Anesthesia Business Consultants: Communique fall06

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CUSTOMER SERVICE – GET IT YOURSELF! . . . . . . . . . . . . . . . . . . 1

SURGEON SATISFACTION: A 360 DEGREE PERSPECTIVE . . . . . . . . . 2

ASSESSING OPERATING ROOM EFFICIENCY . . . . . . . . . . . . . . . . . 7

COMPLIANCE CORNER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

2007 MGMA AAA ANNUAL CONFERENCE . . . . . . . . . . . . . . . . 12

EVENT CALENDAR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Continued on page 4

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➤ I N S I D E T H I S I S S U E :

Customer Service – Get it yourself!That was the headline in last Sunday’spaper here in my Southwest Florida com-munity. This community is burgeoningwith population growth and still recover-ing from last year’s hurricanes. There arenot enough workers to meet the demandand any breathing creature can obtain a jobin the service and construction industry –but what is the work ethic and profession-alism of that worker?

Customer service – let’s look at oureveryday lives. Whether booking a hotelreservation, questioning a bill, trying to getthe TV-cable repaired, or working withyour bank – just think of how difficult it isto speak to a person – typically the “cus-tomer” the guy who’s spending the moneywith the option of taking business else-where, is directed to voice-mail; hears,“push one for this”; “push two for that”; orbest yet, must pay additional fees to speakto a person – How Do You Feel, When Youthe Customer are Treated That Way?

In healthcare we speak a lot about “thecustomer and providing customer service”.Several of my hospital clients have

“Customer Relations Specialists” – I thinkthese individuals are intended to assistpatients with service related issues, howev-er I’ve never really been able to understandwhat these specialists really do. In otherinstances, my hospital clients have“Physician Liaisons” – these individuals areintended to assist physicians based at a

ABC offers Communiqué in electronic formatAnesthesia Business Consultants, LLC (ABC) is happy to announce that Communiqué willbe available through a state-of-the-art electronic format as well as the regular printedversion. Communiqué continues to feature articles focusing on the latest hot topics foranesthesiologists, nurse anesthetists, pain management specialists and anesthesiapractice administrators. We look forward to providing you with many more years ofcompliance, coding and practice management news through Communiqué. Please logon to ABC’s web site at www.anesthesiallc.com and click the link to view the electronicversion of Communiqué online.

CUSTOMER SERVICE –GET IT YOURSELF!

By Jerry Ippolito, Vice President & PrincipalThe Surgery Management Improvement Group, Inc.

CommNEWS_Fall06v6.qxd 11/30/06 3:33 PM

Why has surgeon satisfaction becomeas important to health care leaders as clin-ical and financial outcomes? Each year,health care facilities throughout the worldspend hundreds of thousands of dollarson surgeon satisfaction surveys in anattempt to arrive at the elusive answers towhat truly satisfies a surgeon? Thethought being that if the surgeon is satis-fied, then the patient will be satisfied and

business will be good. Practically everyAmerican industry, to include healthcareand business, is brimming with thousandsof articles, theories and studies about thecritical importance of customer satisfac-tion in steering organizational success.The dilemma is that the act of satisfying isin as much a subjective action as it is asubjective assessment. To satisfy, and inturn be satisfied, is a personal perspective

that can typically be shared and appreciat-ed, but likely not universally scripted andaccepted. In many ways, customer satis-faction follows the simple Golden Rule;treat others as you want to be treated.

Where the customer satisfactionwaters in the health care have becomemuddied is that the traditional customer(the patient) has joined an ever growinglist of customer stakeholders to include

THE COMMUNIQUÉ FALL 2006 PAGE 2

In our competitive society we allwant to know how we are doing. Few ofus are so confident in our endeavors as tonot want some kind of feedback orapprobation, especially those of us in theservice business. The challenge is know-ing what sources to trust. Too often,ulterior motives or our own naivetécloud reality, making it hard to distin-guish the important from the trivial.How often do we only hear what we wantto hear? At least in our business we havesome objective measures of success. Solong as we keep growing and our clientsmaintain their franchises we are happy.The question is, what makes for successin an anesthesia practice? The persistentdissonance and drone of life in the oper-ating room tends to dull one’s senses toeverything but the matter at hand. Whenthe case goes well all is right with theworld, or so it seems. How often, though,is the rising tide a harbinger of a majorstorm? Perhaps more often than most ofus would care to admit.

Our clients used to obsess abouttheir collections. A good month wasdefined simply in terms of a highdeposit. Heaven forbid we came in belowexpectations, though. Little did I knowthat those were the good old days! Now,we are all so focused on the underlyingfactors that generate those collectionsthat the actual numbers on the reportsare almost anticlimactic. The world ofanesthesia practice management has def-initely evolved from its cash-basedaccounting roots to an accrual-basedmodel of cost accounting. Sometimes Ifeel like a stockbroker: even a hint of badnews can send clients in paroxysms ofanxiety. Disaster seems ever-present. Asan organization we spend more timethan ever helping our clients formulatestrategies that will turn adversity intoopportunity.

The entire vocabulary of practicemanagement has changed in the pastfew years. Discussions of gross and netcollections rates have given way to talk

of manpower andstaffing models. Wehear much more about productivity andbenchmarking than we do aboutAccounts Receivable management per-formance. But if there is one topicwhich defines the new era by virtue ofits novelty and lack of understanding; itis customer service. As each topic unfoldsacross the country it is ever more clearthat we must all be constantly updatingour toolset if we want to succeed andthrive in the years ahead.

As always, we hope you find ourauthors’ treatment of these new frontiertopics timely and informative. We go togreat lengths to tap into those industryobservers who we believe have their fin-gers on the pulse of the market. May youfind ways to put these invaluable ideas toeffective use in your practice!

Tony Mira, President & CEO

WHAT MAKES FOR SUCCESS INAN ANESTHESIA PRACTICE?

