Medical Group Practice: Policies & Procedures


January 1, 2013
481 Pages - SKU: APO4938609
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A ‘how-to’ manual of cost-effective, quality-driven policies and procedures for the efficient management of medical group practices and other health care provider offices. Improve productivity, day-to-day medical practice management procedures including infection control, medical record and consent policies and procedures. Designed for modification to adapt to local practices and contract terms. Numerous forms, examples and other helpful tools. Resources include example materials to establish and measure practice metrics including physician staffing (by population), office staff (by physician) requirements, development of a ‘concierge’ or retainer practice; hospitalist programs, compensation strategies, health law, disability evaluations, accreditation site visit standards, web links. and authoritative references.


Introduction
‘Twelve Commandments’ for a satisfying and successful medical practice…
Policy on Policies
Medical Organization P & P for a ‘Provider Manual’
Annual policy review memo format
Quotable Quotes

Core Materials to be included in the Provider’s Toolbox (or Manual)
Introduction and welcome; History – our origins and evolution
Mission and vision statements
Organization chart
List of staff providers/office locations
List of contracted providers; in-network
Administrative and Medical Committees
Communication (translation, interpretation) resource list [language, vision/hearing impaired assists]
Managed Care Contracts list with contact person and phone #

Credentialing Tools
Credentialing, Introduction and P/P
Credentials policy
High risk providers
Provider sanctions

Peer:Peer Evaluations
Evaluation form
Introduction, forms

Ambulatory Care Site/Survey/Audit Visits
Site visit policy/procedure
Criteria/list for facility and medical record site/audit visit
Letter to group to be surveyed (example format)
Surveyor P & Ps; Forms
PacifiCare Assessment Tool
Authorization and release form for medical office site visits

Peer Review
Peer Review Plan; Professional Affairs Committee
Confidentiality Agreements (updated 3-08)
Peer Review Severity Levels/Point System
Peer Review References and Resources
Notes

Education and Training
Physician and Staff Education
Seminar/Conference Request Form
New Employee Orientation, Medical Offices

Patient Education
Education pathway example for Diabetes mellitus, new onset
Prevention and Counseling – Examples
Health Education; Minimum Standards, PacifiCare of California
Advanced Directives – patient handout
References
Insurance
Notes

Medical Practice Management Tools
Physician issues affecting efficient quality practice/ Systems to enhance physician practices
Physician Partnership and Employment Issues
Physician Employment Agreements/Noncompete Clauses or Restrictive Covenants
Self-referral, Stark III regs
Physician-Hospital Joint Ventures
Physician/Practitioner Compensation
Contract issues
The Minnesota Medical Practice Model
The solo medical practice model
Pay for Performance (P4P)
Primary Physician; Job description and work standards – P & P
Panel size
Closed practices
Mentor Policy
Home (house calls)/work site physician services
Computer Order Entry (CPOE)/Electronic prescriptions
Computers in exam rooms
Coverage during absences
Information exchange policy for primary physician/specialists/facilities
Physician staffing requirements, by population
Physician Recruitment
Primary Physician Coordinated Care Policy
Operational measures/benchmarks to track/evaluate practice performance
Letters of condolence
Office Visit Intervals/Frequency, primary physician, by diagnosis [refer to access/appointments section for additional information]
Common obstacles to effective medical group performance
MGMA report on medical group “better performer” characteristics
Office/Support Staffing Requirements
Overhead
‘Hospitalists’ – Managing Physician(s) for Acute Hospital Services
Hospitalist Job Description
Moonlighting
Non-physician Clinician/Physician Extender Standards
Ambulatory/Office-based Surgery guidelines
Fraud & Abuse Issues for Ambulatory Surgery Centers (ASC)
Physician turnover and retention – benchmarks, strategies
Physician recruitment policy and procedures
Medical practice ‘split-ups’ – considerations
Dress to meet patient expectations
Physician profiling P & P
Provider feedback
Steps to improve physician performance, resource utilization, physician/patient satisfaction
Ambulatory encounter/visit benchmark data
Telemedicine/‘Virtual Medicine’/Telehealth
Physician surrogates, extenders
Buying or selling a practice
Notes/Links to additional information

