diabetes practice options, march 2012

OPTIONSDIABETES PRACTICE

™

Improving Patient Care Through Increased Practice Efficiency

Visit www.DiabetesOptions.net to view our digital edition and for more practice options information.

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The Physicians' Foundation

www.physiciansfoundation.org

MARCH 2012

EDITORIAL

3 | DIABETES STRATEGYDiabetes Dashboard Improves Physician Efficiency and Accuracy

6 | CODING UPDATEInstitute a Compliance Plan Now to Avoid Future Coding Audits

11 | INNOVATIONSVirtual Doctor Visits Save Patients Time, Earn Clinicians Extra Income

14 | BILLINGHow to Combat the High Cost of Alienating a Patient

19 | PRACTICE MANAGEMENT NEWSMedicare Proposes New Steps to Reclaim Overpayments

Ibelong to a popular online physician-only networking site (Sermo; www.sermo.com)and was intrigued by the headline about a fellow pediatrician’s spouse. The physicianposting this amusing notion went on to write, “This must happen to many of you. A

friend asks medical advice and your spouse answers for you.” More than 20 physiciansresponded, acknowledging that this happens to them as well.Over the past 40+ years, my wife has shifted from providing pediatric advice to dealing

with the ailments of aging friends and family members. I often listen in amazement as sheadvises her worried friends on the phone about the management of their latest ailments. The pediatrician writing the post on Sermo implied that his wife is perhaps providing a

valuable service. “But the thing is, she’s right!” he wrote. “And cause she’s a mom, she’s farmore empathetic than I am. So she is doing my job better.” After some thought, I decided

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CONTRIBUTORS

David Morrissey

Teri Gatchel, MBA, CPC

Physicians’ Spouses’ Medical Advice Sheds Light on the Benefits of EmpathyBy Michael Bihari, MD, contributing editor

Page 3

IN THIS ISSUE

Neil Baum, MDUrologistNew Orleans

Daniel BeckhamPresidentThe Beckham Co.Bluffton, S.C.Physician and Hospital ConsultantsWhitefish Bay, Wis.

Harold B. Kaiser, MDAllergy & Asthma Specialists, PAMinneapolis

Nathan KaufmanPresidentThe Kaufman GroupDivision of Superior Consultant Co. Inc.Physician and Hospital ConsultantsSan Diego

Peter R. Kongstvedt, MDP.R. Kongstvedt, LLCMcLean, Va.

John W. McDanielPresident and CEO Peak Performance Physicians, LLCNew Orleans

Lee Newcomer, MD, MHASenior Vice President, Oncology UnitedHealthcareMinneapolis

James M. Schibanoff, MDEditor in chiefMilliman Care GuidelinesMilliman USASan Diego

Jacque Sokolov, MDChairmanSokolov, Sokolov, BurgessScottsdale, Ariz.

This newsletter is published by Premier Healthcare Resource, Inc., Morristown, N.J.

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EditorRev DiCerto845/[email protected]

Art DirectorMeridith Feldman

PublisherPremier Healthcare Resource, Inc.150 Washington St.Morristown, NJ 07960973/682-9003; Fax: 973/682-9077 [email protected]

EDITORIAL

EDITORIAL BOARD

to listen more carefully to the content of mywife’s medical interactions with friends. Itturns out that she never diagnoses or recom-mends treatment but listens, provides com-fort, and suggests ways for her friends to findsupport in the community. Most importantand appropriate, she urges people who areconcerned about their health problems tospeak with their physician and to be wellinformed health consumers. I learned during this process that our

friends and acquaintances view my wife as

the “go-to” person when they are troubledand need someone who will listen and pro-vide appropriate advice. As one physician onSermo said, “Maybe we should make themhonorary lay providers.”Perhaps my wife is on to something. In an

article published in the March 2011 issue ofAcademic Medicine, “Physicians’ Empathyand Clinical Outcomes for DiabeticPatients,” the authors tested the hypothesisthat a physician’s empathy is associated withpositive clinical outcomes for diabeticpatients. The authors documented that the“patients of physicians with high empathyscores were significantly more likely to havegood control of hemoglobin A1c (56%) thanwere patients of physicians with low empa-thy scores (40%; P < .001).”The next time my blood sugar is high I will

call my wife instead of my primary carephysician. In this case my wife will not beempathetic but threaten me with a lock onour refrigerator! �

STAFF

Continued from page 1

2 Practice Options/March 2012

More information is available atwww.DiabetesOptions.net

Michael Bihari, MD

Many physician practices haveadopted electronic medicalrecords (EMRs) to improve

care quality and practice efficiency.Unfortunately, they often find theseEMRs to be more frustrating than help-ful. “As data repositories, EMRs amassa large amount of information, theoret-ically allowing us to retrieve any datapoint we need in seconds,” says RichelleJ. Koopman, MD, MS, a practicingphysician and associate professor offamily and community medicine in theUniversity of Missouri’s School ofMedicine. “But too often, EMRs are notpractical point-of-care tools. ManyEMRs are poorly organized, and thedata points we need to evaluate whentreating a particular condition areburied in the record. Physicians oftenexpend considerable effort to retrieveall the facts they need from the EMR.”This problem can be especially acute

in the care of diabetes, a complicateddisorder that requires evaluation ofmultiple indicators. “Physicians mayhave to look in one location for labora-tory values, another for vital signs, athird for a medication list, and then siftthrough notes for smoking status andthe dates of the last foot and eye exam-inations,” says Koopman. “Physicians

will either spend valuable visit timefinding all this necessary information,or will give up and not have full infor-mation upon which to base treatmentdecisions at the time of the visit.”