SURGEON SATISFACTION:A 360 DEGREE PERSPECTIVE

By Hugh Morgan, CMPEDirector, AtlantiCare Anesthesiology


the community, hospital administrationand surgeons. Our challenge isn’t inunderstanding and accepting the ideasand principles of customer satisfaction,but rather in defining who we are sup-posed to satisfy? In recent years, a greatdeal of customer satisfaction endeavors inhealth care have been focused around thesurgeons or the “revenue producing” cus-tomers. The shift in health care frompatient-centric satisfaction to what Iwould refer to as “macro” satisfaction hasplaced operational burdens and unjustexpectations on the specialty of anesthesi-ology. The industry is strewn withdefeated anesthesiology groups who oftentimes are forced to succumb to adminis-tratively supported surgical expectations.How then is it possible for an anesthesiol-ogy practice to survive and thrive in an eraof surgeon-centric satisfaction?

First and foremost, an anesthesiologypractice must define the diverse satisfac-tion stakeholders for who they areresponsible to include patients, nursing,administration and surgeons. The groupshould seek to understand both the com-mon and unique expectations of eachstakeholder group through personalmeetings and feedback surveys which ulti-mately produce the satisfaction criteriaand goals. Although hard to believe,patient’s seem to have become the leastarduous to satisfy. Typically, patient’ssimply expect to be treated with compas-sion and respect and to receive the highestquality and safest medical care with thebest possible outcome. Administration isa little more challenging to satisfy in thatthey usually expect anesthesiology prac-tices to infallibly provide anesthesiaservices and meet fluctuating clinical cov-erage requirements without pause orcancellation and within the most finan-cially insolvent manner possible. Fairlystraightforward expectations, right? Thequandary is that administration’s satisfac-tion expectations are often directly

associated, if not embedded, with that ofsurgeon satisfaction expectations result-ing in a tag-team of operational andfinancial burdens for an anesthesiologypractice. The key is to concurrentlyaddress the administrative and surgicalsatisfaction expectations so that there is aclear understanding by each stakeholderas to how satisfaction expectations candirectly impact anesthesiology’s ability toeffectively satisfy at the expense of groupoperations. It is essential to arrive at a setof reasonable, achievable and mutuallybeneficial administrative and surgicalexpectations so that the satisfaction crite-ria are universally known and not subjectto whimsical modifications. Althoughsome satisfaction expectations are some-what broad and inherently subjective suchas, “adequate coverage” and “immediatelyavailable” it is usually more evident tonotice and hear about the absence ratherthan the presence of satisfaction. Howoften have we heard that if all is quiet,things must be good?

An important facet in achieving sur-geon satisfaction is the ability of ananesthesiology practice to be duly recog-nized by administration and surgeons as

medical colleagues of the surgical staff.Too often, anesthesiology is viewed as ahospital “service” and not as a medicalpractice with a critical role in the overallsafety and care of the patient. Althoughanesthesiology touches numerous clinicalenvironments throughout a hospital, per-haps the most important and visibleinvolvement is within the Perioperativearena. From the preoperative assessmentthrough post surgical recovery, anesthesi-ology plays a vital role in the customersatisfaction of the various perioperativestakeholders, most notably the surgeons.Anesthesiology is the third cog, the othersbeing nursing and surgery, in the wheelthat effectively spins perioperative/surgi-cal services. Like a tire, if any one of thesepreoperative “cogs” experiences problems,the tire goes flat and unfortunate acci-dents can occur. It is important then foreach of the preoperative disciplines to beaccountable to each other for a variety ofsatisfaction criteria to include patientsafety, clinical competency, professionalbehavior and workflow efficiencies. Thechallenge is to develop the mutual periop-erative satisfaction criteria and


Continued on page 11


hospital with service related issues.Humorous as it may seem, as an anesthe-siologist have you ever been approachedby the Physician Liaison at your hospitaland asked, “how are we doing” – probablynot. However in my world of OperatingRoom Management Consulting I doencourage OR Team Leaders andDirectors of Surgical Services to take onthat duty – “how are we doing?”. The phe-nomena however is that we talk a lotabout customer service and we have cus-tomer service specialists of every species,BUT HAVE WE DEFINED WHO THECUSTOMER IS? According to Websterthe customer is:

1. one who purchases a commodity;2. one with expectations of outcomes.

Some years ago I participated in a CQI(Continuous Quality Improvement) pro-gram where the second definition was morecommonly used; in fact the second defini-tion, in my mind, is the most appropriate.We all have needs and rely on performanceand fulfillment of expectations by others –WE ARE ALL EACH OTHER’s CUS-TOMERS.

In the world of the operating room wetypically regard the surgeon as the customer.Ironic as it is, we seldom consider thepatient first. As a consultant I have theopportunity to work with several dozenhospitals each year in many communitiesaround the country – indeed the patient isthe primary customer (even more ironic intoday’s world is that the payor is beginningto usurp this position). As I sit in restau-rants, ride on planes, read local papers I’llcontinuously hear / read about residents’perceptions of the local hospital. I’ve hadthe honor of working with several very pres-tigious community medical centers aroundthe country; if physicians are not on staff atthese centers, they can not build or sustain apractice – if they are not on staff at thesecenters, they are not considered quality doc-tors – THE PATIENT IS HIGHLY

SELECTIVE, and rightfully so! In the world of OR we often speak of

the three or four legged stool – the four cus-tomers; the four constituencies withexpectations; even here we forget about thepatient – aren’t there really at least five cus-tomers:

1. Patient – Expectations of: Qualitycare; Hospitality; Affordability;Accessibility

2. Hospital Administration – Expecta-tions of: Increased business;Increased Margins; Decreased Costs;Maximized utilization of resources

3. OR Staff / Nursing – Expectations of:Ability to deliver quality patient care;Competitive compensation;

Reasonable working conditions; Jobsatisfaction; Reliable and predictablework schedules

4. Surgeons – Expectations of: Qualitypatient care; Sufficient OR access tomeet practice needs; Maximized /efficient use of time; Experienced ORstaff who can anticipate case needs;Equipment and technology meetingprocedural needs; Ability to generatea livelihood comparable to similarspecialists

5. Anesthesiologists – Expectations of:Quality patient care; Optimized uti-lization of time; Competitivecompensation and lifestyle;Predictability of schedules.


