Billing and Coding. Who Cares?

Reimbursement? Who cares? In short, YOU should.

Scenario 1:

It is time for your annual review and you've been working hard all year. You've stayed late to see extra patients and come in occasionally on your days off to cover the shifts of sick co-workers. You decide that you are going to ask for a raise based on the extra efforts that you've put in, but when you do the office manager states that everyone has been working hard so that alone does not justify a raise. Where do you go next? Your next step should be to present objective data. You should be prepared with not only the number of hours that you have put in this year, but also with your revenue (which you get from your billing records!) If you are able to show that you have increased your billings by a significant percentage, you're more likely to get something extra than if you just say you've been "working extra hard". Know what you are being reimbursed - check your billings bi-weekly or monthly to stay on top of it.

Scenario 2: 

You are working for a small family medicine practice with a couple physicians. You are the only PA. The family practice employs a billing and coding specialist to bill for all visits and procedures completed at the practice. You don't know much about billing and coding so you leave it up to the "specialist" to take care of all that. After all, you care about is seeing patients, right? This year, Medicare decides to audit the practice that you work for and they find several fraudulent mistakes in your billing. You have apparently been upcoding* several office procedures and double billing for some office visits. You are now facing criminal charges for defrauding the federal government and are facing jail time and a $300,000 fine. You try explaining that you never actually did any of the billing yourself, but in the eyes of the law, you are still at fault. Know what codes are appropriate. This is a two-way street. Don't overbill, but don't under bill either. Under-billing can be misconstrued as favoritism toward certain patents or it can just hurt the bottom line of your business. Its a Goldilocks and the three bears thing... not too much, not too little... but just right.

Both of these scenaios are real and they show the importance of understanding reimbursement/billing/coding. You've worked really hard to become a PA, don't lose it all because you didn't want to be bothered with the paperwork of billing. 

*upcoding = adding additional codes so that you are paid more money than you should get

Pic: http://www.tormont.com/en/Products-in-English/English-Products/GOLDILOCKS-AND-THE-THREE-BEARS/102518-118-1042.aspx


6 Salary Negotiation Strategies

This entry is a repost from the PRSA Job Center. I thought it was relevant and worth a repost- It makes a lot of the same points that I stated in another one of my entries earlier (Negotiations 101).

Six Salary Negotiation Strategies

Navigating the salary negotiation process can be tricky. You don’t want to overplay your hand, but you can’t afford to sell yourself short either. Many job seekers shy away from negotiating out of fear they’ll blow the deal.

But here’s a little secret: Most employers expect to engage in some back-and-forth discussion at the bargaining table. In fact, more than one-third of executives interviewed by Robert Half said they’re more willing to negotiate salary with top applicants than they were one year ago. Only five percent of hiring managers are less willing to negotiate.

Consider the following six tips for negotiating with finesse:
1.   Understand your market value. Savvy salary negotiating doesn’t involve throwing out a ridiculously high figure and hoping the employer says yes. The best negotiators are well-informed.
Do your homework and support your request with concrete numbers from reputable sources. Review current compensation standards for PR professionals in your area and at your experience level by consulting publications such as The Creative Group’s 2013 Salary Guide. The Occupational Outlook Handbook from the U.S. Department of Labor’s Bureau of Labor Statistics is another valuable resource.
2.   Look at the whole picture. Remember to consider all aspects of the deal, not just pay. An attractive healthcare benefits package, bonus opportunities, a retirement savings plan and perks such as tuition reimbursement or relocation assistance can make up for a lower base salary.
Also, don’t overlook the intangibles when doing your cost/benefit analysis. For instance, flexible scheduling, remote work options and a shorter commute can improve your work/life balance.

3.   Research the firm. Before you start plotting your negotiation strategy, get an idea of how much wiggle room there is. Learn about the organization’s financial standing by reviewing its website and searching for relevant news stories in business and trade publications. If it’s a public company, look at the most recent earnings statements and annual reports.
Ask members of your professional network what they know about the organization, too. If you discover the firm or agency recently announced layoffs or a salary freeze, you’ll probably want to recalibrate your expectations.

4.   Keep it friendly. Always manage negotiation discussions tactfully. You can make a strong case without issuing ultimatums or threatening to walk away if your demands aren’t met. Remember: You’re negotiating with someone who could be your future  boss, not haggling with a used car salesperson you’ll never see again.
Be poised and pleasant, not adversarial. And be a straight shooter. Candidates sometimes falsely claim to have a more lucrative job offer from another company only to have the misguided bluff called and end up with nothing.
5.   Ask to revisit the issue. If the company can’t quite meet your desired salary, ask if the hiring manager would be willing to re-evaluate your compensation in six months. The firm could be in better financial standing by that time, and your manager will have had an opportunity to see the value you provide firsthand. It never hurts to ask, and now’s the time to do so.
6.   Get it in writing.  If your salary negotiation is successful, make sure to get a contract detailing all aspects of the agreement. This includes compensation and any special arrangements (such as a signing bonus, extra personal days or early salary review) you’ve settled upon.
Finally, if you decide to turn down an offer, do it with class. Go out of your way to be gracious and appreciative. It’s best to give the employer the courtesy of a phone call rather than a quick “thanks, but no thanks” email.