Aggregating DataKoopman and colleagues at theUniversity of Missouri believed if theycould gather all pertinent diabetespatient information on one screen, theywould improve their EMR’s usability asa patient care tool. “Instead of spendingtime looking for data, physicians wantto use our limited visit time to considermore complex issues and talk to thepatient,” she says. “We knew if we couldshave a few minutes of data search timeoff of each 15-minute visit while alsoimproving the accuracy of informationretrieval, we could score a big win forboth physicians and patients.” Working with the university’s EMR

vendor, Cerner Corporation of KansasCity, Mo., the physicians developed asummary called the “diabetes dash-board” that allows providers to view allrelevant diabetes indicators on a singlecomputer screen. Red dots indicateunmet quality measures, promptingphysicians to address gaps in care. A recent study led by Koopman

found that physicians using the dash-board were able to correctly identifythe data they needed 100% of the time,compared with 94% when the EMRwas used without the dashboard. Inaddition, the number of mouse clicksneeded to retrieve the information fellfrom 60 clicks to three clicks with theuse of the dashboard, and the averagetime to find all indicators fell from 5.5minutes to 1.3 minutes. The results ofthe study were published in theSeptember/October 2011 issue of theAnnals of Family Medicine. The diabetes dashboard screen

includes a list of all patient diagnoses, alist of allergies, and a medication list.Dates and values are listed for relevantindicators including blood pressure,weight, body mass index, smoking sta-tus, potassium level, chromium level,urine microalbumin-creatinine level,glomerular filtration rate, HbA1c,HDL and LDL cholesterol levels, eyeexamination and foot examination. The dashboard also lists eight dia-

betes performance measures, includingannual HbA1c, HbA1c less than 9.0%,blood pressure less than 140/90mmHg, annual LDL cholesterol, LDLcholesterol less than 130 mg/dL, annu-al microalbumin, eye examination andfoot examination. These measures aremarked with a red dot if they are out ofrange or have not been performedwithin the accepted time period.

Facilitating CommunicationAdditional research would be neededto determine the clinical implicationsfor physician productivity, but theoret-ically the impact for physician efficien-cy and quality of care is positive. “Wehave a 15-minute visit, and if we aregoing to spend five minutes finding allthe needed information, we now haveonly 10 minutes to engage with thepatient,” says Koopman. “If we getthose minutes back, we can use themmore productively by discussing self-care or lifestyle changes such as dietand exercise, or we can consider theneed for more general preventive care

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Practice Options/March 2012 3

DIABETES STRATEGY

Diabetes Dashboard Improves Physician Efficiency and Accuracy

DIABETES STRATEGY

measures such as flu shots and mam-mograms. This time savings allows usto move on to other topics, making thevisit more productive.” Koopman says she uses the diabetes

dashboard every time shetreats a diabetes patient. “Ifind it very useful to havethis big-picture overviewthat I can grasp within aminute,” she says. “I canquickly understand thepatient’s health status andidentify what care elementsneed to be completed. ThenI print the dashboard andgive it to my patients, ensuring thatthey have documentation of their indi-cators to review at home. The dash-board serves as a tangible report thathelps them focus on their self-caregoals.”Sharing the dashboard with the

patient, either on paper or on a com-puter screen, is a good way to enfold itinto the workflow. “Many of us use thedashboard as a communication tool,”Koopman says. “We have 30-inch mon-

itors mounted on the walls of the exam-ination rooms, so patients are able toget involved with their own data. Themore strategies we can adopt to engagepatients in their health—particularlychronic disease patients who arerequired to self-manage their condi-

tion—the more likely it is that out-comes will improve.”Koopman and her colleagues do not

plan to study the impact of the dash-board on clinical outcomes, because

other diabetes care qualityinitiatives in the practicewould make it hard toattribute cause and effect.“However, all the diabetesindicators tracked on thedashboard are well accept-ed steps in care that havebeen proven to generatebetter clinical outcomes, soif we are improving the per-

centage of time that these interventionsoccur, we can assume that we are help-ing our patients.” Furthermore, inhealth systems with pay-for-perfor-mance programs or reporting mea-sures, a dashboard can help physiciansmore easily meet care benchmarks.



Physicians and graduate students from the InformationExperience Laboratory at the University of Missouri workedwith software developer Cerner Corporation, located in

Kansas City, Mo., using a process called user-centered design, todevelop and test a decision support tool called the “diabetesdashboard.” The design involved the use of a mobile usability lab,which recorded both the physicians and the screens they visitedusing specially designed software. “The software is designed tofacilitate the development of software applications in variousindustries, not just in medicine,” says Richelle J. Koopman, MD,MS, of the University of Missouri’s School of Medicine, who ledthe research effort.

Ten University of Missouri Health System family physicians andgeneral internal medicine physicians with outpatient practicestested the system. The physicians were asked to find and recordvalues for ten common diabetes care elements, including thedate and value of the patient’s last HbA1c level, the date andvalue of the last LDL cholesterol level, the value of the last bloodpressure reading, the value of the last urine microalbumin-crea-tinine ratio, dates of the last foot and eye examinations, smokingstatus, and daily use of aspirin. While the physicians searched forthese indicators in the electronic medical record (EMR), the soft-ware recorded how many clicks they made and how much time

they required to retrieve the data. At the same time, physicianswere asked to think aloud; a researcher recorded physicians’comments about their search experience and periodicallyprompted them with questions. The physicians testing the systemwere first asked to search through the EMR for the data as theynormally would; they next watched a 90-second video about howto access the dashboard and then used the dashboard to retrievethe same indicators.

“Most of the errors we recorded in EMR use were errors ofomission, meaning the physicians were not able to find certainindictors,” says Koopman. Nine out of 10 physicians said that thedate of last foot examination, date of last eye examination, andsmoking status were the most difficult elements to find, sincethey tended to be buried in clinic notes or appointment lists. “Thephysicians in the study probably spent a longer time looking forinformation than they normally would during a real patient visit,so we think the error rate in practice could actually be muchhigher.” Other errors involved incorrect recording of data values.Overall, use of the EMR without the dashboard resulted in a 94%accuracy rate; in contrast, the accuracy rate was 100% when thedashboard was used. In addition, use of the dashboard wasabout four minutes quicker.

—DJN

WITH USER-CENTERED DESIGN, UNIVERSITYMEDICAL STAFF HELPS CREATE DIABETES DASHBOARD

“Our surveys suggest that our physicians are a lot happier with the

EMR since we implemented this tool.”—Richelle J. Koopman, MD, MS,

University of Missouri School of Medicine


Physicians tend to resist decisionsupport tools that feel prescriptive tothem, but the diabetes dashboard issimply a reminder for them to do theright thing, observes Koopman. “Also,the dashboard is not intrusive.Physicians do not have to open thedashboard if they don’t want to use it.In contrast, [with other decision sup-port tools,] pop-ups may open at a timewhen they are not relevant toa clinical situation, or alter-natively, may not open whenwe need them. The trend indecision support involvesmaking a tool available, butnot forcing an intrusion onclinicians’ practice patterns.”