CUSTOMER SERVICE – GET IT YOURSELF!Continued from page 1

Surgeons

Anesthesiology

Administration NursingPatient

Surgeons

Anesthesiology

Administration NursingPatient

COMPROMISE IS KEY TO OPTIMIZING CUSTOMER SATISFACTION & MAINTAINING

A PATIENT FOCUSED PROGRAM

WithoutCompromise thePatient Stands

Alone


If any one customer’s or constituent’sexpectations are fully satisfied (the 100percent level) then fulfillment of other’sexpectations will suffer.

I hope we’re now all agreed that thepatient belongs in the center of our uni-verse as professionals in the field ofhealthcare. Let’s move on to the “nuts-and-bolts” of developing customersatisfaction in the OR. Let’s first talkabout the surgeon as we always hear thatthe surgeon is the customer. Typically thesurgeon (or medical staff in general)wants to be regarded as a patron or cus-tomer of the hospital; the customermaintains the option to shop elsewhere.The hospital-business will not survivewithout the physician (and patient) cus-tomer(s). As in the retail environmentthe physician-customer maintains anexpectation that the vendor (hospital)delivers a quality product. However,unique to the hospital setting is that theproduct is truly a service vs. a tangibleproduct; physician-customers place pri-mary emphasis on the hospital meetingtheir service oriented expectations.Physician-customers typically “Want whatthey want, when they want it”. The physi-cian customer typically forgets that evenin the most service oriented, traditionalenvironment (whether Ritz Carlton,Nieman Marcus or Lexus dealership)hours of operation, dress codes, pricingstrategies, rules of conduct, (etc.) existand are required to effectively and reliablymeet the majority of customers’ expecta-tions. Too frequently physicians /surgeons expect the administrative team(and anesthesiology) to meet 100 percentof expectations 100 percent of the time onterms established by the physician-cus-tomer at any given point in time. Thismind-set, if allowed, diminishes the abili-ty to optimize service to the othercustomers (patients, nursing, anesthesiol-ogy, administration). Compromise is key.

Now what you’ve been waiting for –does anesthesiology ever get to be the cus-tomer and what role does anesthesiologyplay in meeting customer service / satis-

faction requirements? Surgeons will grav-itate to those hospitals and ASCs where asuperior level of anesthesiology care isprovided – where there is choice. Patientsare generally unaware of the level of care /expertise provided by the anesthesia serv-ice and really don’t make decisions basedon this factor. Doctors, I know this isgoing to hurt, but I now have to drop thebomb – in my nearly thirty years inhealthcare and fourteen years in consult-ing, I can not site an instance where ananesthesiologist referred a case to a hospi-tal (pain management or a personalreferral aside). Indeed, quality anesthesi-ologists and CRNA (AA’s) are in shortsupply these days and do have numerousjob / practice opportunities, but typicallyanesthesiology’s decision of where to “per-form / take a case: requires a career andgeographic move – very different from thesurgeon’s opportunities. Doctors, we justhave to “bite-the-bullet” and deal withreality. I spend a sizeable amount of mytime in consulting and interviewing anes-thesiologists around the country and alltoo frequently I’ll hear: “My income isdecreasing because they (meaning hospitaladministration) have lost the outpatientbusiness”. In polite terms I’ll ask, “Whatrole did anesthesiology play in retaining

that business?” Generally I’ll continuewith the anesthesiologist and ask, “Do youconsider yourself a consulting specialist? “Almost universally the anesthesiologistresponds “Yes” – well then, don’t consult-ing specialists need to garner referrals;develop and protect referral sources? Itthen begins to sink in. In the old days andstill in some pockets of the country, anes-thesiologists teamed up with surgeons andfollowed the surgeon all around town pro-viding anesthesia for the surgeon’s case.The surgeon was treated as a customer orclient of the anesthesiologist; the anesthe-siologist was expected to provide a certainlevel of service (I know I’m rubbing salt inthe wound – sorry). Today the model hasgreatly changed and rightfully so due tothe economics of healthcare – one sur-geon’s practice can not support ananesthesiologist at today’s reimbursementlevels. So then, the anesthesiologist, all themore, needs to expand and further devel-op the practice base – the anesthesiologistrequires more clients / customers to gen-erate the expected livelihood; theanesthesiologist needs to: “Market to theCustomer; Build the Business”.

As we wrap this up, let’s focus on anes-thesia’s role in customer service in theoperating room as well as anesthesia’s posi-


Continued on page 6


tion as a customer. In general, customers’expectations, regardless of who the cus-tomer is, will not be met unlessexpectations are reasonable and clearlydefined. Most frequently for anesthesiathis is defining how many sites are staffedby hour of day and day of week; this CANNOT be a moving target if customer serv-ice is to be effectively delivered.

Only as a few examples, as a customer,anesthesia should be able to rely on:

• Development of clearly defined andagreed to expectations with regard tosites staffed;

• Competitive compensation andlifestyle for services rendered deliver-ing to expectations (potentiallyrequiring a hospital stipend);

• An OR committee (or governancebody) having developed effectivescheduling policies and proceduresand further, consistently enforcingthem;

• Surgeons’ offices effectively commu-nicating with OR scheduling;

• Surgeons effectively communicatingwith anesthesia with regard to diffi-cult cases or sick patients;

• Nursing effectively implementingpreadmission screening protocolsthat have been developed jointly withanesthesia;

• Charts being complete on the day ofsurgery;

• Patients being appropriately preparedfor surgery in either a Day-surgeryunit or on the hospital floor;

• Ability to transport the patient to theOR in a timely manner in order tohave on-time case starts;

• Surgeons reporting to the OR on timefor on-time case starts;

• Experienced OR staff and appropri-ately set-up cases in order to reducecase times;

• Experienced charge nurses workingwith anesthesia to run the day’sschedule;

• Experienced PACU staff who canfunction with relative independence;

• Lots of other stuff...