The bottom line is that you want to do everything possible to leave the door open to future contact. Just because you weren’t able to come to an agreement for this particular position doesn’t mean there won’t be a more desirable or suitable opportunity at the company down the line.
The Creative Group is a specialized staffing service placing interactive, design, marketing, advertising and public relations professionals with a variety of firms. More information, including online job-hunting services, candidate portfolios and TCG’s award-winning career magazine, can be found at creativegroup.com.


Become Great At Knot Tying

Several months back during my surgery rotation, my preceptor and chief resident (Dr. Smith*) gave me some great advice becoming better at surgical knot tying so I thought I would share.

  • Learn the square knot and be able to tie it by perfectly and quickly (by hand and instrument). There are lots of surgical knots to learn, but the square knot will get you through most situations. 
  • Practice tying everyday. You often see medical students/residents walking around with string hanging from the tie their scrub pants or to a loop in their white coat.... this is because they are practicing tying in their down time. I started doing it and it is amazing how much practice you can get during the day - on the elevator, during rounds, on the T on the way to work. Dr. Smith said he still practices tying 100s of knots a day and he has been doing so since his first day of residency four years ago.
  • Make it second nature. When you first start you will need to look at the string/thread and concentrate... however the goal is to be able to tie and tie well while doing something else. Dr. Smith recommended practicing knot tying during your favorite show at home while sitting on the couch. If you don't have scrubs on - place a coffee mug between your knees and use the handle of the mug as an anchor. 
  • Materials. Since suture packs are expensive and I doubt the hospital would appreciate you snagging a bunch of $4-5 brand new suture packs to *practice* tying - there are other options. 1) after each of your OR cases, ask the scrub nurse if there are any opened, unused sutures left that you could have to practice with - if not, they get thrown away and 2) go to a sporting goods store and buy your own. Fishing line (mono filament and braided) are remarkably similar to suture material and you can buy 1800 yds of mono filament line for about $8 and 100 yds of braided for about $6.
This is the brand of braided line that I use. It is similar to "string ties". Purchased it at Dick's Sporting Goods for $6.

Using the arm of a mug as an anchor works great if you don't have scrubs on.

*Dr. Smith is a fictional name.


Free Book for Your Surgical Rotation

Scribd is a great resource for free textbooks (and not just the cheap ones). You can buy a subscription to have total access (Premium) or you can upload non-copyrighted materials and get a Premium membership for free.

I found this surgical book written for students on their surgical rotations. It is pretty awesome and comprehensive. A snippet from the table of contents is below.


Cardiac Surgery Made Ridiculously Simple

Cardiac Surgery Made Ridiculously Simple is a good resource if you are heading into a Cardiac rotation. Below are some additional resources listed on this site:

A good reference is: Cardiac Surgery in the Adult 

An online reference text “Cardiothoracic Surgery Notes” for residents 

An online Johns Hopkins Cardiac Intern Survival Guide is available at http://www.ctsnet.org/doc/2695



Free GI Textbook

"It was over ten years ago that we identified the need for an introductory gastroenterology textbook that would be useful to students, residents, family physicians and specialists. We decided this textbook should be relatively concise and readable, with appropriate figures, tables and algorithms, providing a logical and practical approach to patient management. It should cover the pathological basis of gastrointestinal and hepatobiliary disease, provide a list of learning objectives and be well indexed. We intended the book would not replace the standard encyclopedic tomes or excellent in-depth reviews, but would instead present a complementary first step to the vast and exciting field of gastroenterology. We also recognized that there was a place for important topics such as the clinical trials that form the basis of much of our modern practice and the crucial new area of molecular biology as it applies to clinical practice and patient care. We also thought it important that such a tribute to Canadian gastroenterology be made available in both official languages, English and French. And we considered it essential to bring out such a text- book in a timely manner and at a modest cost."

This is a FREE textbook.  


Preparing for PA School Interviews

'Tis the time for interviews at many PA schools and quite a few pre-PAers have emailed asking how to best prepare. Each interview process is slightly different so I would encourage you to reach out to current PA students at the school that you are interviewing at to ask them specific questions. PA school is difficult to get into - so don't waste the opportunity - PREPARE!