Medical Records – refer to the preceding ‘Criteria/list for facility and medical record site/audit visits’
General Policies and Procedures for Medical Records
Chart order standards
Medical Record Documentation Standards
Medical history and Physical Exam – core elements listed
Medical Record Log – example
Office visit/Encounter forms – resource
Release of Medical Record Information, P & P, law, form
Resources related to medical records/Medical information disclosure
Confidentiality Issues
Access to medical records following death
Authorization to Transfer Medical Records, example formats
Authorization to Release Medical Records, example formats
Affidavit to accompany medical records
Signature requirements/staff initials/signature sheet
Corrections in the medical records
Patient rights to copy of records
Confidential Fax Transmission Format
Behavioral Health/Psychotherapy Notes – Release to Medicare, Others
Unsolicited test results, P & P, example letter formats
Notification letter to patients regarding test results of possible concern.
Electronic Medical Records/Electronic Health Records (HER)
Online Medical Records
Medical & Other Records: Retention Policy
Medical Records Storage – Security Requirements
Medical Records Reference list
Medical Reporting Requirements
Medical Records – Coding – Web Site Resources
Notes – links to additional medical record P & Ps

Consents for Treatment
Introduction, Capacity to consent
Informed consent policy
Development process for consent forms, example form
Brochure for patients
Procedures requiring informed consent
Procedures for Obtaining Informed Consent. Making Health Care Safer. A Critical Analysis of Patient Safety Practices. Evidence Report/Technology Assessment, No. 43. Chapter 48. Agency for Healthcare Research and Quality, July 2001
Refusal of treatment form
Procedure consent form
Against Medical Advice (AMA) Policy and Procedure; forms
Interpreter’s Statement
HIV testing, consent and payment procedures
Consent for hysterectomy
Consent for immunizations
Consent for photography during a surgical procedure
General Consent for surgery, anesthetics and other medical services formats
Consent for sterilization form
Consent for Oral Contraceptives (‘the pill’)
Prostate Needle Biopsy consent form
Rubber band ligation, hemorrhoids
Telemedicine consent form
DNR/withholding of treatment order form
Gastroscopy – information sheet and consent form
PEG consent
Notes

Office Services Management Toolbox
Office Services Management
Patient-centered care model
Annual Review of Fees, Codes, Policies
Brand Name Identity/Welcome Letter
PacifiCare Welcoming Letter
Welcome calls (New 5-06)
MGMA “better performers” see higher revenues, efficiencies
Due diligence
HIPAA – regulations and resources, web links
Confidentiality and Privacy policy example
Sign-in sheets
Access/Appointments -
Time intervals to appointment
Auditing/tracking access to care
Group Visits/Shared Appointments
Open Access (OA)/Access Time for Appointment Standards
Time Allocation for Routine Primary Care Visits
‘Walk-in’ Patient Triage
Address Format for All Adult Patients and Visitors
Wait Times
After Hours Services
‘On Call’ Policy and Procedure


Communication
Telephone communication – access and risks
Frequent callers: a high risk group for utilization of care
Telephone log
Telephone Technique and Triage
Telephone Access and ‘Hold’ Time
Messages
MDHub.com
Telephone Calls from Patients
Communication with Hearing Impaired Patients
Communication with Patients and Visitors – Limited English Proficiency
E-mail/web-based/online ‘Visits’/consults
Complaint Management
Transport of Patients to Area Hospitals
Admitting Process: Office to Hospital
Vital Signs and Weights – standardized procedures
Chaperone in Exam Room for Pelvic Exams
Smoke-free Environment Policy
Appointment Scheduling Policy – refer to the preceding ‘open access’ guideline
Appointment Reminders
Missed or ‘No Show’ Appointment Policy
Patient termination/dismissal Issues
Reschedule Notification Letter format
Appeal process for missed appointment charge
Patient Registration
Registration Form
Payment Policy, Assignment of Benefits – forms
Insurance payment (or non-payment) release agreement form
Red Flags Rule
Medicare
Handout for Medicare Patients (re: nonparticipating provider)
Waiver of liability/Financial Responsibility statement, general, form
Waiver of liability for Medicare/Advanced beneficiary notice of noncoverage (ABN)
Collection policy
Lien attachment form
Third party liability information sheet
Locum tenens and reciprocal billing arrangements
Superbill examples
Unsnarling Patient’s Medical Bills
Notes
Emergency Care, Acute Services
Emergency Care Committee
ACLS Certification
Emergency ‘On-site’ Triage Policy
Emergency Telephone Triage
Office Emergency/Code Blue Policy and Procedure
Code Blue
Evaluation of Code Blue Response
‘Stat Nurse’ Call
Electrocardiograms
Reducing ER Care Visits
Physical Abuse Policy
Emergency Equipment
Adult Crash Cart: Content List
Crash Cart/Defibrillator Check Lists
Pediatric crash carts
Algorithms
Urgent Care Flow Algorithm
Specialty Referral by UCC Physician Algorithm
Priority Care Appointment following UCC Visit
UCC Patient Disposition Algorithm
Pre-Admission Function/ER Algorithm; Notes

