December 2005

Entrepreneurial Spirit

By Tammy Richmond, MS, OTRL

The end of the year is a good time for rehab managers to make a full year’s accounting of clinical and business documentation

December 31 is knocking on your office door, and it is an opportunity to wrap up operational and managerial tasks and start anew on solid footing for the New Year. Accomplishing this goal can be divided into two major categories: health care tasks and operational tasks. Both areas are vital to legally protecting your practice, your staff, and your consumers.

First, health care tasks are those practice and managerial line items that should be completed all year long but require a reassessment at least once a year. Federal, state, and local health care requirements and standards of care change and deserve your proactive approach to compliance. The three main components include: federal and state compliance and regulations, documentation, and reimbursement.¹

To comply with federal and state regulations and policies, have these paper items in place and up to date. They include: your state practice act, standards of practice (AOTA or APTA), licensing or certification laws and regulations, appropriate use of personnel and supervision, and HIPAA Notice of Privacy statement and HIPAA updates.¹ Discuss these items with staff members and have them initial the agenda sheet of the meeting to keep away future "I didn't know" comments and possible legal repercussions.

Documentation requirements are determined by federal and state policies and regulations, by accreditation and organizational agencies that your practice operates under, and by established standards of care. They include but are not limited to the following: policy and procedure manual, informed consent, unusual occurrence report, medical records, evidence-based medicine, or outcome measurements.

MANUAL REVIEW
The policy and procedure manual should be reviewed by all staff and revised as needed to represent the current operations in your practice. You may also need to add more policies as you identify areas most commonly missed such as disciplinary actions and medical record management. You and your staff must read through and initial each policy. I suggest you make this less time-consuming and tedious by taking one policy per week all year long so by the end of the year you are left with little or none to review. As a manager, it will be your annual responsibility to make sure all previous reviewed policies are still current. In addition, take out the unusual occurrence reports and discuss how incidents and further similar incidents can be avoided or properly handled in the upcoming year. Many times, staff members are unaware that something occurred during the year, especially when staff meetings are far and few between and flex staffing is popular. Identify high-risk areas to include in a risk management policy.

Outcome measurements are now part of our standards of care, and should be explained by the diagnoses commonly treated by you and your staff. Share in the responsibility of determining what is evidence-based medicine and measurements for your practice by assigning each appropriate staff member certain diagnostic areas to specialize in or treat and have them bring peer-reviewed articles and other related supportive documentation to assist in deciding what outcome measurements are indicative of best practice standards for current treatment interventions in your practice operations. Once determined, you can include those in a protocol format or include as a policy and procedure of treatment standards. If you decide to use them in a protocol format, all staff must utilize them consistently. Keep in mind that your staff needs to be qualified to provide the interventions that you currently or plan to provide, and the evidence-based intervention needs to fall within your scope of practice.

Reimbursement and financial management are vital to your practice survival. Having knowledge of and educating you and your staff on current reimbursement trends, strategies, and denials or restrictions should be done year round to avoid losing time and money. However, an annual review of payment methodologies, billing and coding changes and requirements, and information on any other sources of payment that your practice includes and/or needs to include and improve on should be addressed at your end of year staff meeting. If you outsource your billing, make sure to have your billing personnel present. Discuss common documentation and coding errors and changes, upcoming pending external reimbursement threats such as the Medicare cap, or state legislative bills affecting reimbursement and other possible payment sources such as cash programs, grants, or product and service expansion. Update billing sheets and fee schedules. Managers need to review their provider network contracts and any other payor contracts to determine whether inclusion into contracts is still viable or if numbers need negotiating with applicable payors.

OPERATIONAL MATTERS
Operational tasks include the daily business operations. The three main operational areas include: human resources, workflow management, and facility management.¹

Human resources are those operational tasks that fall under employee management and should be addressed at least annually. Pull your employees' files and check for current and signed agreements or contracts; signed employee orientation; job description; copy of license; certifications, credentials, and professional liability insurance as applicable; a current CPR card; time, attendance, or vacation records; continuing education documentation; performance evaluations; disciplinary actions; or peer reviews. You should make it a holiday habit to have employees update their file along with your annual performance evaluation. This information is confidential and should be kept in a safe and locked place and handled individually with each staff member. Staff orientation is often overlooked, which can leave you legally liable if an unfortunate, unusual occurrence takes place and you or your staff is found to be negligent on the proper use of modalities, equipment, or other practice operations such as infection control or emergency procedures.

Wage, benefits, and workplace safety are regulations and policies that are established by either federal or state agencies or both. Employee labor laws vary from state to state and require expert advice and interpretation or at the very least proactive researching and gathering of information at your state's small business Web portal or secretary of state Web site. Do not assume your fellow colleagues know the answers. Small business tax accountants and attorneys can assist you. Examples of labor laws include: workers' compensation insurance, Fair Labor Standards Act, state minimum wages, work week standards, posting of labor codes or standards, employment taxes and required benefits, OSHA, and the Americans with Disabilities Act (ADA). There are often fines and penalties for not complying.

Workflow management is a name given to those daily operational tasks that make your practice run effectively and efficiently and are best dealt with by establishing a general checklist that you can review and revise at the end of the year.1 Be certain to specifically address legal compliance since this is an area normally performed annually. Legal or small business compliance involves addressing all business and clinical contracts. Other tasks that need attending are government filings such as quarterly taxes, Federal Employer Identification Number (FEIN) and Medicare PIN number or other required tasks, paying or updating your business structure filings such as state fees for corporations or limited liability companies, seller's permit, filing of fictitious business name, employment policies and labor laws, and corporate records including nonprofit annual record keeping if applicable.

Another area worthy of an annual upgrade is your marketing material. You may have included new services or products not mentioned on current marketing materials, or you and your staff have decided that a part of your business and practice goals for the upcoming year is to include new specialty services, therefore, additional marketing literature and promotions will be necessary. Marketing to the three Ps—patients, physicians, and payors—may require three different marketing strategies or material. An annual end of the year client survey is a great way to assess the effectiveness of current services and products including customer services and can give you insight on where you should place your efforts in the next year's business goals.

Unnecessary liabilities found in faulty equipment or in the physical layout in your facility can be costly so perform your annual facility check before the end of the year. This includes such areas as: equipment maintenance, lighting, security systems, compliance with the ADA, supply inventory, computer and electronic upkeep, storage of materials, and anything else you can visibly see or that is handled during the course of work and therapeutic interventions. You are checking for overall safety, cleanliness, and upkeep.

Establishing good practice standards and legally protecting yourself from unwanted business circumstances involves taking the time to put together an annual legal checks and balances worksheet. Utilize the holiday time to reflect and reassess your business goals and practice operations both personally and with your staff. Seek out experts and resources to assist in your knowledge and management of your private practice business.

Tammy Richmond, MS, OTRL, is COO and co-founder of Ultimate Rehab, LLC, a consulting company specializing in practice management and operations, and owner of Hands 4 Health, a private clinical practice, both in Los Angeles. She may be reached at (888) REHAB-53 or on the Web at .

REFERENCE

1. Richmond T, Powers D. Business Fundamentals for the Rehabilitation Professional. Thorofare, NJ: SLACK Incorporated; 2004.

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