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    Andrew Hajde
    Andrew Hajde, CMPE
    Cristy Good
    Cristy Good, MPH, MBA, CPC, CMPE

    Shifts in patient volumes, cancellations of elective procedures, supply-chain shortages, staffing concerns and much more all require healthcare administrators to disrupt old workflows and operations in favor of adapting and evolving how practices run — all to ensure that they continue running rather than closing amid the competing pressures faced during the COVID-19 pandemic.

    The following 12 areas are essential in helping medical practices to evolve and excel throughout the course of the COVID-19 pandemic, according to MGMA industry experts:

    1. Planning, decision-making and crisis management

    The ability to act quickly and decisively and make plans that have both short- and long-term financial implications can make a huge difference in medical practice operations. Adapting and pivoting to the daily changes at both a federal and state level is essential to help a practice to continue operations while offering patient care and protecting providers and staff.

    2. Continuity of operations as an “essential business”

    Medical practices are essential businesses and can and should continue operations during a governmental stay-at-home order. Each employee who reports to a clinic or office should be issued a letter attesting to their “essential” status in case they are questioned by a law enforcement officer.

    3. Managing volumes and revenue

    An April 7 MGMA Stat poll found that 97% of practices reported a drop in patient volume amid COVID-19, and more than 70% of the practices reported said volumes declined by 50% or more.

    The long-term viability of a practice is dependent on the ability to continue to see patients throughout the crisis in addition to any federal/state assistance that may be offered. Continuity of care for patients also is crucial, as maintaining access to care helps to prevent issues with medical malpractice relating to patient abandonment.

    Telehealth services have proven to be popular options to see patients as quickly as possible during the pandemic. Many practices have reported shifting some or all patient visits to telehealth. Practices with multiple locations seeing patients suspected of having COVID-19 have redirected those patients to a dedicated location to handle those cases to limit the risk of exposure.

    Practices that depend on surgical volumes will have to work closely with hospitals and surgical centers to resume surgeries as soon as possible if they are put on hold during a crisis.

    4. A/R and collections

    Keeping the billing office running during this time is challenging yet crucial for maintaining a tight revenue cycle. Keeping up with documentation and coding updates during this time is also important as the Centers for Medicare & Medicaid Services (CMS) has released guidance on billing and reimbursement for treating COVID-19. The American Medical Association (AMA) has also added unique codes for reporting novel coronavirus testing.

    Stress to your staff the goal of getting as close to collecting 100% of the practice’s outstanding A/R as possible to boost cash during a period of reduced patient volumes. Success also can be measured through many metrics: total denials received, total appealed, cases not appealed and why, total cases overturned and associated financial impact, second-level denials and failed appeals. Document the data associated in a denials management program.

    5. Expenses and financial obligations

    Carefully analyze all fixed and variable expenses to keep only the bare minimum of expenses being paid out. Even with fixed expenses such as a building lease payment, it may be possible to work with the building owner to obtain some leniency for when payments will be due.

    For variable expenses there are expenses that can be cancelled or put on hold, such as waiting room cable/satellite TV service or paper shredding services that could be replaced with a small shredder owned by the practice. Even for utilities or other mandatory expenses, consider contacting the providers to see how they are willing to assist you financially; they may be offering services (e.g., higher speed internet) at significantly reduced prices for the foreseeable future. Determine any possible rate changes for employee health/dental insurance benefits to adjust for any potential increase. All these efforts will dramatically increase how long a practice can operate with a reduced revenue stream.

    6. Loans and lines of credit

    Numerous efforts are underway at the federal level to aid healthcare business owners with loans and payroll assistance. Additionally, numerous banks can assist practices to bridge this challenging period with loans or lines of credit. Practices and business owners of all sizes should be analyzing their available liquid assets and then calculate across a range of scenarios how long they can maintain their financial viability over the next several months and beyond. A pro forma is an excellent tool to help calculate best- and worst-case scenarios and take the actions needed until a practice can return to normal volumes.

    7. Optimizing PPE use

    Personal protective equipment (PPE) is used every day. With recent shortages and supply-chain interruptions, it is important to follow guidelines on how best to handle PPE and identify alternative ways to provide care safely for both providers and patients.

    Track how quickly you are using supplies. The CDC’s “burn rate” calculator will help determine your average consumption rate for each type of PPE and allow you to estimate how long remaining supplies will last.

    8. Staffing and HR

    Your staff are the most important part of your organization, and it is very important to communicate often and openly during this busy and scary time. Think creatively as to how and where providers and staff may be used to minimize layoffs, furloughs and terminations, and work with legal counsel, as necessary, to review the rules in your state regarding workforce reductions.

    Practice leaders should understand the employment provisions in the Families First Coronavirus Response Act (FFCRA), including the Department of Labor’s April 6 temporary regulations for implementing emergency FMLA and sick leave under the law.

    Remember that there will be a time when operations return to normal, and you will need to be prepared to staff appropriately.

    9. Business insurance coverage

    It is important to understand what is and what is not covered by your business insurance during a pandemic. You will need to consult legal counsel on your options under your existing policy and what happens when there are government orders that may restrict or govern your business operations.

    Just as with a natural disaster, a public health emergency is potentially time to evaluate the interruption of business coverage within your practice’s existing insurance policies.  

    10. Special projects and training for staff

    As certain elements of normal operations are put on hold, consider initiating special projects and training for staff who might otherwise be underutilized as duties and roles evolve. Examples of projects to minimize such downtime include optimizing EHRs. Use of a priority decision matrix and SWOT analysis tools can help a leader determine what normally were low-priority initiatives and keep staff productive.

    11. Leadership and mental health considerations

    Writing for STAT News, Jessica Gold, MD, assistant professor of psychiatry at Washington University in St. Louis, labeled healthcare workers’ mental health as a “crisis” within the pandemic, and that the inspiration derived by the general public in resilient, strong doctors and nurses is not the reality for many of those frontline providers. “Underneath it, many healthcare workers are barely keeping it together. They are anxious and they are afraid. They aren’t sleeping and they find themselves crying more than usual.”

    Dan Diamond, MD, notes that healthcare leaders need to approach the chaos of the COVID-19 pandemic with a measure of self-compassion and focusing on your team. “Healthcare was difficult before COVID-19 … now we need to show up with each other, and bring kindness and openness and curiosity, and ask how we can support each other,” Diamond said in a recent MGMA Insights podcast.

    In an essay for The New Yorker, Dhruv Khullar, MD, MPP, assistant professor, Weill Cornell Medical College, notes that peer support groups are springing up among doctors and others. “We check in with one another, discussing the frustrations of supply shortages, the anxiety of making hard decisions, the helplessness that comes from feeling that, despite your best efforts, people will die,” Khullar wrote.

    A successful practice leader needs to bring that same degree of mindfulness to what his or her physicians, nurses and staff are facing each day, and that looking out for their mental well-being should not be far behind ensuring their physical safety.

    12. Practice workflows and consolidation of workloads

    During any period of tight cashflow it is critical to maximize efficiency in every aspect of practice operations. Cross-training and consolidating workloads will enhance a practice’s ability to be nimble and respond to the constantly changing environment. For many staff this can be maximizing the duties they perform from home if teleworking, or being flexible to respond to needed tasks in the practice facility. Utilizing Lean techniques to reduce waste with processes and creating new documented workflow diagrams and flowcharts can improve efficiencies and revenue while keeping hours worked to a minimum.

    Additional resources

    Andrew Hajde

    Written By

    Andrew Hajde, CMPE

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