In providing customer services anesthesiashould be expected to:

• Be current in state-of-the art anesthe-sia care with an emphasis onambulatory anesthesia;

• Maintain reasonable flexibility withregard to agreed expectations – main-tain an attitude of meeting orexceeding expectations;

• Assure consistent and reliable staffingfor all anesthesia sites agreed to;

• Collaborate with nursing to developstate-of-the-art preadmission guide-lines; agree as a group to establishedguidelines;

• Screen all ASA III and above patientsand visit with all inpatients prior tothe day of surgery;

• Develop processes to administeranesthesia consults for the preadmis-sion unit;

• Call patients on the evening prior tosurgery;

• Be as familiar as possible withpatients’ conditions prior to the dayof surgery;

• Review patient charts at least the dayprior to surgery;

• Proactively work with nursing inschedule planning and management;

• Begin reviewing the schedule withnursing several days prior to surgery;

• Facilitate getting patients into the ORfor on-time case starts;

• Facilitate expediting turnaroundtime;

• Maintain an effective medical direc-tion model where CRNA direction isbased on case complexity, patientacuity and CRNA skill level;

• Be promptly available to CRNAs dur-ing on-going cases;

• Be promptly available to CRNAs casesto expedite induction and emergence;

• Develop a staffing model and serviceagreement model whereby anesthesiastaffing requirements of OR-periph-eral sites does not disrupt OR staffing;

• Develop a Q/I and education modelfor all anesthesiologists, CRNAs andhospital staff (RNs; RTs) whereappropriate;

• Assign lead individuals to foster skillsand business development in keyservices such as cardiac / vascular, OB,ambulatory, pain (potentially neuro,trauma, pediatrics);

• Play a key role in developing and sus-taining YOUR OWN BUSINESS byfocusing on what is required to devel-op a marketable and financially viablesurgical program with increasing casevolume;

• Focus on delivering the highest levelof patient care with respect for thepatient’s time; provide hospitality;

• Focus on defining expectations andthen exceeding those client / customerexpectations and your business / anes-thesia practice will flourish (1).

(1) Depending on expectations, payor mix andOR efficiencies / case times there may always bea need to approach hospital administration fora subsidy payment to deliver on expectations.


Continued from page 5

CUSTOMER SERVICE – GET IT YOURSELF!



The measurement ofoperating room effi-ciency used to be oneof those arcane sci-ences reserved for aspecial breed of con-sultant with experience

in balancing the political and practicalrequirements of the daily management ofa suite of operating rooms, but not anymore. Given the impact of inefficientoperating room management on anesthe-sia coverage and call requirements, O.R.utilization is rapidly becoming a key factorin an anesthesia practice’s need for finan-cial support. While the causes ofinefficient operating room utilization tendto be complex and directly related to ahospital’s need to compete for surgeonallegiance in increasingly competitivemarkets, it is not uncommon for anesthe-siologists to be invited to join the fray. Theconcept of an anesthesiologist or an anes-thesia department designee playing somerole in O.R. management is not new. Manypractices have had a “floor person,”“Clinical Day Director,” or “Captain of theShip” for years. Typically, these have beenombudsmen providing a customer servicerather than aggressive managers empow-ered to actively modify surgeon behavior.The problem is simply that for all theirexperience in the arena, most anesthesiol-ogists have yet to develop the necessarytools and strategies to make them effectiveagents of change.

From an anesthesia perspective alldiscussions of operating efficiency ulti-mately hinge on the economics ofcoverage and call. This takes some over-eager practitioners right to a discussion of

profitability. From a management per-spective, however, an exploration ofbenchmarks and metrics may be moreuseful in the strategic positioning of anes-thesia as a contributor to the solution ofdeclining productivity. Establishing acommon vocabulary of performance uti-lization is deceptively complex. It is notuncommon to hospital administrations toview any data from the anesthesia practicewith a healthy dose of skepticism. As in somany exercises in change, managementtime must be spent educating all the stake-holders so that they agree on the problem,accept the metrics and share some owner-ship for the process.

Most observers would agree all met-

rics should be viewed and tabulated byanesthetizing location. Let us furtherassume, for the sake of this discussion, thatan anesthetizing location is an actual orvirtual location that requires dedicatedanesthesia personnel for part or all of a 24hour period. By this definition each oper-ating room is an anesthetizing location, asis the delivery suite, the Cystoscopy room,or any other physical space where anesthe-sia services might be required. Thedefinition becomes a little less clear whenthe dedicated personnel are required toprovide a variety of non-operating roomservices. Each practice must work throughits own definition of N.O.R.A. (Non-Operating Room Anesthesia)

ASSESSING OPERATING ROOM

EFFICIENCYBy Jody Locke

Continued on page 8



requirements.One school views operating room

efficiency through the absolute lens of aparticular metric such as cases, units orminutes per anesthetizing location day.There is considerable discussion across thecountry as to appropriate points of refer-ence. There is some data to support anoptimal number of cases per location day,but as even the most casual observer of thespecialty will note not all cases are of equalacuity or duration. Others prefer to focuson total ASA units billed per location perday (base, time, modifier and incidentalunits) and will site the magic number 50as an ideal productivity benchmark. Stillothers prefer to measure and monitor

minutes. Actual anesthesia time has theadvantage of corresponding, more or less,to the operating room time captured bythe hospital staff. Discussions of anesthe-sia time can take a number of directionsdepending upon how important it is toidentify when activity occurs. It has beensuggested that an operating room thatgenerates 6 hours of anesthesia timebetween 7 AM and 3 PM is running atoptimum efficiency. Obviously, all bench-marks and standards must be adjusted tomeet the particular requirements andchallenges of the facility.