Physician SatisfactionWhen an EMR is introducedto a practice, physicians tendto grumble, Koopman states.“Physicians generally resistanything new because it will disrupttheir practice patterns,” she says. “WithEMR adoption, physicians need to betrained, and they are concerned aboutwhether the EMR will cause anincrease in their workload. However,the physicians who tested the dash-

board immediately asked how quicklyit could become available for ongoinguse. When we released this dashboard,our physicians said it was exactly whatthey needed. Our chief medical infor-mation officer said it was the best-received change to the EMR in itseight-year history.”Since the diabetes dashboard was

introduced, the University of Missouri

has added several features, including alink to a diabetes treatment algorithmand a second link that automaticallycalculates the patient’s Framinghamrisk score. Data from the dashboardcan now be directly imported into apatient’s progress note, following physi-

cians’ suggestions that this wouldimprove the quality and efficiency oftheir visit documentation. Followingthe success of the diabetes dashboard,summary dashboards have been devel-oped for other outpatient chronic con-ditions, including asthma, hyperten-sion, hyperlipidemia, heart failure, andchronic obstructive pulmonary disease,and inpatient dashboards are being

used in both the intensive careunit and the neonatal intensivecare unit. Post-study interviews, as

well as anecdotal reports fromusers, indicate that physiciansare highly satisfied with thetool. “Unfortunately, manyphysicians hate their practice’sEMR,” Koopman states.“Giving our physicians a rea-son to love our EMR is reallysignificant. Our surveys sug-gest that our physicians are a

lot happier with the EMR since weimplemented this tool. They feel likethey can meet care expectations moreeasily, and believe that they can providebetter quality care.” �—Reported and written by Deborah J.Neveleff, in North Potomac, Md.

“We knew if we could shave a few minutes of data search time off of

each 15-minute visit while alsoimproving the accuracy of informa-

tion retrieval, we could score a big win for both physicians

and patients,” Koopman says.

Diabetes is a particularly challenging disease because itinvolves tracking many indicators, affects several organ sys-tems, and is associated with frequent serious complica-

tions. “Summary data are particularly important in diabetes care.There is a lot to think about, and the stakes are high,” saysRichelle J. Koopman, MD, MS, associate professor of family andcommunity medicine in the University of Missouri School ofMedicine, which, in association with Kansas City, Mo.-basedCerner Corporation, helped to design a “diabetes dashboard”that aggregates relevant diabetes indicators from a practice’selectronic medical record onto a single screen. “Not only are wetracking multiple indicators, but each is associated with a differ-ent interval for completion. Blood pressure should be taken atevery visit, the foot examination should be performed at leastyearly, HbA1c should be checked every three to six months

depending on control, and cholesterol should be checked annual-ly. It can be difficult to track all these indicators. Because diabetesis such a complex disease, it is one of the conditions that isaddressed most frequently by developers of decision supporttools.”

“We asked the physicians what they would normally do if theycould not locate an indicator in the chart,” says Koopman. “Theysaid they might ask the patient for the information; but, of course,this information might be of questionable accuracy. If they couldnot locate a laboratory value, they indicated that they would justreorder the test, which obviously results in a delay in care andincurs unnecessary costs. For other care elements, like the footexamination, they might just ignore it and plan to address it at thenext visit.”

—DJN

PHYSICIAN: DECISION SUPPORT MAY ELIMINATE SKIPPED, REPEATED TESTS FOR DIABETES PATIENTS

Over the past decade, theCenters for Medicare &Medicaid Services (CMS) have

invested millions of dollars to increaseaudit enforcement efforts in an attemptto ensure that medical providers willadhere to their rules and regulations.The Patient Protection and AffordableCare Act, which was signed into law onMarch 23, 2010, includes conditions forprovider enrollment into Medicare,Medicaid, or the Children’s HealthInsurance Program (CHIP). The law

also requires health care providers tomaintain a coding and billing compli-ance program. On January 1, 2012,CMS announced its intention to fundadditional projects to further reduceimproper payments and eliminatefraud, waste, and abuse. In a technology-driven environment,

most providers submit Medicare andMedicaid claims electronically, exposingtheir information at record speed to amuch higher level of scrutiny and anincreased expectation that claims arereported accurately. CMS enlistsMedicare administrative contractors,recovery audit contractors, zone pro-gram integrity contractors, Medicaidintegrity contractors, comprehensiveerror rate testing professionals, theDepartment of Justice, and the FBI,along with a host of other enforcementagencies, to recover government spend-ing. Because of the increasing number ofgovernment contractors aggressivelytrying to identify Medicare andMedicaid overpayments and fraudulentclaims, providers can no longer flyunder the radar when it comes to claimssubmission; when information is inac-curately reported, it becomes highlyprobable that the provider will be sub-jected to an audit.

Reducing Audit RiskProviders can arm themselves with aplan to reduce their risk of being audit-ed while practicing compliant billingactivities. First and foremost it is impor-tant that they take advantage of the pub-lished results from these governmentagencies. They should familiarize them-selves with the areas targeted by eachagency and incorporate procedures intotheir plans to avoid violations. Forexample, according to CMS’s CERTProgram, the top four reasons medicalproviders receive improper payment aremissing physician orders, illegible or

missing signatures, failure to meetnational or local policy requirements,and medical records that do not supportthe medical necessity of care that hasbeen provided to patients. Providers canuse this information to begin creatingthe first four procedures of their compli-ance plans. Doing so is critical to ensur-ing that they will be paid for their workand will ultimately help them to reducethe risk of undergoing an audit.A compliance plan provides structure

to help a provider prevent, detect, andcorrect wrongdoing. It is a provider’sfirst line of defense if erroneous billing isfound, enabling the provider to provethat reasonable efforts were taken toavoid fraud and abuse. Improved codingand documentation increase a practice’sreimbursement while supporting com-pliance and reducing the risk of its hav-ing to pay penalties.

Develop a PlanPractices need to gain a fundamentalunderstanding of the billing and report-ing requirements. The first thing a prac-tice developing a compliance planneeds to do is to identify a resource. In2000, the Office of the InspectorGeneral (OIG) encouraged practices todevelop a plan to support accurate cod-ing and billing activities. The OIG offersguidance through their “Seven BasicComponents of a VoluntaryCompliance Program.” The elementsrequired to develop and implement acompliance plan include: 1. Choose a compliance officer withinthe practice who has the authority tomake decisions, uses sound judg-ment, and is organized and wellrespected within the practice.