Miscellaneous Policies and Tools
References for former employees
Shred for Confidentiality
Patient Rights and Responsibilities
Advanced Directives, policy
‘Living Will’ Declaration; California example
Malpractice Insurance and Elder Law Abuse Lawsuits
Patient Discharge from Practice/Termination of Care
Documenting noncompliance
Physician Request for Transfer of Care with example letter
Reassignment of primary physician
Patient contracts
Discharge of terminated patients presenting for medical care, P&P
Nursing Services
Billing tips
Code correctly!
Billing for ‘Incident To’ Services
Billing for ‘Concurrent’ Inpatient Services
Outpatient Surgery – Patient Instruction Sheet
Document/Record retention – P & P
Median number of ambulatory encounters per physician, by specialty
Major reasons for outpatient visits, all US, 2000
Medical Practice Web Site – an essential tool
Medical Management/Practice Web Sites
Scribes – Non-physicians acting as scribes for physicians
References and resources for Office Management
Notes

Office Pharmaceutical/DME – Policies and Procedures
Introduction; P & T Committee
Formulary
Drug Samples – P&P, Joint Commission requirements
Procedure for Stock Drugs
Refrigerator/freezer temperature log – example format
Procedure for Storage
Distribution and Storage of Schedule II Drugs
Outdated Drug Inspection and Removal
Orders for Medications, Tests and Treatments
Pharmaceutical Standards
Controlled Substance Reorder/Refill Guidelines
Referral to UCC for Parenteral Medication Administration
Administration of injection; Ordering provider not present
Patient wait time after an injection, by drug class
Treatment of Mild Reaction to Any Substance
Treatment of Anaphylaxis
Preparation and Administration of Antineoplastic Agents
Mandatory Therapeutic Substitution Example
Altered/Falsified Prescriptions, P & P
Peak Expiratory Flow Meters – to monitor asthma care at home
Tamper-Resistant Prescription Policy for Medicaid
Notes

Risk Management and Safety
Introduction
Risk Management, Safety and Infection Control: Master Policy
Facilities and Environment – Policy
CPR Training Policy example
Malpractice avoidance
Tracking Significant Abnormal Diagnostic Results
Facility Disaster Plans
Bomb Threat Emergency
Earthquake Safety
Electrical Emergency
Fire Emergencies
Fire Safety Procedures
Risk Manager/Patient Relations Manager Responsibility Policy
Incident report
Safety Standards, PacifiCare of California
Customer concern form
Risk Management – Patient Compliance
Facility Management, Risk Management Notes

Infection Control
Resources
Infection Control Committee
Exposure Control Plan
Biohazard and Hazmat Services
¨Hepatitis B vaccination
CDC Universal Precautions guidelines
Work Practice Controls
Personal Protective Equipment (PPE)
Environmental (housekeeping) services
Laundry
Compliance
¨Communication of infectious hazards to employees
¨Training program – required components
Staff exposure to patients of communicable disease
Clinical Infection Control Policy – Ambulatory Care
Blood-Borne Pathogens – Occupational Post-exposure Policy
Universal Precautions, policy and procedures
Infection Control Records – form
Infection control, general personnel policy
In-service acknowledgement form
Designation of Clean and Not-Clean/‘Dirty’ Patient Care Items & Equipment
Air Decontamination
‘Dirty-Clean’ Work Flow Policy
Refrigerator: Maintenance/Monitoring Policy
Linen: Handling, Storage, Transportation and Processing
Cleaning Examination Rooms
Cleaning toys
Hand washing P & Ps
Soap/Lotion Containers
Hand washing Policy & Procedure
Hand drying
Hand cleansers, JCAHO queries
Biohazard waste disposal
Medical Waste Management
Waste Management: Authority and Responsibility
Enforcement of the Waste Management Plan
Legionella – prevention
Decontamination, Disinfection and Sterilization of Equipment – endoscopy resources
Manual Instrument Cleaning
High Level Disinfection Policy
Glutaraldehyde Potency Testing Policy
Glutaraldehyde toxicity concerns
Autoclave Sterilization Policy
Autoclave: Biological Monitoring, Cleaning and Servicing
Autoclave Recall and Outdate Procedures
Storage of Sterile Supplies
Communicable Disease: Managing Known or Suspected Patients
Managing HIV
HIV: Post-Exposure Evaluation
HIV: Testing/Release of Information
HIV Test: Information and consent form
Authorization: release of information related to HIV testing
Communicable Disease: Reporting
Hepatitis
Hepatitis B – introduction
Hepatitis B Vaccine Declination Form
Hepatitis B Vaccination: Post-exposure Evaluation
Hepatitis B: Informational Pamphlet
Hepatitis B Vaccine: Informed Consent Form
Hepatitis C
Post-exposure Incident Report Form
Request for Source Individual Evaluation by Another Facility – example letter
Evaluation of Source Individual – form
Exposure Follow-up Record
Tuberculosis Control Plan
Creutzfeldt-Jackob Disease (CJD)/v CJD with other Transmissible Spongiform Encephalopathies
Skin disinfection to prevent catheter-related blood-stream infection
Screening for Methicillin Resistant Staph Aureus (MRSA)
VRSA (Vancomycin Resistant Staphylococcus Aureus); VRSE (Vancomycin Resistant Staphylococcus Epidermidis); VISA (Vancomycin Intermediate Staphylococcus Aureus); VISE (Vancomycin Intermediate Staphylococcus Epidermidis)
Vancomycin Resistant Enterococcus (VRE) Detection
Reuse of Disposable Items – Policy
Blood borne pathogens – exposure determination record
Animal guests in the medical environment (
Exam for Infection Control Class
Acknowledgement
Notes