Proponents of such metrics argue thatwhile they may not be a perfect measure-ment of every situation at least they

provide a consistent frame of reference.They lend themselves to an objective com-parison of facilities. An operating roomthat consistently generates 40 ASA unitsper location day is clearly less efficientthan one that generates 50 or more units.

Inevitably, the question arises: Whichmetric is best? “Best” is a relative termbecause all valid data has some value if it isapplied judiciously. A determination ofthe most appropriate metric or approachfor a particular setting should hinge ontwo separate issues: reliability and credi-bility. Many anesthesiologists put greatstock in measuring total ASA units perlocation day, because they know how theyget paid for anesthesia, but such an


ASSESSING OPERATING ROOM EFFICIENCY

Hours per Location Day Versus Hours Per Location Dayshift

6.011030596 5.944845679 5.964393939 5.90016835 5.973765432

4.2152884624.031243032 3.951185897 3.96497669 3.914597902 3.963269231 3.855992196 3.880512821

6.193117284

5.723054214 5.664907407

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06

Avg Hours per Location Day Avg Hours per Day Shift Location



Continued on page 14

DAY Day of Week CASES CHARGES UnitsExpected

CollectionsAnes.

Locations

Units/ Anesthetizi

ng/ Location

DayExpected Gross $ /

Location Day

1 Wednesday 25 $29,113.50 447.9 $15,005 12 37.33 $1,250.39

2 Thursday 28 $22,919.00 352.6 $11,812 12 29.38 $984.34

3 Friday 40 $37,128.00 571.2 $19,135 9 63.47 $2,126.13

4 Saturday 29 $25,148.00 386.9 $12,961 4 96.72 $3,240.22

5 Sunday 7 $5,512.00 84.8 $2,841 3 28.27 $946.93

6 Monday 5 $4,160.00 64.0 $2,144 12 5.33 $178.67

7 Tuesday 32 $24,687.00 379.8 $12,723 12 31.65 $1,060.28

8 Wednesday 32 $26,344.50 405.3 $13,578 12 33.78 $1,131.46

9 Thursday 28 $22,386.00 344.4 $11,537 12 28.70 $961.45

10 Friday 47 $40,703.00 626.2 $20,978 9 69.58 $2,330.86

11 Saturday 25 $23,965.50 368.7 $12,351 4 92.18 $3,087.86

12 Sunday 10 $7,228.00 111.2 $3,725 3 37.07 $1,241.73

13 Monday 4 $3,692.00 56.8 $1,903 12 4.73 $158.57

14 Tuesday 29 $26,955.50 414.7 $13,892 12 34.56 $1,157.70

15 Wednesday 27 $26,718.00 411.0 $13,770 12 34.25 $1,147.50

Anesthetizing Location Production Metrics for

Month of March 2005 (Based on DOS Data)

16 Thursday 39 $37,076.00 570.4 $19,108 12 47.53 $1,592.37

17 Friday 40 $32,922.50 506.5 $16,968 9 56.28 $1,885.31

18 Saturday 32 $29,428.00 452.7 $15,167 4 113.18 $3,791.68

19 Sunday 10 $10,991.50 169.1 $5,665 3 56.37 $1,888.28

20 Monday 8 $7,553.00 116.2 $3,893 12 9.68 $324.39

21 Tuesday 26 $24,017.50 369.5 $12,378 12 30.79 $1,031.52

22 Wednesday 32 $29,107.50 447.8 $15,002 12 37.32 $1,250.13

23 Thursday 14 $11,011.00 169.4 $5,675 12 14.12 $472.91

24 Friday 28 $21,671.00 333.4 $11,169 9 37.04 $1,240.99

25 Saturday 20 $18,359.00 282.4 $9,462 4 70.61 $2,365.49

26 Sunday 10 $8,495.50 130.7 $4,378 3 43.57 $1,459.48


Since the publication of the OIGCompliance Guidance for Individual andSmall Group Physician Practices (here-inafter the “OIG Guidance”) in 2000,many anesthesia practices have had someexperience with compliance auditing.The first of the seven compliance pro-gram elements recommended by the OIGis conducting internal monitoring andauditing through the performance ofperiodic audits. What does this entailfor an anesthesia practice? Althoughphysicians may not be legally required toconduct internal audits and the factremains that the OIG Guidance is only aset of recommendations, many expertsrecommend that physician practicesshould strive to conduct internal audit-ing at least on an annual basis.

Conducting annual audits shouldprove beneficial in assisting the practicein identifying issues that should beaddressed or corrected thereby reducingongoing risks to the practice. By per-forming an audit on at least an annualbasis, the practice should avoid messy sit-uations such as identifying a significantproblem or issue that may have beenoccurring for a significant time period

resulting in potential large overpaymentsreceived by the practice. Such circum-stances can raise significant questions forthe practice related to payback and dis-closure obligations.

A common question facing anesthe-sia practices when deciding to conductan internal audit (either by internal staffor hiring an outside consulting group) is“how many records should we review?”While there is no exact right or wrong

number, it is reasonable for the practiceto limit the record review to a manage-able and practical number for severalreasons including costs. In the OIGGuidance, the OIG suggests that anappropriate sample size may be five (5)to ten (10) records per physician in thepractice. In many situations, a group’sdecision to audit between 5 and 10records per physician would be reason-able. Some outside consultants that havean economic interest in reviewing manyrecords, may suggest too large of a sam-ple size. The practice must keep this inmind when hiring and coordinating anaudit with outside help. Outside con-sultants can and do provide valuableassistance and expertise for many prac-tices, however, the practice shouldmaintain control of the process and notsimply allow the consultants to directand select the sample size. Given that theauditors will typically identify problemareas, it is also important for the practiceto conduct the internal audit under theattorney/client privilege. This process isnot complicated and involves the prac-tice’s attorney directing the auditors toperform the audit under the


As part of our desire to keep both clients andreaders up to date, the Communiqué has beenprinting compliance information since itsinception. In the Compliance Corner, we willnow formally keep you abreast of the variouscompliance issues and/or pick out a topic thatwould be of interest to most of our readers.

