Health Information Compliance Alert

Published on Fri May 07, 2021 PDF

Organize and then communicate the needs of your other team members.

It’s common for practices to take on new providers during the summer months when things are often slower and transitions are easier. Whether your organization has regular turnover or is small enough that a new provider is a big change, figuring out how to set a strong foundation for your new colleague is important — and if you aren’t a clinician yourself, the process is, perhaps, even more fraught.

Use these tips to communicate the nuts and bolts of onboarding realities for new clinicians.

Do the Planning

Getting organized makes every point in the process smoother; you’ll know exactly what information you need to cover with a new provider.

One way to get organized is through using a template for all onboarding, says Victoria Moll, CPC, COC, CPMA, CRC, CPRC, CEO of Contempo Coding LLC in Fleetwood, Pennsylvania. A template will help you make sure that you don’t forget any crucial information. Think of the template as including items you always go over anyway.

You know you don’t need to go over anything involving patient care, since that’s what clinicians are trained to do, but covering some aspects of documentation and other sorts of paperwork is important. If your office has a template for inputting patient information or other form of EHR, make sure your clinician knows the ins and outs of how to best report that documentation. Highlight how problematic it is to copy and paste information between patients or between patient visits.

Tip: Cover what’s medically appropriate and document that, but you don’t need to provide a complete review of systems (ROS) for every patient for billing purposes, Moll says.

Concentrate on documentation requirements, common errors, expectations from other staff — as far as what information other team members need to do their own jobs — and who the physician should go to with any questions.

“Don’t make your doctor be a coder,” she says.

Don’t forget: It’s also essential that new providers receive training on the various software programs and the relevant cybersecurity, too. You can’t assume that they’ll know the ins and outs on all matters of health IT and HIPAA compliance.

New providers may not know the nuances of and regulations for telehealth services either. If your practice is utilizing virtual care options and taking advantages of the Medicare telehealth expansion during the COVID-19 public health emergency (PHE), then these new clinicians need to know how to compliantly use your specific practice tools and how your clinical team documents the services for the coding and billing staff.

Frame Pertinent Info Around Provider’s Perspective

“What is important to you when auditing a note is not what’s important to a provider,” says Shannon DeConda, CPC, CPMA, CEMA, CMSCS, president of NAMAS and partner at DoctorsManagement, in a 2021 HEALTHCON session.

With this in mind, you should focus on the absolute necessities of what providers need to know about documentation necessities like the pertinent aspects of evaluation and management (E/M) services — and communicate the pertinent knowledge by framing it around patient care.

Remember, a provider’s job is patient care — “documentation validates the care; we must always remember that this is their perception,” DeConda says.

Make Audits Work for Everyone

Audits conducted by one’s own practice can be a useful tool for everyone for figuring out what needs work or even what requires better communication.

As you onboard new providers, frame audits as a regular means of checking in. Decide — and tell — them how many audits you will do, within which timeframe.

In the meantime, track your trends. Analyzing that data can help you decide the timeframe in which you review, how many cases you’ll audit, whether there should be a pass/fail threshold, and the necessary follow-up protocol, Moll says.

When you do follow-up, don’t approach the provider with a readthrough of every single case. Do the work ahead of time to figure out what can be improved and how, so you can approach the provider with opportunities to improve instead of errors to be reconciled, Moll recommends. Make it a conversation.

Bottom line: Training providers who are new to your practice doesn’t have to be a headache for everyone involved. Get organized, determine what constitutes a “best practice,” and what will work for the minimum quality you’ll accept, Moll says. Set — and communicate — expectations, as well timelines for following up.