2. Prepare a standards of conduct state-ment describing how business is to beconducted within the practice.

3. Develop a written plan formalizingthe practice’s policies and procedures.

CODING UPDATEInstitute a Compliance Plan Now to Avoid Future Coding Audits

Teri Gatchel, MBA, CPC, is theRegional Director–Southwest, forAAPC Physician Services(www.aapcps.com). She has 20years of experience in health careas a practice administrator,national speaker, and consultant.She has worked with physicianpractices to enhance their finan-cial performance in both academ-ic and private practice settingsand has taught seminars on cod-ing and reimbursement for theAmerican Academy of Otolaryn-gology, the American Society forPlastic Surgery, American Aca-demy of Orthopaedics, and theAmerican College of Surgeons.

Continued on page 10


The policies must comply with feder-al and state regulations and mustinclude responsibility for reportingviolations. Specific procedures mustexist that address accurate codingand billing.

4. Establish a training program com-municating the practice’s compliantbilling and coding procedures andupdate the staff annually.

5. Screen new employees to safeguardagainst previous offenders. To avoidclaims of negligent hiring, practicesshould conduct background checksand use online resources to take extraprecautions when hiring. A list ofexcluded individuals and entities canbe found at http://exclusions.oig.hhs.gov/ and the U.S. GovernmentAccountability Office’s (GAO)debarred contractors list can beviewed at www.epls.gov/ epls/search.do?ssn=true.

6. Enforce the practice’s policies andprocedures and take disciplinaryaction for employees who fail to fol-low compliance procedures. Create areporting mechanism for perceivedproblems.

7. Conduct a baseline audit and moni-tor to ensure the practice’s proceduresare being followed to reduce the riskof receiving improper payment.

Self AuditingAn important part of any effective com-pliance plan is a documentation audit. Aself audit is where taking one steptoward compliance can move a practice

toward improved financial health.AAPC Physician Services audit reviewsindicate that physicians are under-cod-ing by approximately 15% and over-coding (or under-documenting)approximately 27% of submitted claims.For the average primary care physician,this degree of under-coding equates toover $23,000 per year in missed revenue.A simple chart review can help a prac-tice optimize its rightful reimbursementand identify areas for improved docu-mentation and coding. Results of suchreviews often highlight incorrect codingpatterns, introduce new opportunitiesfor reform, and offer compliant solu-tions to maximize reimbursement.The following checklist can assist

practices in conducting their documen-tation audits: • Create a timeline for the audit andinclude the frequency to performalong with the number of providers.

• Select an auditor. Whether you choosesomeone internal or seek outside assis-tance, consider the qualifications ofthe auditor carefully.

• Determine an area to target. For exam-ple, random, based on a sample mix of the codes reported most often; or focused, based on an identifiedproblem.

• Will the audit be prospective or retro-spective? A prospective audit requiresreviewing claims prior to submissionto ensure their accuracy before beingreleased, in comparison to a retrospec-tive audit of claims after submission.Identified errors should be communi-

cated and corrective action taken withthe carrier.

• Establish a margin of error goal. TheOIG allows a minimum of 95% accu-racy as a standard, allowing a 5% mar-gin of error.

• Identify your sample size. The OIGrecommends 10 cases per provider.One method of selection is to compareyour utilization to that of your peersand focus on the outliers.

• Analyze coding errors and identifystrengths and weaknesses to target foreducation and training.

• Use credible reference materials such asAmerican Medical Association (AMA)Current Procedural Terminology(CPT) guidelines, National CorrectCoding Initiative (NCCI) edits, CMSE/M documentation guidelines (1995or 1997), and National CoverageDetermination (NCD) and LocalCoverage Determination (LCD) poli-cies based on your location.

• Review CPT and ICD-9-CM alongwith modifiers.

• Record your findings and documentyour progress.CMS continues to invest time and

resources to reduce fraud, eliminatebilling errors, and improve education onbilling and coding issues. It is in the bestinterest of all providers and practices toimplement a compliance plan or, if oneis already in place, make sure it is up todate. Once a medical practice has imple-mented a plan of action, it will be on itsway to improved financial health and arisk-free new year. �


Numerous online resources exist to help practices maintaincoding and billing compliance with Centers for Medicare &Medicaid Services (CMS) regulations. Being aware of the

regulations and remaining compliant will reduce a practice’schances of being audited. Here are a few useful resources:• A notice from the Office of the Inspector General (OIG) delin-

eating the components of a successful compliance program canbe found at http://oig.hhs.gov/authorities/docs/physician.pdf.

• A listing of Medicare claim review programs, including MRs,

National Correct Coding Initiative (NCCI) edits, medically unlike-ly edits (MUEs), the Comprehensive Error Rate Testing (CERT)Program, and the Recovery Audit Program, can be accessed atwww.cms.gov/MLNProducts/downloads/MCRP_Booklet.pdf.

• A list of planned activities of the OIG can be found athttp://oig.hhs.gov/reports-and-publications/workplan/index.asp.

• A detailed article from the American Medical Association outlin-ing steps practices can take to improve their compliance can beaccessed at http://tinyurl.com/75557wv. —TG

ONLINE RESOURCES CAN HELP PRACTICES REMAIN COMPLIANT

CODING UPDATE



The traditional doctor visit is rifewith challenges and inefficien-cies, such as wasted time sched-

uling appointments, complicatedinsurance claims, lack of physiciantime, and limited access to care formany patients. A number of cliniciansare now experimenting with a poten-tially less expensive and less time-con-suming way to provide routine medicalcare: the virtual doctor visit.The virtual doctor visit is a type of

doctor-patient interaction in whichboth parties interact not in the doctor’sphysical office, but over the Internetusing technologies such as e-mail,instant messaging, and videoconfer-encing. Virtual visits are generally paidfor out-of-pocket by patients, althoughsome insurers are beginning to reim-burse for the service because theybelieve it is cost-effective and increasespatient satisfaction, according to anOctober 2007 article available on thewebsite for the American Associationof Family Physicians (www.aafp.org).Last year, New York became the

fourth state to provide virtual physicianvisits covered by BlueCross/BlueShield.“Physicians have been performing atype of virtual patient visit through e-mail for years; new virtual physicianvisits will provide them with somecompensation for their time,” notesCynthia A. Ambres, a chief medicalofficer for BlueCross/BlueShield, in aMarch 2010 Computerworld article(www.computerworld.com).