COMPLIANCE AUDITING: HOW MANY

RECORDS SHOULD YOU REVIEW?By Abby Pendleton

Wachler & Associates, P.C.


measurement tool for which each of theperioperative disciplines will be account-able and to encourage global participationas a means to achieving higher levels ofperformance and satisfaction.

Earlier this year, with input from myperioperative leadership colleagues atAtlantiCare, I initiated the development ofa 360 degree Perioperative SatisfactionSurvey to purposefully achieve higher lev-els of mutual perioperative satisfactionand drive higher levels of perioperativeperformance. The 360 degree approachfor survey and evaluation purposes is not anew concept as business leaders have suc-cessfully used 360 surveys as a means ofassessing leadership at every organization-al level. Although surgeon specificsatisfaction surveys had previously beenattempted at AtlantiCare, the thought wasthat a comprehensive 360 degree surveywould likely surface common satisfactionand dissatisfaction themes affecting all ofthe perioperative disciplines to include thesurgeons. The intent was to obtain defini-tive feedback on the common satisfactionand dissatisfaction themes so that the lead-ership of each perioperative disciplinecould address the universal issues of the

discipline rather than issues of isolated dis-satisfaction. A set of mutually inclusivesatisfaction criteria with basic effectivescoring was developed and scoring that fellabove or below acceptable targets requiredsupportive elaboration so that dissatisfac-tion could be effectively addressed. Theleaders of each perioperative disciplinewere tasked with distributing the 360degree survey to their respective col-leagues. Each perioperative discipline hadthe opportunity to survey each of the otherdisciplines as well as their own discipline.As with any feedback survey, it was impor-tant to establish deadlines for surveysubmission dates so that feedback is timelyand action plans for improvement can beefficiently developed. The survey success iscompletely dependant on the level of par-ticipation or you will have developed thebest satisfaction survey with no feedbackto improve satisfaction or performance.

The key point is that to achieve higherlevels of surgeon satisfaction is to concur-rently achieve higher levels of nursing andanesthesiology satisfaction. Within theperioperative arena, none of the disciplinescan achieve high levels of satisfaction with-out the other disciplines also being

effectively satisfied. It comes down to amutual respect and understanding of thecritical roles that each discipline plays indetermining the performance, culture andoverall success of perioperative and surgi-cal services. In the end, it becomes anexercise in futility to attempt to satisfy onediscipline, namely surgeons, at the expenseof the other two perioperative disciplines,nursing and anesthesiology.



SURGEON SATISFACTION: A 360 DEGREE PERSPECTIVE

attorney/client privilege.In addition to the cost issues, if the

goal of the audit is early identification ofissues or patterns, a large volume ofrecords is typically not necessary. In fact,many auditors will begin to identifyissues/patterns in the first 10 to 20records. For example, in auditing anes-thesia records, it usually does not takemany records to identify whether thephysicians are fully documenting med-ical direction requirements or whether

anesthesia time is being rounded. In theanesthesia setting, many auditors suggesta review of a full day of cases in order toperform a concurrency review in con-nection with the audit. The practice willhave to make a determination as towhether an independent check of con-currency is necessary.

Accordingly, while there may not beone “magic” number for complianceauditing, your practice should take a rea-sonable approach by selecting enough

records to accomplish the goal of theaudit, which in many routine compli-ance audit situations is to identify areasneeding attention. For many practices,selecting a minimum of 5 records perphysician will accomplish this goal. Ofcourse, once issues are identified, thepractice should perform specific focusedfollow-up audits to oversee that correc-tive action measures that were put intoplace (e.g., educating providers or estab-lishing new policies) are working.



We are pleased to announce that thisyear’s MGMA AAA annual conferencewill be held April 29 – May 2, 2007 at thespectacular Four Diamond SheratonHotel and Towers in Seattle, WA. Forthose who have never attended this anes-thesia practice management conference, itis one of the best in the industry. Thisyear, due to popular member demand, weadded two half-days of pain managementspecific practice management informa-tion as a pre-conference on Saturdayafternoon and Sunday morning, in addi-tion to offering a pain track throughoutthe concurrent sessions of the main con-ference. Typically attended byapproximately 300 administrators, physi-cians, practice managers, billing serviceowners, consultants and others involvedin advanced level anesthesiology and painpractice administration, it also providesan exceptional forum for networking andinformation exchange. Early in the con-ference we offer roundtable discussionson specific issues of interest that allowpeople to meet others in comparablepractices or with similar concerns. Weinclude a number of social events to pro-vide further networking opportunities.People who have attended this meetingfor many years develop friendships thatprovide continuing networking supportthroughout the year.

Once again, we have an exceptionalgroup of speakers lined up for this year’sconference and pain management pre-conference. The pain pre-conference is

scheduled to begin on Saturday, April28th from 1:00 to 5:00 p.m. and Sunday,April 29th from 8:00 a.m. to 12:00 p.m.The keynote speaker is Doug Merrill, MDfrom Virginia Mason Clinic located inSeattle. Dr. Merrill, a leading physician inthe chronic pain management field, willshare his vision in “The Future of Pain.”Other speakers include nationallyrenowned healthcare attorneys VickiMyckowiak, Esq., and Jennifer Bolen, J.D.,who will address fraud and abuse riskareas and compliance concepts for thepain management provider, respectively.Also, nationally known speakers, DevonaSlater, CHC and Marvel J. Hammer, RN,CPC, CCS-P, ACS-PM, CHCO will dis-cuss pain management coding, billing,and appeals. In response to memberrequests, this information-packed pre-conference was designed to meet thespecific needs of our members with pain-management practices.