Below I have listed some generalized advice to help you prepare for your interviews:
  • Know the history of the profession. Even if they don't ask you about it directly, try to incorporate it into an answer or two. It shows that you've done your research.
  • Have a good (and genuine) answer of WHY you want to be a PA. I have heard many "generic" answers and those are boring and don't set you apart from anyone else. Be able to say not only why you want to be a PA, but why you don't want to be a nurse/MD/radiology tech/etc.
  • Come up with good questions for your interviewers. Remember, you are interviewing them too. Why *this* and not another school? 
  • Ask what their pass rate for the PANCE is and how they prepare their students to pass - after all, that's the goal of your education!
  • During the group session - assert yourself, but don't be too pushy. You need to be remembered.
  • Know about some of the changes in healthcare. Be able to speak intelligently about the role of PAs in national healthcare law as well as state.
  • Be aware of any recent legislation in your state affecting PAs (visit your state chapter website for more info)
  • Be able to answer the "standard" interview Qs: what are your strengths/weaknesses, tell me about a difficult encounter with a patient or boss, etc
  • Wear a suit. 
  • Be able to explain any weird parts of your resume (if you have them) - for example, if you got a "C+" in biology or you took 2 months off to backpack around Europe - come up with a good REASON why, not an excuse.
  • If you had a medically relevant job/career prior to applying to PA school - mention it.
  • Bring several copies of your resume. If no one asks you for it, no big deal - but you don't ever want to be asked (even once) and not have one.

Pic: http://www.snellingnj.com/blog/bid/53533/The-Characteristics-of-a-Great-Interview


Tips on Finding a Good Elective Rotation

One thing that I have learned from being involved in so many PA and PA student activities is that all PA programs are very different. They all need to meet ARC-PA standards, but the ways in which they meet them varies. For example, some schools have elective rotations, some don't. Some help you set them up, some don't. I have had a few people email me and ask me how to go about setting up their electives, but each program varies so much it is difficult advice to give. Below are some general tips to consider when trying to set up your elective. These tips are helpful only if you know what you want your elective to be - if not, see one of my earlier posts (Choosing an Elective Rotation) to help narrow it down.
  1. Check with your program director. Most program directors have been around the PA profession for a while and have made a multitude of contacts over that time. Much of this is about who you know.
  2. Network, network, network. Attend any and all PA events that you can make it to and don't be a wallflower! Reach out and say hi to people. If you make a connections, get their contact info and follow up.
  3. Join the PA organization for whatever field you are interested in pursuing. You can find most on Facebook or with a good Google search. Some of these organizations are better/more organized than others, but make the effort to reach out to them. They may have a list of mentors that are willing to take students. The cardiovascular PA group is fantastically organized and has offered free student membership in the past.
  4. Check with your state chapter. They may have a mentor program for student members as well.
  5. Contact the department directly. I only suggest this if it OK'd by your school. Some schools do not allow students to directly contact potential sites so... ASK FIRST.
  6. Do your homework on the institution. It is important that you know what type of rotation you are signing up for since your elective is likely something you may seek employment in in the future. Big, teaching hospitals are great because you see a high volume of patients and often see rare/unusual cases, which can be super exciting! The downside is that these large institutions generally have residents and medical students that are fighting for these cool cases as well. These means that you may not get as much hands-on time as you would like - especially in the OR. If you want lots of hands-on experience, you may want to look at a mid-size or small hospital. The down side to this is usually a smaller patient load with more "bread and butter" cases - but you will likely get to participate more and have more responsibility. These are not the exact scenario at every hospital, but are things you consider and ask about before committing your one elective to it.
In the end, hopefully you are successful in getting the elective of your dreams. If not, learn as much as you can from whatever elective you end up in and don't be discouraged. If you weren't able to find a "Trauma" rotation, that doesn't mean that you will never work in trauma. Where there's a will, there's a way.

Pic: http://www.whatsnextblog.com/2008/09/whats_the_best_advice_you_ever_got/


Approach to Volume Disorders, Part 3

Fluid Replacement Therapy

 I have also attached a chart that should be helpful in understanding when to give which type of fluid.


Approach to Volume Disorders, Part 2

Assessing Volume Status

  • Track ins and outs (Is & Os) - this is not an exact science because you can't exactly measure insensible losses, but it will give you an idea of the volume status
  • Normal urine output of an adult = 1mL/kg per hr 
  • Skin turgor and mucous membranes are difficult to assess and are not always reliable
  • Daily wts are a good way to assess volume trends
  • Don't lose sight of the BIG PICTURE. What is the overall health of your patient?
    • Pts with: fever, burns, open wounds have a higher insensible loss
    • For each degree over 37 degree C, estimate an increase in loss of 100mL/ day
    • Pts with CHF may have pulmonary edema so pay close attention to their volume status
    • Pts with end stage renal dz are prone to hypervolemia
    • Pts with hypOalbuminemia tend to "3rd space" fluids out of vasculature and are therefore total body hypervolemic, but intra-vascularly depleted

Source: Step up to Medicine (Agabegi and Agabegi)