PRACTICE MANAGEMENT

1. PRACTICE MANAGEMENT TOP 10 THINGS YOU NEED TO KNOW

2. AGENDA • CORE VALUES • CORPORATE OR PARTNERSHIP DOCUMENTS • GOVERNANCE • BEHAVIORAL ISSUES • DASHBOARD REPORTS • EMPLOYMENT ISSUES • RISK MANAGEMENT • MEDICAL RECORDS • ICD-10 • SUPERVISION OF PHYSICIAN EXTENDERS

3. Core Values

4. Core Values Built To Last

5. Core Values The organization’s essential and enduring tenets A small set of general guiding principles Not to be confused with goals or policies Not to be compromised for financial or short-term expediency Collins & Porras - Built To Last

6. Core Values • JFP has a strong religious foundation and believes in “Loving God’s People” • Individuals are valued for the ‘Skills and Opinions’ they bring to the practice. • The group works with a Team Approach to promote the concept of one practice. • A Full Scope of Care will be provided. • Every individual is expected to work hard and help each other. • There is a life outside the group, therefore, a Balanced Life will be encouraged. • High Quality Patient Care is expected. • Everyone at JFP will strive for Excellence and Superior Performance. • JFP will provide The Best Possible Medical Care. • JFP will treat all people with Respect and Dignity.

7. Core Values • The physicians will maintain “High Ethics.” • The group will create an environment which will promote a “Team Approach.” • Physicians are expected to “Work Hard” and help each other. • The practice is committed to the orthopaedic needs of the community. • Physicians will show humility. • There is a life outside the group, therefore a “Balanced Life” and “Family Involvement” will be encouraged. • The group will exercise fiscal responsibility. • Community involvement is supported by the practice. • “High Quality Patient Care” is expected.

8. Core Values • The group is more important than the individual, hence “One Practice” • The group will create an environment which will promote a Team Approach • A Full Scope of Care will be provided • Physicians are expected to work hard and help each other • There is a life outside the group, therefore, a Balanced Life will be encouraged • High Quality Patient Care is expected • The Group will strive for Excellence and Superior Performance • The will provide The Best Possible Medical Care

9. Core Values • Patients and achieving Excellent Surgical Outcomes. • We are Compassionate and always put the Patient First. • We expect everyone to Work Hard and we will Support Each Other to ensure a Balanced Life. • Pride – We will strive to protect and foster those things we hold dear. • We are proud to be General Surgeons • We are proud to be associated with the Physicians In This Practice • We are proud our Employees • We are proud of our Legacy • It is essential to Like Each Other and to work in a Collegial Spirit. • We will treat all people with Humility, Equality, Dignity and Respect. • We respect the Individual Strengths and Specialty Skills of each physician. • We understand that Open and Continual Communication is crucial. • Our Employees are Part of the Memphis Surgery Associate Family. • We will do our part to Sustain General Surgery as a noble and honorable profession.

10. Core Values How To Use Them • Dealing with a behavioral issues • Making policy and purchasing decisions • Recruitment • Dealing with people • Setting clinic standards • Setting priorities

11. CORORATE or PARTNERSHIPDOCUMENTS

12. Articles of Incorporation Stock Certificates By-Laws Buy-Sell Agreements Employment Agreement Pension, Profit Sharing, & Retirement Partnership Agreements Operating Agreements Minutes Leases Benefits Documents Managed Care Contracts CORPORATE or PARTNERSHIP DOCUMENTS

13. CORPORATE or PARTNERSHIP DOCUMENTS WE DON’T HAVE TO PUT ANYTHING IN WRITING WE TRUST EACH OTHER THE ATTORNEY REPRESENTING YOUR EX-PARTNER OR YOUR SPOUSE IS NEVER YOUR FRIEND

14. CORPORATE or PARTNERSHIP DOCUMENTS • OWNERSHIP OF MEDICAL RECORDS • BUY-IN • NON-COMPETE • PAY FORMULAS • MALPRACTICE • PREMIUMS • TAIL COVERAGE • VALUE OF PRACTICE • TIME TO PARTNERSHIP • TERMINATION • BY GROUP • BY PARTNER • DEATH • DISABILITY • RETIREMENT HOW IS THE PRACTICE GOVERNED?

