The top administrative challenges and what to do about them

Every year, Medical Economics® asks our physician readers what challenges they are facing in their practices. And every year, we get the same answer as the top challenge: administrative burdens.

For our first issue of 2023, we decided to take a stab at fleshing out
what some of those administrative burdens are and what physicians
can do about them in their practice. We focused on five
administrative burdens that our readers commonly tell us
are major issues.

Challenge 1: Prior Authorizations

The number of prior authorization requests continues to increase — despite promises to the contrary by payers — costing physicians time and money. A Medical Group Management Association (MGMA) poll found that 70% of medical groups indicated that prior authorizations increased in the last year.

Physicians say that their practices continue to struggle with either a lack of response or no response from payers, increased time spent by staff to try to gain approval and a lack of automation in the process.

All these difficulties can lead to delays in patient care. A University of Colorado study found that 93% of physicians reported care delays and that 82% reported cases of treatment abandonment (when the patient does not follow through) because of prior authorization requirements.

“There’s not one standardized way to submit prior authorizations or additional information — maybe clinical information or chart information — to the health plans,” says Anders Gilberg, senior vice president of government affairs for MGMA. “Each health plan thinks they have the best proprietary way to make it really easy.”

But with practices dealing with
20 to 30 payers, that can mean 20 to 30 different websites and passwords.

“The way it works is you have to hire staff to go in there and learn each one of those processes, which is time-consuming and redundant,” says Gilberg. “Ideally, we’re looking for one standard and one way of submitting them, such as pushing a button or maybe having it integrated with an electronic medical record and the clinical record. We could provide the information health plans need but do so in a streamlined way that isn’t just multiplied by 20 and having that staff burden.”

Although that solution doesn’t exist yet and physicians can’t change the prior authorization demands from payers, they can take the following steps to minimize the burden.

Designate a prior authorization champion. Having one person run point on prior authorizations will help that person learn what each payer wants and the best ways to get authorizations approved in a timely manner.

Keep detailed notes for each patient. All it takes is one piece of information to be missing from a patient’s chart for a payer to deny the authorization. Always keep this in mind when documenting a patient’s condition and what tests have been done. If something is abnormal, document it.

Learn what the payers want. Payers will have different requirements before authorizing tests like an MRI. If the payer requires an X-ray first, make a note of that for future reference and complete as many of the requirements as possible before submitting the prior authorization.

Be persistent. Just because a payer denies the first request doesn’t mean you should give up. Some payers have staff with minimal medical backgrounds who review initial requests and may just be looking for key “trigger” words as a reason to reject a claim. An appeal will most likely go to someone with more medical training.

Recruit the patient. Have the patient call the insurance company if necessary. They will be talking to a different department and may either get a different answer or gain clues on what is needed to get the prior authorization approved.

Escalate, escalate, escalate. There is little point in arguing with a payer-employed nurse over a complex medical issue that may be well outside their expertise. Ask for a peer-to-peer review or, in extreme cases, to speak with the medical director or chief medical officer. They still may not have experience in the relevant specialty but will at least have a background to better understand the specific challenge being addressed.

Challenge 2: Staffing

Staffing has emerged as a top issue for physicians, and heading into 2023, the situation may be going from bad to worse.

In 2022, lack of staffing was one of the toughest issues identified by Medical Economics®’ annual physician report and a MGMA survey. Most physicians reported shortages across all roles, and according to the latest findings from The Physicians Foundation, 73% had significant or moderate shortages of registered nurses.

“What we’re seeing across the board, regardless of whether it’s a physician-owned or hospital-owned practice, is that it’s a challenge to recruit and retain support staff,” says Ron Holder, M.H.A., chief operating officer for MGMA. “And support staff — medical assistants, nurses and office staff — are critically important for physicians’ practices to succeed. And their challenges are compensation and costs keeping with inflation.”

What are the best ways to keep employees and find new ones?

All the strategies recommended for 2022 — increasing pay and perks, having flexible work hours, listening to employees’ suggestions for workplace improvement and more — could still work in 2023. What follows are more tips to take your recruitment and retention to the next level this year.

Get ready to pay, especially for office staff. Holder notes that when restaurants, retailers or other businesses pay more than doctors’ practices, clerical workers can take their organizational and customer service skills where they can make more money.

All staff should work at the top of their license. “Working on top of licensure is doing the things that they were trained to do and not having to do things that other people in the practice could effectively do at a lower level of licensure,” Holder says. “You have to maximize your licensure at every level.”

Find ways to manage the workload. If your practice is shorthanded, don’t just pile more work onto everyone else. That can lead to feelings of dissatisfaction that make employees look for new jobs, Holder says. If they leave, that could make the situation worse. In 2022, some MGMA members reported closing practices one additional day a week to spread staff across their locations to avoid cutting hours.

