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    The process of reopening and recovery during the COVID-19 pandemic — after months of stay-at-home orders and restrictions on elective procedures — can be just as difficult as the shutdown process was, if not more complex.

    Implementing new safety and cleaning protocols, sourcing personal protective equipment (PPE) and updating patient scheduling all become new challenges, in addition to determining the best ways to engage patients to come back and bring volumes closer to a pre-pandemic level.

    To help make sense of the current climate, a trio of practice management experts from MGMA Consulting recently tackled these issues in a July 9 webinar, “MGMA Consultant Roundtable and Q&A: COVID-19 Recovery":

    • Nancy Enos, FACMPE, CPMA, CEMC, CPC-I, CPC, principal, Enos Medical Coding
    • Owen Dahl, MBA, FACHE, CHBC, LSSMBB, consultant, Owen Dahl Consulting
    • Adrienne Palmer Lloyd, MHA, FACHE, chief administrative officer, ophthalmology, Duke Eye Center.

    Your space and social distancing

    When it comes to meeting recommended social distancing guidelines from public health experts, Dahl says that a six-foot distance should be considered a bare minimum and reinforced by staff adhering to that requirement by limiting congregating in break areas and pushing meeting attendance to virtual meetings, such as through Zoom.

    Having patients wait in a car until they can be called into the office when the exam room is ready remains a key recommendation to limit issues with exposure in a waiting room. Updating schedules to see sick patients at different hours than patients who do not have high risk for COVID-19 exposure is also advisable, Dahl said.

    Technology to limit touching

    Practices with robust patient portals should be enabling them for any integrations with mobile device apps so appointment requests and questions for providers don’t require in-person interactions, Enos advised. Practice leaders should take a secret-shopper-style approach to looking at the clinic facility through the eyes of a patient to understand where high-touch surfaces and high-traffic corridors are to reduce potential contamination at regular intervals.

    “Do you have some kind of an automated front door, or go low tech and use a doorstop,” Enos said about eliminating touchpoints on entryways. “It might not be a good [with] air conditioning going out the door, but you don’t want patients touching things that they don’t have to.”

    Additionally, taking credit card payments over the phone or via the portal following an appointment can allow patients to exit your facility as quickly as possible and limit potential exposure from anyone who is infected with coronavirus. “Eliminating touch, with every tool that we can, is really important at this time,” Enos said.

    Cleaning conundrums: Safety and scheduling

    In situations in which a patient is seen in a room without exhibiting symptoms and there are no aerosol-generating procedures, Dahl said that following the OSHA bloodborne pathogens standard as a general precaution is highly recommended.

    But in situations that pose higher risk for coronavirus contamination, the extra efforts recommended by the Centers for Disease Control and Prevention (CDC) — including letting the room sit empty depending on the number of air changes per hour — should be followed, Dahl advised. That also includes proper disposal of potentially contaminated items, such as exam table paper.

    Accounting for the downtime for room cleaning should be done in scheduling a provider for a window of telehealth visits that can be done elsewhere in the facility until the exam room is ready for a patient again.

    Lloyd advised understanding when a provider would most prefer a block window of telehealth visits, and then scheduling in-person patient visits according to appointment types that could minimize the risk of exam room downtime due to unexpected patients who pose COVID-19 concerns.

    PPE concerns continue

    An informal poll of roundtable attendees found about three-fourths of practice leaders are still struggling with acquiring PPE. In new hotspot areas such as Texas, acquiring new PPE has become difficult for many practices, and some organizations are looking to acquire reusable PPEs that can be cleaned properly after initial use and reduce the organization’s overall PPE burn rate.

    • Click here for CDC guidance on decontamination and reuse of respirators such as N95s.

    As Lloyd noted, practices should consider policies about wearing makeup or other substances that, once in contact with PPE, can hinder the ability to clean them properly. Staff and providers also need to ensure any patients who need N95s — such as those showing symptoms, undergoing lengthy procedures or where there’s risk of airborne exposures — should wear them properly throughout the appointment/procedure.

    Many practices are now opting for plastic face shields in place of single-use PPE in situations in which providers have to be closer to the patient, including specialties such as ophthalmology, Lloyd added.

    Regardless of the resurgence of COVID-19 in specific areas, Lloyd said there remains ongoing concern about securing PPE paired with a “get-it-when-you-can mentality” that has to be balanced against the risk of overstocking.

    The right balance for telehealth

    While most practices expanded telehealth early in the COVID-19 crisis, the outcomes have varied across specialties, Lloyd said. “Some of the behavioral health groups [and] primary care groups that I’ve worked with have seen really great success [with telehealth],” Lloyd noted, whereas practices with procedure-based imaging requirements (e.g., cardiology, ophthalmology, orthopedics) are still working through making telemedicine work for them.
    Those practices have opportunities to perform some non-billable care activity via phone or video calls, such as preoperative testing, assessments, reviewing chart history and reconciliation. These are primarily benefits to the patient to make an actual in-office visit more efficient, but it also limits exposure by getting the patient in and out quickly.
    The telehealth “cliff” faced by practices if regulatory waivers are ended could pose issues for patients who now appreciate not having to travel to a practice for a visit, Enos said. “Once you give someone something, it’s hard to take it away,” Enos noted, underscoring the widespread hope that those telehealth waivers are extended or made permanent.

    Regardless of the outcome, Enos recommended that practices make certain that their telehealth platforms are HIPAA compliant to ensure the safety of patients’ protected health information (PHI) for the long term.
    On the payer front, Enos noted that many practices are “starting to see more of a plateau” after months of responding to updated payer rules on telehealth services, which made it difficult to correctly code and resubmit claims to ensure they were billed properly.

    Volume and revenue

    For many specialty practices that rely heavily on referrals from primary care offices that have not being operating near pre-COVID-19 levels, Dahl recommended that specialty practice leaders remain in “constant communication” with your best referral sources and monitor how their recovery efforts are going.
    It’s also important that those referral sources also understand your practice’s commitment to safety, so that those referring physicians “can tell their patients that you’re doing everything you can” in terms of facility cleaning and PPE usage.
    From a revenue perspective, Enos said that practice leaders should take time to review claims denials and error codes from rejected claims to ensure that proper place of service (POS) codes for each CPT code are being applied. She also insisted that practices “be clear on the technology that is authorized for billing a certain type of CPT code,” whether that’s audio or audio and visual in telehealth services.
    These steps can then help practices audit claims going back to the first billing rule changes in March and find any opportunities to resubmit claims so that money isn’t left on the table. “There’s a lot of revenue out there to be captured with better understanding of all the final billing rules,” Enos added.

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