Online DiagnosesOne online platform through whichpatients can receive clinical services ina virtual setting is the dermatologyprovider Skin of Mine (www.skinofmine.com). The site utilizes a simple,four-step process:1. The patient takes a digital picture ofhis or her skin condition.

2. The patient uploads the photos tothe website along with an accompa-nying description of onset, symp-toms, and relevant medical history(prompted by the system).

3. Skin of Mine uses proprietary algo-rithms to provide a quantitativeanalysis of images of skin conditions.The algorithm has the ability to iden-tify particularly dangerous condi-tions and will refer the patient insuch cases to a dermatologist.

4. A Skin of Mine clinician analyzes thephoto and information.

5. The clinician provides the patient adiagnosis, including treatment rec-ommendations and prescriptions, ifnecessary. This system also allows patients to

track their progress. Patients with pso-riasis, for instance, can upload imagesto the server and follow a psoriasisalgorithm that will quantify their con-dition. Over time, they can see whethera lesion is responding to therapy orworsening. “The United States spends more than

$2 billion per year on skin cancer treat-ment,” says Sean Elwell, chief strategist

and project manager at Skin of Mine.“Preventive medicine that could detectpremalignant lesions before theymetastasize could potentially save dol-lars on expensive chemotherapy treat-ments as well as lives. Melanoma has a95% death rate if it metastasizes, and a95% survival rate if detected early—adramatic difference in outcome. A flex-ible, anytime-anywhere maintenanceprogram that could track the develop-ment of moles, for example, could beprofoundly beneficial.”Skin of Mine promises a response

within 24 hours, which is a great timesavings for the patient, who would nototherwise get a traditional appoint-ment in such a short time span. “Thenational average waiting time to see adermatologist is about six weeks, but itvaries greatly by region,” says Elwell.“In the Boston area, for instance, theaverage waiting time is more than threemonths. There’s no comparison to thetraditional system when it comes totime.”

Clinicians’ ExperienceBeth Panoff, a nurse practitioner in the

INNOVATIONSVirtual Doctor Visits Save Patients Time, Earn Clinicians Extra Income


Department of Anesthesia at StamfordHospital in Stamford, Conn., beganperforming online skin consultationsfor Skin of Mine in April 2011, and hasbeen using these consulta-tions to generate extraincome ever since.Consultation requests comedirectly to Panoff from Skinof Mine via e-mail. Panoffthen has a deadline of 24hours to log onto the portalwith her secure ID and pass-word, view the patient’s case, andrespond with her analysis and treat-ment recommendation. If she feels sheneeds more information, she canrequest it from the patient. Panoff isauthorized to prescribe medications inNew York and Connecticut, where sheis licensed, if it is necessary. “If a condi-tion required a prescription, I wouldsuggest that,” says Panoff. “But if I canrecommend something over the

counter that is mild and will do thetrick, then I wouldn’t jump to a pre-scription strength drug.”Since some medical problems

require an in-office consultation, or insome cases, a visit to the emergencydepartment, the clinician should beable to discern which conditions arereasonable to diagnose and treat in thevirtual setting and which are not, saysElwell. “The professionals must knowtheir limitations and refer when neces-sary,” he says.Diagnosis is aided by the Skin of

Mine protocol, which prompts patients

to provide medical information andupload a photo before the clinician iscontacted. “The photos are helpful; buta good medical history, which is

prompted by the Skin ofMine questions thepatients are required toanswer, is always valu-able,” says Panoff. “Thesystem is pretty thor-ough.”The service is discreet

and professional.Clinicians do not have access topatients’ personal contact informationor vice-versa. This separation is helpfulin establishing professional boundariesand preventing consultation requestsfrom becoming intrusive, Panoff says. Consultations typically take about

15-20 minutes of the clinician’s time,for which they are directly compensat-ed via PayPal, says Panoff. The ratepaid is competitive with what she


Family practice doctors are incorporat-ing this technology into their private

practices, and it has even been appliedwith success at the hospital level.

VIRTUAL VISITS ENABLE REIMBURSEMENT WITH LESS OVERHEAD, PHYSICIAN REPORTS

Incorporating virtual office visits in which a patient uploads adigital image of his or her medical complaint along with adescription and history onto a practice’s server into a primary

care practice allows physicians to achieve better outcomes forpatients and create a more satisfying and financially sound prac-tice, says Michelle Eads, MD. In an article in Family PracticeManagement, this Colorado-based family physician shares herexperiences with jumpstarting her virtual practice.

Eads started e-mailing with patients upon opening her solopractice. Patients initially paid $50 per year for this service. Theywere advised that e-mail may not be a completely secure meansof communication. After three years Eads updated her website tooffer a more secure system for virtual office visits.

The following year Eads began participating in a pilot projectwith Kaiser Permanente of Colorado Springs. Through the KaiserPermanente program she was reimbursed $50 per virtual officevisit, about 95% of the reimbursement for a 99213 CPT code inEads’s area. Since a physician can typically conduct a virtual visitwith fewer overhead costs and in a shorter time than is requiredfor a face-to-face visit, they are an effective way for a medicalpractice to increase its cash flow, Eads writes.

Upon initiation of a virtual office visit by a patient, Eads receivesan alert message in a designated e-mail inbox. “I then log into the

secure Web portal and find the patient’s virtual office visitrequest,” she writes. “I can also open any files the patient hasattached.

“I then determine whether I need to query the patient for moredetails (I do this infrequently), abort the virtual visit and request anin-office appointment instead (a rare occurrence), or complete thevirtual encounter (this happens the majority of the time),” Eadscontinues. She writes out a set of instructions for the patient,which she uploads and saves on the site for the patient to review.“I can then import the complete visit documentation into my elec-tronic health record (I could also print it for a paper chart, if need-ed),” she writes. “With a few key strokes, the prescription is elec-tronically sent to the pharmacy, and the patient or insurance com-pany is billed for the visit.”

A virtual office visit system can help to significantly streamlinephysicians’ workflow, Eads says. When engaging in a virtual visit,patients have the luxury of being able to take as much time as theyneed to complete the physician’s online questions regarding theirhistory and symptoms. “Yet the information is presented to thephysician in a concise, complete format that aids rapid diagnosisand treatment,” Eads concludes. The complete article can beaccessed for free at www.aafp.org/fpm/2007/1000/p20.html.

—SC

INNOVATIONS



would earn in the same period of timein an office environment, she says. Shewould strongly consider working solelyin the virtual venue if traffic increasedenough to make doing so financiallyviable, she reports.