If you’re in a small practice, embrace flexibility. Staff crunches in large health systems lead to analyses about pay changes for dozens, perhaps hundreds, of employees. Small practices don’t have that burden, Holder notes. “If you only have two medical assistants in your practice and one of them leaves, you basically can adjust your pay grade on the fly in order to recruit back for that one,” he says.

Be equitable and fair. Although early careerists with one to two years of experience are sparking bidding wars in the hunt for new workers, Holder says they should not start at higher salaries than staff with more experience.

Move new staff quickly to the midpoint. Recruiting and retaining staff with minimum qualifications and less experience often are more difficult than keeping those with 10 or more years of experience and who may stay with an organization for reasons beyond just a salary.

“Therefore, it’s a contemporary practice to be more dynamic to those who would be lower in the pay grade, moving them toward the midpoint faster, with growth in pay slowing a little in the higher part of the pay grade,” Holder says. “You have to be dynamic for those people who are looking to grow their compensation the fastest because if you don’t, someone else might.”

Streamline, streamline, streamline. Look for ways that every worker can reduce the number of clicks to complete tasks and for ways that medical assistants can help with record entry and patient intake.

Challenge 3: Patient Communication

I

t wasn’t so long ago, relatively speaking, that doctors and medical practices had only a few ways of communicating with patients (and vice versa): in person, by landline telephone, or via U.S. mail.

Now those days seem as quaint as the era of travel by horse and buggy. Today medical providers and patients have a myriad of new communication tools at their disposal, such as text messaging, telehealth, patient portals and social media platforms — not to mention the widespread use of cell phones.

The explosion in communication technologies brings numerous challenges for doctors and medical practices, starting with patient expectations. Patients, especially younger ones, expect the same ease and convenience in communicating with their doctor that they find when shopping or ordering a meal online. In a recent survey of 2,000 adults, 61% said they wanted health care to mimic the experience provided by a customer service app, and 79% said they wanted the ability to use technology to manage their overall health care experience.

“Patients want the convenience of connecting with your practice however and whenever they want — by phone, website or text, inside or outside office hours,” says Justin Jacobson, vice president of patient engagement solutions for Nuance Communications Inc., a technology company that offers conversational artificial intelligence solutions.

COVID-19’s arrival further highlighted the importance that patients place on communicating with their doctor. In a 2021 survey of patients by health care software company SymphonyRM, now Actium Health, 41% of respondents said they had less confidence in their doctor since the arrival of COVID-19, mainly due to a lack of communication about the disease. Conversely, those who reported more confidence said it was due to their provider’s rapid transition to virtual care, frequency of communication about COVID-19 and use of digital communication tools.

For medical practices, the implications are clear. Their success increasingly depends on their ability to acquire and integrate the communication channels that patients have come to expect in other aspects of their daily lives. Practices that meet those expectations can reap benefits such as higher levels of patient engagement and loyalty, a stronger bottom line and improved patient outcomes.

Among the newer communication tools, texting may offer the most advantages for the least cost and effort. Practices can use automated text messages to remind patients of upcoming appointments (thereby reducing no-shows), share pre-appointment requirements such as fasting, and inform them when they are due to receive preventive services like colonoscopies and vaccinations.

In addition, follow-up text messages are more effective than telephone calls at reducing hospital readmissions or emergency department visits following hospital discharge, according to a 2022 study published in JAMA Network Open.

A further benefit of texting is its popularity with patients. A 2021 health survey by Healthcare Information and Management Systems Society/Solutionreach Inc. found that 65% of patients want to get appointment confirmation/reminders and pre-visit care instructions via text message. Moreover, more than one-third of those surveyed — including 64% of those age 50 and younger — said they’d be willing to change providers to receive text messages and other modern forms of communication. Nearly 90% cited convenience as the primary reason why they preferred texting versus other means of communicating with their doctor.

Ultimately, the goal of all patient communications should be to create an approach that “empowers patients to become active participants in their care,” says Gary Hamilton, CEO of InteliChart, a developer and provider of patient engagement solutions. “This requires physicians and all other medical staff to develop good communication skills and address patient needs effectively.”

Here are three tips for using new technologies to improve patient communications:

• Try to meet patients where they are. Find out what mode of communication each patient prefers and use it as much as possible when communicating with that patient.
• Install and use as many different communication forms as your practice budget allows, and let patients know you have them and how to use them.
• Assign a staff member responsibility for monitoring the patient portal, including answering patients’ questions about how to use it and what information is available on it and triaging messages and requests that come through it.

Challenge 4: Care management coding

Providing care management services, including chronic care management (CCM) and principal care management (PCM), is not easy.

The first overarching challenge is that not enough patients actually participate in care management with a primary care physician. In fact, a recent report from the Primary Care Collaborative and the American Academy of Family Physicians’ Robert Graham Center found that more Americans lack a consistent source of health care — most often primary care — despite the COVID-19 pandemic.