Quality Improvement Toolbox
Quality programs needed by medical groups
Patient Satisfaction Surveys/Questionnaires (Service Evaluation Forms)
Additional quality measures – NQF
Ethics
Religious/Cultural Policy Manual
Healthcare Apologies/Medical Error Disclosures
Reminders
Preventive Health Care Interventions – for high-risk populations
Admission orders, standardized
Presurgical screening tests
Skilled vs. Custodial (non-skilled) Levels of Care Services
Custodial Level of Care: Informational Hand-out sheet
Test results – communication
Tracking needed follow-up – tool
Mammogram follow-up – tool
Clinical Performance Measures, ‘Pay for Performance’ and Gain Sharing programs
Physicians Office Quality Improvement Tool Kit (Ohio KePRO)
Sentinel event reports P & P/Dashboard reports
Quality-related Web Sites
Quality references and resources
Norton Healthcare Physician Office Quality Monitor
Quality Notes

Case Management (CM)
Introduction to CM
CM policy
CM: SNF
CM: Home Health and Hospice Services
CMS ‘face-to-face’ visit requirements for home health services payment
Home Health Referral Procedures – commercial and Medicare plan members
Discharge Planning – policy and procedure
Homebound program
High risk screens
High Risk Case Detection
Congestive Heart Failure Case Management
CM Outcome Measures
Primary Case Manager
Hospital Case Manager
Hospital Director, CM Services, position description
Case Manager, position description
Discharge Planner, position description
Screening case manager candidates
Case Management duties
CM References and resources
CM Notes

Utilization/Capitation Management Toolbox
Major challenges for UM cost control (update 8-07)
Medicare is targeting costly physicians (New 3-07)
Capitation fundamentals
Benefit and eligibility determination verification – P & P
Identification Card
Waiver of liability: Financial Responsibility Guarantee Form
Eligibility FAQs
Eligibility and Benefits Verification – P & P
Waiver of Co-payments – P & P
Appeal of Denial – procedure
Grievance tracking
Authorization approval notification form
Authorization denial notification form
Outpatient surgical authorizations – procedure
Transitional Care Center policy
Diagnostic referrals, streamlined process
Diagnostic radiology referral form for streamlined process
Authorization of special services
Submission of encounter data and claims
Coordination of Benefits
Third party liability
Preadmission review
Preadmission CM Screening Tool
Concurrent review
Discharge planning
Sanctions and Fines – Utilization Management, P & P
UM Committee Meeting Attendance Requirements
Quarterly Primary Physician Dinner Meeting Attendance Requirement
Specialty Pre-Admission Authorization; Primary Physician Notification
Notification to Primary Physician of Pending Authorization
Utilization check lists
Common reasons for denials
Appeals process and procedure
Provider Sanctions and Fines: QI Committee
Fine Notification Form
Notes

Concierge or retainer practice
Table of contents for Concierge practice section
Notes
References – Concierge Practice

Addendum
Financial benchmarks/’vital signs’ for a medical practice
Administrative Costs – medical practice
OIG Provider alert
Medical office job descriptions – refer to Apollo’s Healthcare Job Descriptions for Providers, Medical Directors and Staff
Provider alert – Physician involvement in diagnostic clinics
Consultations
Disability certifications
Patient-centered ‘Medical Home’ Model
Physician ‘self-referral’ issues
Notes

References and resources
Alternative practice models – cash-only practices
The Hippocratic Oath
Immigration issues for physicians
Joint Commission Resources; Other Resources;
Web sites posting physician feedback by patients, public
Health care price information on the web – sites listed
Clinical tool kits
Legal (health-related) resources on the web
Medical Director/Medical supervision responsibilities

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