Further ApplicationsFor clinicians who would pre-fer to incorporate Skin ofMine into their practicerather than participate in itseparately, a localized versionof the service is also available.This Android applicationallows clinicians to uploadtheir patients’ records and to respondflexibly to their queries, even afteroffice hours. Both health care profes-sionals and patients can use the appfrom anywhere. For example, a patientwho is on vacation and has a skin con-dition flare-up could be treated

remotely using the app, rather than cut-ting the vacation short or seeing a dif-ferent physician.“These virtual consultations have

been very positive for me,” Panoff says.“I’m excited to be part of this new era in

health care, and I think it’s great to beable to do this on the side in addition tomy nine-to-five job. I’m also helpingpeople who, due to lack of health insur-ance, wouldn’t otherwise make anappointment to get something minor—like acne or eczema—treated.”

Virtual doctor visits can be appliedto numerous specialties. The pediatricwebsite Ask Dr. Sears(www.askdrsears.com) now offers vir-tual office visits to parents across theUnited States. Family practice doctors

are incorporating this tech-nology into their private prac-tices, and it has even beenapplied with success at thehospital level. However, thevirtual visit may lend itselfparticularly well to dermatol-ogy for several reasons: der-matology diagnosis is per-formed largely visually, the

wait time for a dermatology appoint-ment is notoriously long, and earlydiagnosis of precancerous moles is crit-ical to increasing patient survival andreducing health care expenditures. �—Reported by Editor Rev DiCerto. Writtenby Stacy Clapp, in Orangeburg, N.Y.

Some insurers are beginning to reimburse for the service because they believe it is cost-effective and

increases patient satisfaction.

Recent studies show that treating patients through telemedi-cine, in which physicians use video, digital photography, andInternet technologies to examine patients and review their

symptoms and complaints, can be as effective as an in-office visit,and can improve doctor-patient communication. Studies publishedin 2011 in the journal PLoS ONE (http://tinyurl.com/6r3fpr5)assessed the Hospital Clinic of Barcelona’s Virtual Hospital,designed to remotely care for HIV-infected patients. Eighty-threeHIV-infected patients with access to a computer and broadbandInternet were randomized to be monitored either through VirtualHospital (arm I), which included virtual video-based consultations,telepharmacy, virtual library, and virtual community; or throughstandard care at the day hospital (arm II). After one year of followup, patients switched their care to the other arm.

Of the 87 patients studied, 85% felt that Virtual Hospitalimproved their access to clinical data. In addition, they reported ahigh comfort level with the videoconference system.

The study also showed that patients save time and money whenthey don’t need to travel to appointments and wait for visits andmedication. For health care professionals, the virtual hospital opti-mized time and space spent on consultations. Visit duration wasreduced from 20 minutes down to 10 minutes, allowing for moreconsultations. In addition, the program makes fast and directphysician-patient communication possible. More information

about this program can be found at http://tinyurl.com/6c2cowk. Another study, published in the Journal of Telemedicine and

Telecare, reported similar results. A total of 175 patients were ran-domized to one of two arms. In the first arm, the patients com-pleted a visit (virtual or face-to-face) with a physician; they thencompleted a second visit via the other modality with anotherphysician. In the second arm, patients had both types of visits withtwo different physicians.

Results showed that the feasibility and effectiveness of evalua-tions done through videoconferencing were similar to face-to-facevisits on most measures—including time spent with the physician,ease of interaction, and personal aspects of the interaction.“Videoconferencing between a provider and patients allows forthe evaluation of many issues that may not require an office visitand can be achieved in a shorter time,” notes Ronald F. Dixon, MD,the study’s principal investigator.

Based on these encouraging results, this virtual model is a“viable option in circumstances where patients need to be moni-tored routinely for chronic conditions like diabetes, hypertension,obesity, or depression, and where self-management strategies arenot working,” says Dixon. “Virtual visits may also be effective fortriage of acute, non-urgent issues like back pain or respiratoryinfections.” The abstract for the study can be viewed athttp://tinyurl.com/77vjejb. —SC

TELEMEDICINE CAN BE AS EFFECTIVE AS OFFICE VISITS, STUDIES SHOW


All physicians understand thatas health care costs rise,patients demand a higher level

of service. This expectation goesbeyond the bedside to include everyaspect of the patient encounter, fromcheck-in to final statement. Every indi-vidual involved in the patient experi-ence has an impact on satisfaction,from receptionists to medical staff. According to the 2010 Consumer

Impact Study from Waltham, Mass.-based Connace (http://connance.com/), the billing and collections

process is no exception to this rule.This survey of patients found a strongcorrelation between the billing and col-lections experience and a patient’s loyalty to a provider. In fact, when a patient found the billingand collections experience favorable,about 99% of the time they reportedbeing satisfied with the overall providerexperience.

Negative RepercussionsWhile a patient’s loyalty can be severelyaffected by a negative post-care experi-ence, what effect will that change inattitude have on a medical practice’sbottom line? Here are a few examples:

The lifetime value of a patient. Lossof a single patient’s lifetime householdhealth care expenditure is estimated tobe on average more than $1.5 millionfor hospitals and over $1 million forphysician-related expenses, accordingto statistics from the U.S. CensusBureau.

Malpractice suits. When it comes tomalpractice suits, it doesn’t matterwhether a physician wins, loses, or set-tles. Being sued by a patient is one ofthe most stressful and expensive situa-tions a hospital or physician can expe-rience. The risk of being involved in alawsuit raises from 0% for practices andhospitals with very good patient satis-faction ratings to 19% for those with avery poor rating. In more than 90% ofcases that go to trial, physicians arefound not to be negligent; yet morethan $110,000 per case is spent defend-ing those claims.

Lower reimbursement. Under theCenters for Medicare & MedicaidServices’ (CMS) value-based purchasingproposal, beginning in October 2012 asmuch as 1% of diagnosis-related group(DRG) Medicare payments will be atrisk for hospital providers with lowpatient satisfaction scores. These satis-

faction surveys will be conducted ran-domly with discharged patients, includ-ing patients who are too young toreceive Medicare coverage. According toCMS, more than 3,000 hospitals will beaffected, with potentially $850 million atstake. By 2017, this percentage is expect-ed to increase to 2%.