“The volume of people with chronic disease — and particularly more than one — is growing fast,” says Tom Ferry, president and CEO of Engooden Health, a CCM services provider. “So is the number of people aging into Medicare. One in 4 American adults and 66% of Medicare beneficiaries now have multiple chronic conditions. And the Medicare population increases by 1.5 million people annually.

“At the same time, fewer primary care providers are available to take care of this growing population, an issue compounded by more clinicians leaving the field. These factors have created a situation that’s overwhelming the health care system.”

The second challenge, germane to the administrative burdens facing medical practices, is that managing care plans involves a good deal of coding and documentation so that physicians and their practices can get compensated for the time they spend on them. New codes, introduced in 2022, can benefit both physicians and patients but require understanding to make sure they are used correctly.

What follows is a brief explainer on using CCM and PCM codes correctly.

PCM services. New Current Procedural Terminology (CPT) codes were added in early 2022 to describe PCM services. These codes are similar to CCM service codes in that the work involves the establishment, implementation, revision and monitoring of a care plan for a patient. However, PCM focuses on a single condition rather than two or more.

CPT code 99424 describes the first 30 minutes of a PCM service per calendar month provided by a physician or qualified health care professional. To capture each additional 30 minutes of service in addition to 99424, CPT code 99425 would be reported. CPT codes 99426 and 99427 also describe PCM services, but these are for clinical staff time directed by a physician or qualified health care professional.

Medicare now accepts CPT codes 99424, 99425, 99426 and 99427 and discontinued Healthcare Common Procedure Coding System codes G2064 and G2065.

For a detailed explanation for the codes, see PCM Services chart at left.

CCM services. Reminder: CCM involves monitoring two or more chronic conditions. A new CPT code was created in early 2022 to describe each additional 30 minutes of a CCM service performed by a physician or qualified health care professional. CPT code 99437 may be reported in addition to CPT code 99491.

Challenge 5: Quality metric reporting

Quality metric reporting can be a significant challenge to health care administration due to a number of obstacles. First and foremost, you need buy-in from the physicians providing the care to the patients. Without this, it is difficult to make any meaningful changes to the pattern of care provided.

Second, it requires having a very robust quality and data analytics team in your health care system. The startup costs for this can be very high, and it may not always be easy to quantify the direct reimbursement seen from this.

“As medical practitioners, we strive to provide great quality care to our patients,” says Marc Afman, D.O., medical director of Clinical Integrated Network with University of Michigan Health-West in Wyoming, Michigan. “However, improving quality at the expense of increased costs does not lead to improved value to the community and the patients we serve. This has been a major paradigm shift on how we have practiced medicine in the past.”

Previously, he explains, physicians worked only in a fee-for-service environment with less emphasis placed on quality. In today’s health care landscape, physicians are asking providers to find the balance between providing exceptional quality to patients while still being mindful of the costs incurred to obtain this.

“A large focus of our efforts is on quality initiatives and reporting,” Afman says. “We are continually working with various payers on how to improve the quality of care provided from the payer perspective. Sometimes it comes down to making simple changes to the level of specificity of diagnosis coding or including additional appropriate diagnosis codes that explain the medical decision-making process (to determine) whether or not we get credit for some quality measures.”

Researchers have found that consumers are interested in quality measures that convey information about a physician’s technical care and interpersonal skills. Typically, technical quality is measured using clinical information found in administrative databases, electronic health records or medical charts, whereas interpersonal quality is measured using patient surveys.

The patient is always the first and foremost priority, but it’s now also important for physicians to maintain high-quality scores to be able to earn the reimbursement and quality ratings that enable the health system to continue to take care of the patient.

Leah Alexander, M.D., a pediatrician at PediatriCare Associates in Fair Lawn, New Jersey, notes that the quality of health care is important to patients, providers and payers and that in an effort to improve quality and value, many organizations are now focusing on quality metric reporting.

Although this can be a useful tool, it also presents some challenges.

“There is no standard definition of what constitutes a ‘quality’ metric,” she says. “This can make it difficult to compare data across different organizations. Additionally, collecting accurate data can be challenging. For example, electronic health records ... may not always capture all the relevant data points.”

Another challenge is that quality metrics often focus on process measures rather than outcome measures. This can make it difficult to assess whether a particular intervention is actually improving patient care. Also, some quality metrics may be subject to gaming, meaning that providers may focus on meeting the metric rather than on providing high-quality care.

“Despite these challenges, quality metric reporting can be a useful tool for improving quality and value in health care,” Alexander says. “To overcome the challenges, it is important to work with an experienced partner who can help you collect accurate data and interpret (these data) in a way that will improve patient care.”

Additionally, it is important to focus on outcome measures rather than process measures. By doing so, physicians can ensure that quality metrics are actually making a difference in the lives of their patients.