15. CORPORATE or PARTNERSHIP DOCUMENTS ARE THE DOCUMENTS SIGNED? DOES ANYONE KNOW WHERE THE DOCUMENTS ARE?

16. Governance

17. Organizational Structure Board Committees Administrator Develops Core Values Hires & Terminates All Personnel Matters Physician Recruitment Physicians Approves By - Laws Safety of Pts & and Approves MD Pay Plan Finance Employees Operating Agreements Approves Physician Develops & Monitors Technology Develops & Approve Partnership Budget Strategic Plan Accepts Committee Operates Company Building Approves Budget Reports Within Budget Fiduciary Operation of Finds Way to Improve Settles Physician Operations Company Behavioral Issues Op Approves Policies Managed Care Hires & Operations Sets Performance Terminates Administrator Standards Implements Strategic Marketing Plan Evaluates Administrator Performance All Contractual Obligations President Sets Agenda Implements Policies Studies Issues Brought Facility by Administrator Resource for Administrator Physician Behavioral Issues Appoints Committees

18. Governance Things To Remember • The group comes before the individual • All must follow the decisions of the board • There must be repercussions for those that do not comply • The manager works for the Board, not any one physician • The employee must have the right to say “no” and to send things to the Board • All the employees work for the manager • The physicians must send the employees to the manager

19. Governance Scenarios • One of the physicians tells the manager to do some and she does not think it is in the best interest of the practice • One of the physician goes to the front desk and tells them send patients back even if a new chart is not, yet, been set-up in the system • A physician is habitually late, doesn’t do his charts in a timely manner and sloughs off on call.

20. Behavioral Issues

21. Behavioral Issues Examples of Disruptive Behavior Remember to look for a pattern. •  Fails to comply with practice standards • Shames others for negative outcomes • Uses foul, abusive language • Arbitrarily sidesteps policies • Acts in ways that are perceived of as sexual harassment • Threatens staff or associates with retribution, litigation or violence • Criticizes staff in front of others • Discourteous and disrespecting others in the healthcare team • Casts slurs on someone’s ethnic identification • Relies on intimidation to accomplish goals • Fails to respond to direct questions relating to patient care • Tells others they are stupid, untrainable or uneducable • Disregards the personal/professional comfort of colleagues • Disparages others’ care or behavior in front of patients/family • Reprimands others in front of patients/family or team members • Uses bodily contact with team members which is not therapeutic or mutual • Refuses to interpret or write orders legibly • Refuses to apologize after harming someone • Shuns those with whom there is a communication problem • Refuses to respond to constructive feedback or criticism • Shuns the use of appropriate grievance channels • Threatening, assaultive and violates others’ professional space • Repetitively cynical and aggressive

22. Behavioral Issues Positive Examples of Professionalism • Compliance with practice standards • Using conflict resolution skills in negotiating differences and disagreements • Addressing concerns about clinical differences directly and privately • Approaching dissatisfaction with policies through established grievance channels • Supporting policies that promote cooperation and teamwork • Listening to and trying to understand constructive feedback

23. Behavioral Issues Approaches to Dealing With the Physician • There must be a clear understanding that it this point the physician is to be treated as an employee and not an owner. • The guiding logic should be – “How would the practice deal with any other employee that acted inappropriately?” • Counseling • Treatment • Corrective Action Plan For The Employee • Disability • Discipline • Termination • The practice, it’s patients and employees must be protected. • Careful consideration must be given to the fact that if the physician is determined be disabled that ADA regulations may apply.