Word-of-mouth advertising. Dis-satisfied patients can do significantdamage to a provider’s reputation whendiscussing their experience with otherpotential patients. This damage canoccur whether or not a patient choosesto remain with their provider. The per-ception consumers have of service qual-ity plays a disproportionate role in theirchoice of provider. On average, cus-tomers are twice as likely to talk about a bad experience as they are to share a positive one, according to researchpresented in a 2009 white paper titled “Customer Satisfaction and the Success of Your Organization,” from Baltimore, Md.-based Carson Research Consulting. Inc. (www.carsonresearch.com). Conversely, patientswho are highly satisfied with theirproviders’ billing processes are morethan twice as likely to recommend thephysician to a friend and more than fivetimes as likely to recommend the hospi-tal, compared with those who are lessthan satisfied, according to the 2011Connance Consumer Impact Study.

Best PracticesFortunately for health care providers,there are a number of techniques thatcan be employed to help preserve posi-tive patient relationships while enhanc-ing the provider’s bottom line. Thetechniques include:

Train nonclinical staff members oncustomer service. Every service repre-sentative communicating with apatient must know what they should doto keep the patient satisfied, especially

BILLING How to Combat the High Cost of Alienating a PatientBy David G. Morrisey, director of development, KeyBridge Medical Revenue Management

David Morrissey, director ofdevelopment for KeyBridgeMedical Management (www.keybridgemed.com) of Lima, Oh.,has over 30 years of experiencein health care and managementtraining. He teaches seminarsand courses around the countryon effective communicationskills and the keys to motivation.He is a member of the MedicalGroup Management Association,the Healthcare FinancialManagement Association, andthe Michigan Association ofHealthcare Access Professionals.



those involved with the patient’smoney. The training should be aimed,from a patient-centered and patient-friendly perspective, at ensuring thatthe business end of the process meetsthe patient’s needs and expectations. Training for such nonclinical staff

should include education on whypatients expect and deserve more valueas out-of-pocket expenses increase;how each employee contributes to cus-tomer service and affects patient satis-faction and loyalty; the lifetime finan-cial value of a patient and the potentialcosts associated with patient dissatisfac-tion; and advanced patient communi-cation techniques for rev-enue cycle staff, includingrapport-building skills,how to avoid resistance,and influence and persua-sion skills.In addition, it is essen-

tial to train point-of-ser-vice staff on how to request paymentsfrom patients, since few people arecomfortable doing so. Many untrainedrepresentatives often resort to passiveinquiries like, “Would you like to payyour balance today?” Enquiries likethis enable the patient to simply answer“no,” or provide an excuse. Ideally, thebetter approach would involve the rep-resentative stating the balance and then

saying, “For your convenience we offer[list your payment options]. Howwould you like to take care of thistoday?” This is just one example of howmodifying everyday communicationtechniques can make a difference andmotivate patients to pay.

Examine all features of the billingprocess. At times, the billing processcan be lengthy and complex, creatingmore opportunities for patient dissatis-faction. Every aspect of the billingprocess should be reviewed regularly toensure patients receive clear, concise,and frequent communication about thepayment collection process.

The Westchester, Ill.-basedHealthcare Financial ManagementAssociation (HFMA; www.hfma.org)began the Patient Friendly BillingInitiative several years ago and is a greatresource for best practices. Useful infor-mation can be found at the group’s web-site by searching the phrase “patient-friendly billing.” Designed to ensurethat patients are made aware of their

financial responsibilities in a clear man-ner, HFMA’s initiative is based on a cen-tral theme: Communicate informationto patients in a manner that helps thepatient understand what their financialobligations are and the ways they canmeet those responsibilities, and thencome to an agreement with the patientabout how they will pay or otherwiseresolve the financial obligation.

Assess Outside ProvidersA commonly overlooked area is howpatient satisfaction is affected by out-sourced business process providers,particularly receivables management

and bad debt recovery part-ners. These companies directlyinteract with your patients andplay a critical role in their ulti-mate satisfaction. Here aresome tips for assessing out-sourced businesses and theirprocesses:

• Include questions about your out-sourced processes in your patient loy-alty surveys.

• Check your vendor’s rating and com-plaint history with the Better BusinessBureau (www.bbb.org/us) or contactyour state’s Attorney General’s officeto see if there are complaints aboutthe vendors you are using. Keep inmind that what you find may only be

Focusing on patient satisfaction fulfills the essential mission of health

care and makes business sense.

According to research performed by the American MedicalAssociation, health care providers have nine opportunitiesto educate their patients about their financial policies and

patient responsibilities. These opportunities should be used to con-dition patients to think that it is normal and expected to take careof their out-of-pocket expenses at the time of service rather thanto be billed for those responsibilities later.

Most of these education opportunities involve adding simplewritten communication at normal points of contact that a patientmay encounter during their experience with the provider. They are:1. Appointment scheduling2. Provider website

3. Welcome letter4. Insurance verification5. Appointment reminder6. Patient check-in7. Patient check-out8. Claim processing/patient invoice9. Appeal letter.

At each step, the payment policy, payment method options, andthe patient’s outstanding balances should be clearly stated. Doingso can mean the difference between a brisk cash flow for a prac-tice and a large stack of accounts receivable.

—DM

AMA: PRACTICES HAVE NINE OPPORTUNITIESTO EDUCATE PATIENTS ON FINANCIAL RESPONSIBILITIES



BILLING


BILLING

the tip of the iceberg. According tothe American Medical Association’spublication “The Case for MedicalLiability Reform,” only about 5% ofdissatisfied customers will lodge aformal complaint. That means thatfor every complaint that is filed, thereare 19 more patients who are just asdissatisfied but don’t think it is theirjob to tell you.