On Monday morning, physicianswho attend the conference are invited tojoin Dr. Craig Johnson, ASA liaison to

MGMA AAA, and other colleagues forbreakfast. As in past years, this “physicianonly” informal networking event givesphysicians an opportunity to discuss cur-rent topics and exchange informationpertinent to their practices. Our keynotespeaker (special thanks to Tony Mira andAnesthesia Business Consultants, LLC fortheir generous sponsorship of this event)is Jim Bergquist, president, BizFutures.This Seattle-based consulting companyhas been featured on National PublicRadio and has an impressive list of clients,including Microsoft and Boeing. The highenergy and high impact presentation –designed to inspire and motivate employ-ees – is fun and educational.Other general session speakers includeMark J. Lema, MD, president, AmericanSociety of Anesthesiologists, Norman ACohen, MD, American Society ofAnesthesiologists’ Committee onEconomics, and Alexander Hannenberg,MD, Vice-President Professional Affairs,ASA. Back by popular demand, national-ly known health care futurist James E.Orlikoff, Orlikoff & Associates, Inc.,Chicago, will discuss “The Impact ofTechnology on the Healthcare System.”

As usual, the concurrent sessions willinclude many experienced speakers cover-ing a great variety of new and timelytopics. This year we will be adding afourth option to the concurrent sessionsto provide a specific pain track in the mainconference as well as the pre-conferenceofferings. Topics to be covered in the con-

2007 MGMA AAA ANNUAL CONFERENCE

PROVIDES EXCEPTIONAL EDUCATION AND

NETWORKING OPPORTUNITY

By Kelly DennisMBA, ACS-AP, CPC, President-Elect, MGMA AAA, Leesburg, FL



current sessions include: “Modifier Magicfor Pain Management Coding,” by MarvelJ. Hammer, RN, CPC, CCS-P, ACS-PM,CHCO; “General Competency –Communication Skills,” by Sara M. Larch,MSHA, FACMPE, chief operating officer,University Physicians, Inc.; “To EAR ornot to EAR - What you Need to HearBefore Implementing an ElectronicAnesthesia Record,” by Phil Mesisca, MBA,CMPE, CEO, University of PennsylvaniaHealth System; “Pain Clinic Operationsand Profitability,” by Devona J. Slater,CHC, CMCP; “Achieving Optimum BackOffice Productivity,” by Jody Locke, vicepresident of anesthesia and pain manage-ment services, Anesthesia BusinessConsultants, LLC.

In addition to these excellent speak-ers, many who are members of MGMAAAA, roundtables will be moderated bymembers, who facilitate discussion andshare their experiences on a variety ofissues of interest.

Social events run the gamut frombreakfast, lunch and networking recep-tions to a golf tournament and casualget-togethers by members. Each year, anintroductory session is held for newadministrators and a special reception isheld prior to the opening reception forfirst-time attendees to help them meetpeople and start networking right away.Most of the key anesthesiology and painmanagement vendors are “on hand” assponsors and exhibitors during the breaksto demonstrate their products and servic-es, answer questions and solicit feedback.It provides a great forum to comparisonshop and evaluate products your practicemay need.

The Sheraton Seattle Hotel andTowers, the location of our 2007 meeting, islocated in the city’s vibrant core and hasrecently undergone a 14 million dollar ren-ovation of the lobby, restaurants, guestrooms and suites. Sheraton Seattle has

been the recipient of Meetings andConventions Gold Key Award for five con-secutive years. It is conveniently locatednext to the sights, sounds, and experiencesof one of the greatest cities in the northwestand just steps from world-famous PikePlace Market and the world-class shopping,exciting nightlife and gourmet restaurantsthat surround this magnificent hotel. Thehotel is located at 1400 Sixth Avenue indowntown Seattle. For more information,visit http://www.seattle.com/sheraton-seattle/

To learn more about the conference,view the brochure or to sign up yourselfand/or your administrator, visitwww.mgma.com/education/calendar/,find the appropriate dates and click on the

MGMA AAA annual conference. Or youcan call 1-877-ASK-MGMA and requestto have a hard copy brochure mailed toyou. ASA members who sign up withtheir administrator who is an MGMAAAA member may attend at the memberrate. There is also a special rate availablefor non-members to include purchase oftheir initial membership and obtain themembership price for the conference.Please do not hesitate to contact me, [email protected] or MGMA AAApresident Jack Beecher,[email protected], should you havequestions or need more informationabout the conference or any aspect ofMGMA AAA membership. We hope tosee you in April, 2007!!



approach may be viewed with great suspi-cion by hospital administrators who donot understand how anesthesia basic val-ues and time units are determined. Inother words, if a particular metric doesnot serve the goal of providing commoncoinage for a discussion of managementoptions it will serve no practical purpose.

Another school of thought is moreconcerned with the relationship betweencoverage commitments and actual pro-duction patterns. In this variation on thetheme actual hours of anesthesia time aredivided by total hours of staff coverage.Such an approach factors in such issues ascall and distinctions between short andlong rooms. The advantage of such a per-spective is that it can be customized to anyparticular configuration of anesthetizinglocations. The disadvantage is that allapplications become relative.

Included below are examples of eachof the two approaches to the measuring ofoperating room productivity. Not everyanesthesia practice will want to developthe tools to generate such reports,although more practices should probablybe exploring the possibilities than are cur-

rently doing so because too often it is theinitiation of a serious subsidy discussionthat triggers the need to look at productiv-ity. Practices that have been monitoringO.R. metrics over time have much greaterconversance with their applicability and

relevance. The fact is that as is true of theadministration of anesthesia, it is difficultto manage what one does not measure.While anesthesia practices have tradition-ally focused on the measurement andmanagement of billings and collections,more and more are beginning to realizethat the one piece of the equation they didnot choose to monitor is the one that hasthe greatest impact on the income andlifestyle of the members.