24. Behavioral Issues Confronting The Individual • Agreement within the leadership or governing body with the action to be taken • A clear understanding about who (Spokesperson) is responsible for confronting the disruptive physician • Be resolute in explaining the problem (do not debate) • Have an action plan prepared to present

25. Behavioral Issues Support & Assistance Arkansas Foundation for Physicians Health

26. Behavioral Issues Assessing The Problem What If Physician Denies The Problem? Or The Practice Wants to Have The Physician Assessed Before Suggesting A Plan. VANDERBILT COMPREHENSIVE ASSESSMENT PROGRAM FOR PROFESSIONALS (V-CAP)

27. Behavioral Issues Vanderbilt Comprehensive Assessment Program for Professionals (V-CAP) • Psychological Testing and Reports • Psychiatric Evaluation • Psychosocial History (may include interviews with family members) • History and Physical, where indicated • Blood Work and Drug Testing, when indicated • Collateral Information – with client permission other interested parties maybe interviewed • Follow-up Sessions • Comprehensive Report for Client & Practice

28. Behavioral Issues Action Plan • Identify the inappropriate behavior (no debate) • Insure that the physician understands the spokesperson speaks for the whole group • List actions that the group is going to require of the individual, • Such as: • Be evaluated by Vanderbilt • Come under the care of a psychologist • Get charts caught up by a specific date • Stop doing surgery • Attend anger management course • Apologize to surgical team • Follow the prescribed action plan • Physicians Health Program • Create a monitoring plan • Give regular feedback • Define repercussions for failure to adhere to the plan

29. Behavioral Issues Financial Considerations • A Key Question - The physician’s professional competency has been brought into question, does adding a financial burden on top that aid in bringing about a positive outcome? • Is the practice willing to support the physician by: • Protecting his/her income? • Paying for all evaluations & treatment? • If compassion does not prevail, ask the question • Will the practice be better off financially if this physician can be helped?

30. Behavioral Issues Manager’s Role • Group Practice • Insure that proper governance & responsibilities are in place • Support the Board and the Spokesperson • Be supportive of the physician, but not an enabler • Aid in the monitoring process • Keep the plan on schedule • Solo Practice • If the rapport is there – the manager may need to deal with the physician • Request advice and assistance from the state’s physician health program • The hospital may be of assistance – same problems are likely to be present there as well • Consider bringing a third party into the situation • If patients, employees and the manager’s wellbeing are at risk and the manager cannot bring about change they should leave the practice • If patients are at risk and the manager is unable to bring about change the licensing board should be informed

31. DASHBOARD REPORTS

32. DASHBOARD REPORTS DO YOU GET PILES OF REPORTS? BUT NO INFORMATION?

33. DASHBOARD REPORTS • OPERATING FINANCIAL DATA • ACCOUNTS RECEIVABLE • CASH • BENCHMARKS

34. DASHBOARD REPORTS OPERATING FINANCIAL DATA PRODUCTIVITY • Relative Value Units (RVU) • Charges • Collections • Office Visits • Procedures • Admissions • Days Worked

35. OPERATING FINANCIAL DATA REVENUE Gross Revenue Net Revenue Office Ancillaries Procedures Hospital Extenders DASHBOARD REPORTS

36. DASHBOARD REPORTS OPERATING FINANCIAL DATA EXPENSES • Employee • Building • Other • Physician

37. ACCOUNTS RECEIVABLE Total A/R Days in A/R A/R Aging Credit Balance Report DASHBOARD REPORTS

38. CASH Cash vs. Net Income DASHBOARD REPORTS

39. CASH Cash vs. Net Income Bank Balances DASHBOARD REPORTS

40. BENCHMARKS Internal Prior Years Doctor to Doctor Budget External Medical Group Management Association (MGMA) Specialty Societies Hospital Health Plans DASHBOARD REPORTS

