adoption have already been announced.
• Technical Assistance: Not only are financial incentives present, but technical assistance is also being offered through the establishment of Regional Exchange Centers. Missouri’s Technical Assistance Center has been established and is preparing to provide assistance to small practices that need it most, and are not being courted by large vendors. Working together with other small practices through the Assistance Center offers the power of group contract negotiation, group learning, and a louder voice to encourage vendor responsiveness.
• Urgency: The sooner you start, the sooner you’ll realize the benefits for both yourself and your patients. Learning to take advantage of the power of an EHR will give you tools that will enable you to take your practice up a notch. EHRs can handle large amounts of complex data, instantly retrieve medical knowledge, track performance and adherence to evidence-based medicine, transform that data into usable information to improve care, validate insurance coverage and requirements, and eliminate the need for repetitive data collection and work. Easy record retrieval, access anywhere/anytime, and data sharing with colleagues and patients are long overdue, and initiatives are taking place in Missouri to expand health information exchange.
• Legacy: If you plan to recruit a young physician or sell your practice, modern EHR technology will be expected.

While this effort remains in the planning stages, physicians who are interested in learning more about the Regional Extension Center should contact Cora Butler at Primaris, 573-673-4099 or cbutler@primaris.org.

Works Cited

Hillestad, R., Bigelow, J., Bower, A., & Girosi, F. (2005). Can Electronic Medical Record Systems Transform Health Care? Potential Health Benefits, Savings, and Costs. Health Affairs, 24 (5), 111103-18.
Swartz, N. (2007). Americans Prefer Electronic Health Records. Information Management Journal, 41 (4), 8.
Swartz, N. (2005). Electronic Health Records Could Save $81 Billion. Information Management Journal, 39 (6), 6.

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