It has been said that you cannot man-age what you do not measure.Anesthesiologists know this intuitively,because the availability of reliable physio-logic data about a patient’s response to thetrauma of surgery and anesthesia playssuch a critical role in the consistent out-comes of today’s practitioners. Theconverse is also true: what you do notmeasure, you cannot manage. Anecdotaldiscussions tend not to support seriouschange. If O.R. productivity is an issue foryour practice then an investment in thetools and resources to capture the data andmonitor it closely is a small price to pay forthe opportunity to be part of the solutionrather than a victim of the problem.

ASSESSING OPERATING ROOM EFFICIENCYContinued from page 9

27 Monday 6 $4,927.00 75.8 $2,539 12 6.32 $211.61

28 Tuesday 27 $28,073.50 431.9 $14,469 13 33.22 $1,112.97

29 Wednesday 35 $36,305.50 558.5 $18,711 14 39.90 $1,336.52

30 Thursday 38 $38,389.00 590.6 $19,785 15 39.37 $1,319.01

31 Friday 39 $37,050.00 570.0 $19,095 12 47.50 $1,591.25

Totals 772 $702,038 10,800.6 $361,819 298629 $572,910 8,814.0 $295,269 270143 $129,128 1,986.6 $66,550 28

24.90 22,646.37 348.41 8.76 36.24 $1,524.3129.95 27,281.43 419.71 12.86 32.64 $1,064.33

Weekends

Overall AveragesWeekday Averages

Weekdays



Coding CornerCoding Corner

Speakers at anesthesia coding sem-

inars often harp on the importance of

indicating the use of hardware when

documenting spinal surgery. The argu-

ment is that failure to indicate the use

of hardware will result in the loss of five

billable units. While it is useful to keep

this in mind when reporting spinal pro-

cedures, this is hardly the end of the

story. New surgical techniques make it

imperative that not only is the surgical

approach and location clearly indicat-

ed, but that the coders understand the

significance of each indication.

A case in point is a practice that

routinely reported a spinal procedure

indicated as “TLIF.” The indication

obviously made sense to the anesthesi-

ologists, but was not at all clear to the

coders. A review of various reference

materials indicated the following

options for which the corresponding

anesthesia basic values are indicated.

Another physician reported a pro-

cedure as “ACDF,” which was interpreted

as Anterior Diskectomy with fusion and

the coder selected CPT code 22554. A

review of a standard coder’s reference

indicated such a procedure does not

typically involve instrumentation. A

review of the surgical operative report,

however, clearly indicated the use of

plates and screws. This clarification

resulted in a base value of 13 instead of

10.

The bottom line is that the place-

ment or removal of plates, screws, rods,

cages or dowels during spine surgery

should be clearly noted together with

the level of the procedure. It is always a

good habit when providing anesthesia

for a procedure that is new to your

practice to confirm the best way to doc-

ument the surgery so that the coders

will be able to code it appropriately. For

ABC clients this is a standard part of the

service.

DOCUMENTINGSPINAL SURGERY

By Jody Locke,Vice PresidentAnesthesia Business Consultants, LLC

Thoracic Lumbar 8 units

Interbody Fusion

Transforaminal Lumbar 8 units

Interbody Fusion

Translaminar Instrumentation 13 unitswith Fusion


PROFESSIONAL EVENTS

DATE EVENT PLACE CONTACT INFO

Dec. 8-12, 2006 New York State Society of Anesthesiologists New York Marriott Marquis, www.nyssa-pga.orgPostgraduate Assembly in Anesthesiology New York, NY

Dec. 13, 2006 “Pain Managment 2007 Coding Update and Live Webcast and Audio Conference www.mgma.comCommon Coding Pitfalls to Avoid!” 2:00 p.m. to 3:30 p.m. ESTSpeaker: Linda Van Horn, MBA Sponsored by MGMA

Jan. 18, 2007 Anesthesia Coding Updates Live Webcast and Audio Conference www.mgma.comSpeaker: Debbie Farmer Sponsored by MGMA

Jan. 26-28, 2007 Arizona Society of Anesthesiologists Scottsdale Resort and Conference www.az-anes.orgAnnual Mtg. Center, Scottsdale, Arizona

Jan. 26-28, 2007 ASA Conference on Practice Management Pointe Hilton-Tapatio Cliffs Resort, www.asahq.orgPhoenix, AZ

Feb. 7-10, 2007 American Academy of Pain Medicine Ernest N. Morial Convention Center, www.painmed.orgAnnual Meeting New Orleans

March 8-11, 2007 Society of Pediatric Anesthesia Pointe Hilton Squaw Peak, www.pedsanesthesia.orgWinter Meeting Phoenix, Arizona

April 19-22, 2007 32nd Annual Regional Anesthesia The Westin Bayshore Hotel, www.asra.comMeeting and Workshops Vancouver, British Columbia, Canada

April 21-25, 2007 Society of Cardiovascular Anesthesiologists Palais des Congres de Montreal www.scahq.orgAnnual Meeting and Workshops Montreal, Quebec, Canada

April 26-28, 2007 AUA 54th Annual Meeting Sheraton Hotel and Towers, www.auahq.org/annualmtgChicago, IL

April 29-May 2,2007 MGMA AAA Annual Conference Sheraton Seattle Hotel & Towers, www.mgma.comSeattle, WA

May 16-19, 2007 Society of Obstetric Anesthesia and Perinatology Fairmont Banff Springs, www.soap.orgAnnual Meeting Alberta, Canada

May 31- Jun 3, 2007 CSA/UCSD Annual Meeting & Clinical Sheraton San Diego Hotel & Marina, www.csahq.orgAnesthesia Update San Diego, CA,

Sept. 28-30, 2007 South Carolina Society of Anesthesiologists Grove Park Inn, Asheville, www.scanesthesia.comAnnual Meeting North Carolina

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Anesthesia Business Consultants: Communique fall06

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