41. 2012 2012 2013 2013 % Monthly % YTD MGMA MGMA May YTD May YTD Change Change Monthly YTD Productivity Charges $ 57,332.11 $ 259,667.14 $ 65,877.56 $ 315,889.74 14.9% 21.7% $ 62,381.92 $ 311,909.60 Office Visits 266 1,399 320 1,511 20.3% 8.0% 292 1,460 Procedures 8 47 15 55 87.5% 17.0% 11 55 RVUs 300 1,415 333 1,684 11.0% 19.0% 322 1,610 Revenue Net Receipts $ 41,221.22 $ 187,687.33 $ 46,779.56 $ 230,489.66 13.5% 22.8% $ 44,046.83 $ 220,234.15 Refunds $ 1,755.66 $ 7,598.30 $ 1,301.09 $ 5,578.87 -25.9% -26.6% Other Income $ 3,000.00 $ 15,000.00 $ 3,000.00 $ 15,000.00 0.0% 0.0% Total Revenue $ 42,465.56 $ 195,089.03 $ 48,478.47 $ 239,910.79 14.2% 23.0% $ 44,046.83 $ 220,234.15 Expenses Employee Costs $ 15,889.56 $ 75,877.32 $ 14,877.23 $ 65,887.44 -6.4% -13.2% $ 13,669.67 $ 68,348.35 Building Costs $ 3,855.00 $ 19,275.00 $ 5,000.00 $ 25,000.00 29.7% 29.7% $ 3,748.25 $ 18,741.25 Other Expenses $ 11,100.80 $ 66,405.34 $ 8,588.63 $ 54,984.72 -22.6% -17.2% $ 8,700.41 $ 43,502.05 Total Expenses $ 30,845.36 $ 161,557.66 $ 28,465.86 $ 145,872.16 -7.7% -9.7% $ 26,118.33 $ 130,591.65 Net Revenue $ 11,620.20 $ 33,531.37 $ 20,012.61 $ 94,038.63 72.2% 180.4% $ 17,928.50 $ 89,642.50 Physician Costs $ 10,000.00 $ 50,000.00 $ 12,000.00 $ 60,000.00 20.0% 20.0% $ 17,735.17 $ 88,675.85 Net Income $ 1,620.20 $ (16,468.63) $ 8,012.61 $ 34,038.63 52.2% 306.7% $ 193.33 $ 966.65 2012 2013 MGMA A/R Total A/R $ 89,667.32 $ 78,661.88 $ 74,402.00 Days in A/R 47.57 36.32 35.62 Credit Balances $ (12,878.55) $ (368.89) 2012 2013 2012 2013 MGMA Cash Transcription $ 5,678.16 $ 3,124.99 $ 3,817.92 Checking Account $ 256.77 $ 15,063.22 Investment Account $ 3,353.88 $ 35,115.22

42. EMPLOYMENT ISSUES

43. EMPLOYMENT ISSUES EMPLOYMENT LAWS • ADEA • ADA • COBRA • ERISA • FUTA • OSHA • THA • CRA • INA • FMLA • FLSA • DBRA • EPA • CCPA

44. EMPLOYMENT ISSUES EMPLOYMENT APPLICATIONS AND INTERVIEW LEGALITIES • Race • Religion • National Origin • Sex • Marital Status • Pregnancy • Disability • Height/Weight/Age

45. EMPLOYMENT ISSUES Fair Labor Standards Act • 1938 • 1 or More Employees • Salaried/Hourly • Record Keeping • Minimum Wage • Overtime Pay • Child Labor

46. EMPLOYMENT ISSUES FAIR LABOR STANDARDS ACT EXEMPTIONS • Executive • Administrative • Professional • Highly Compensated

47. EMPLOYMENT ISSUES FAIR LABOR STANDARDS ACT EXEMPT EMPLOYEES • No overtime required • No time card required • Regular, predetermined salary • No reduction in pay because of the quantity or quality of work • No deductions for absences of less than one day

48. EMPLOYMENT ISSUES FAIR LABOR STANDARDS ACT TYPICAL EXEMPT POSITIONS • Doctors • Administrators/Managers • Nurse Practitioners • Midwives • Physical/Occupational Therapists • Registered Nurses

49. EMPLOYMENT ISSUES FAIR LABOR STANDARDS ACT TYPICAL NONEXEMPT/COVERED POSITIONS • Receptionists • Telephone Operators • Bookkeepers • Insurance Clerks • X-Ray/Ultrasound Technologists • LPN • Medical Assistants • Registered Nurses

50. EMPLOYMENT ISSUES FAIR LABOR STANDARDS ACT COVERED EMPLOYEES • Must keep records • Must maintain timecards • Must be paid overtime • Must be paid at least minimum wage