• Communicate the expectations youhave when it comes to treatingpatients with dignity and respect toyour outside vendors. If these expec-tations are not being met, it may betime to reevaluate the relationshipwith the vendor.Too often, providers select collection

methods and processes based uponmarket trends as opposed to whatworks best for them. No two providersare alike. Two hospitals, for example,may appear to have similar characteris-tics on the outside but may have differ-ent patient demographics, staff compe-tencies, account dispositions and infor-mation system capabilities. Each ofthese factors affects which collectionprocesses will work best for a particularinstitution.It is critical for providers to seek rev-

enue collection partners with moreexpertise in collecting patient paymentsthan their own staff. This expertiseshould include the ability to effectivelycommunicate with patients during thebilling process. Effective communica-tion can easily eliminate the majority ofissues that block providers from collect-ing what is owed in a timely fashion.Providers should look for partners

that have reputations for excellentcommunication, rapport-building andnegotiation skills, or the providers willbenefit only from cost reductions dueto economies of scale. Revenue collec-tion partners should be required to letthe providers listen to some actual con-versations between their personnel andpatients and judge for themselves ifthey are handling patients with the dig-nity and respect they deserve andexpect. The right partner will help apractice to preserve its reputation aswell as sustain patient relationships—and ultimately ensure future opportu-nities to provide health care services.The same goes for a practice’s tech-

nological and operations capabilities. Arevenue collections partner shouldhave technological and operations sys-tems that are designed for the specific

purposes they are contracted for, andshould use proven methods that pro-duce results that outweigh theprovider’s capabilities. These includebut are not limited to:• Advanced dialing technology• Call recording• Real-time payment acceptance• Online payment portals• Automated payment plan follow-up• Proactive charity care follow-up• Analytical tools for process improve-ment

• Real-time reporting capabilities.Focusing on patient satisfaction ful-

fills the essential mission of health careand makes business sense. There arecosts associated with dissatisfiedpatients that have the potential to bedisastrous given today’s shrinking mar-gins for health care providers.Nonclinical employees have a signifi-cant effect on the perceptions patientsform of a provider and their impactshould be measured. Nonclinical staff,especially those involved with the rev-enue cycle, should be made aware ofthe importance of their role and betrained accordingly in customer ser-vice, patient loyalty, and advancedcommunication skills. �

Any professional from any industry will say that satisfiedcustomers yield repeat business, while dissatisfied cus-tomers are more likely to not return—and may even influ-

ence other potential customers’ decision not to patronize thebusiness. Health care providers typically do a good job of mea-suring their patients’ levels of satisfaction at the bedside, butmost satisfaction surveys ignore the bookends of the patientexperience, scheduling and paying for services.

Patients should be surveyed after clinical services are providedabout the care they received as well as on the scheduling andregistration process. They should also be asked for their feedbackafter the final bill is paid. Surveys should be brief, no more thanthree to five questions, and should take place within two weeksafter payment is processed. Key questions to ask include:

• Were you provided information on your responsibilities to payand estimated costs?

• Was your bill easy to understand?• Did you find the methods offered to pay your bill convenient?• Was the accounts receivable staff easy to work with?• Did you find our financial counselors helpful?• If you worked with a third-party revenue collection provider,

were they friendly and easy to work with?• What are some ways that we could improve the billing

process?A complete picture of a practice’s patients’ level of satisfaction

will enable it to improve on areas in which it is deficient, increas-ing the likelihood that patients will continue to return for care.

—DM

RETAIN PATIENTS BY MEASURING SATISFACTIONDURING BUSINESS, CLINICAL PROCESSES


Medicare Proposes New Steps to Reclaim Overpayments

COURT APPROVES AWARD PAYMENTS IN OUT-OF-NETWORK PHYSICIAN CASE


The American Medical Association (AMA) in January unveiled aredesigned website for its Practice Management Center, fea-turing a new layout that is easier to navigate and faster to use.

The improved website offers physicians easy access to the AMA’swealth of resources, tools and guidance for enhancing the opera-tion of a medical practice, designed to help physicians streamlineadministrative and business issues so they can devote more time tocaring for patients.

The website’s three new sections feature popular topics in prac-tice operations, claims revenue cycle management and health

insurer relations. Easy to find tools and resources can support physi-cians selecting a practice management system, evaluating newbusiness models, establishing fees, negotiating managed care con-tracts and navigating health insurer rules and government regula-tions. It also makes available AMA whitepapers, policy positions,testimony to government bodies and other communications ontopics significant to physician practices.

The free site is available to AMA members and nonmembers.Visit www.ama-assn.org/go/pmc to explore the new PracticeManagement Center website.

AMA WEBSITE OFFERS NEW PRACTICE MANAGEMENT TOOLS

T he Centers for Medicare &Medicaid Services (CMS) onFebruary 14 proposed that

providers and suppliers must reportand return self-identified overpay-ments either within 60 days of theincorrect payment being identified, oron the date when a corresponding costreport is due—whichever is later. Thenew announcement is one in a series ofnew steps Medicare is taking, includingefforts to prevent overpayments fromoccurring. These efforts include lettingprivate auditors working on behalf ofMedicare stop overpayments beforethey occur by expanding the use ofRecovery Audit Contractors; testing

changes to outdated hospital billingsystems to help prevent overbilling;and changing processes for approvingpayments for medical equipment withhigh error rates.A Medicare overpayment means any

funds that a provider receives or retainsunder Medicare to which the provideris not entitled. Examples include:• Duplicate submission of the sameservice or claim;

• Payment to the incorrect payee;• Payment for excluded or medicallyunnecessary services; or

• Payment for noncovered services.Before the Affordable Care Act,

providers did not face an explicit dead-

line for returning Medicare overpay-ments. Under the Affordable Care Act,there will be a specific timeframe bywhich overpayments must be reportedand returned. Any failure to report andreturn the overpayment within theapplicable time frame could be a viola-tion of the False Claims Act. Providersalso could be subject to civil monetarypenalties or excluded from participat-ing in federal health care programs forfailure to report and return an overpay-ment.For more on efforts to limit overpay-

ments and fraud under the AffordableCare Act, visit www.cms.gov/apps/media/fact_sheets.asp.

Afederal court judge in February cleared the way for releas-ing payments in the 2009 settlement that ended the courtchallenge led by the American Medical Association (AMA)

against UnitedHealth Group. Nearly $200 million in awards will bepaid to settle claims from physicians for 15 years of artificially lowpayments from UnitedHealth for out-of-network health services.

During a decade-long fight led by the Litigation Center of theAMA and State Medical Societies, the AMA worked with orga-nized medicine, state regulators and U.S. senators to expose afundamental conflict of interest at UnitedHealth, which calledinto question the entire insurer-controlled system for paying out-

of-network medical bills. AMA brought evidence ofUnitedHealth’s improper business practices to the attention offormer New York Attorney General Andrew Cuomo in 2008, whoconfirmed the abuses with his own investigation.

“The AMA’s stand against UnitedHealth shows that when doc-tors join together and enlist the help of organized medicine, thebest outcome for patients and doctors can be achieved,” saidAMA President Peter W. Carmel, MD. Physicians can turn to theAMA’s newly updated Practice Management Center for addition-al information on the timing of settlement distribution and relat-ed resources.

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