Medical Group Practice: Policies and Procedures

A 467 page resource of policies and procedures for medical groups and outpatient medical or surgical services staff to facilitate the delivery of  high quality cost-effective care and to assist in meeting health plan and regulatory requirements.

List of Contents  

¨       Introduction to the Manual; Policy on Policies; Medical organization P & P for a Provider Manual; Annual policy    review memo format

¨       The Provider’s Toolbox – Your Medical Organization’s Core Information insert section for – Introduction and welcome; History – our origins and evolution; Mission and vision statements; Organization chart; List of staff providers/office locations; List of contracted providers; in-network; Administrative and Medical Committees; Communication Resource List [Translation; vision/hearing impaired assists]; Managed Care Contracts list with contact person and phone #

¨       Credentialing Tools – Credentialing introduction; P & P; High risk providers; Provider sanctions

¨       Peer:Peer Evaluations – Evaluation forms for physicians in same and other specialty areas.

¨       Privileges – Introduction; forms

¨       Ambulatory Care/Medical Office Site/Survey Visit criteria – P & P; extensive detailed survey standards check list; Authorization and release form for medical office site visits

¨       Peer Review – Peer Review Plan; Professional Affairs Committee; Confidentiality Agreements; Peer Review Severity Levels/Point System; Peer Review References and Resources

¨       Education and Training – Physician and Staff Education; Seminar/Conference Request Form; New Employee Orientation – Medical Offices; Patient Education pathway example; Prevention and Counseling – Examples; Health Education; Minimum Standards; PacifiCare of California

¨       Medical Practice Management Tools – Physician employment contract issues - non-compete clauses or restrictive covenants; The Minnesota model; The solo medical practice model; Physician compensation; Pay for Performance (P4P); Primary Physician; Job Description and Work Standards - policy & procedure; Mentor Policy; Home and work site physician services; Computer order entry; Computers in exam rooms; 

        Telemedicine/ 'Virtual Medicine' programs;  Primary Physician Coordinated Care Policy; Operational Measures to Track/Evaluate Group Practice Performance; Letters of Condolence; Office Visits, Primary Physician, by Diagnosis; Physician staffing requirements (by population served); Physician recruitment policy and procedures; Coverage for physician absences;

Common Obstacles to Effective Medical Group Performance; Office staffing requirements; Admitting Physician(s) for Acute Hospital Services; MGMA medical group "best performer" characteristics; (‘Hospitalist’); Physician Extender Standards; Fraud & Abuse Issues for Ambulatory Surgery Centers (ASC) ; Physician Retention - benchmarks and strategies; Medical practice ‘split-ups’ - considerations; Professional dress to meet patient expectations; 

Provider Profiles - P & P;  Case mix adjustment for provider profiles;; Feedback; Steps to improve productivity, resource management, physician/patient satisfaction ; Ambulatory encounter/visit benchmark data.

¨       Medical Records – General Policies and Procedures for Medical Records; Medical Record Documentation Standards; Medical Record Log - example; Release of Medical Record Information; Psychotherapy notes; Confidentiality Issues; Authorization to Transfer Medical Records; formats; Affidavit to accompany medical records; Staff signature/initials sheet; Making changes to a medical record; Medical Record Documentation Standards; Affidavit to accompany medical records; Patient rights to copy records; Confidential Fax Transmission Format; Unsolicited test results, P & P, example letter formats;  Notification letter to patients regarding test results of possible concern; Electronic Medical Records; Medical Records Retention Policy; Online Medical Records; Medical Records Storage – Security Requirements; References and Resources, Medical Records and Coding Web Site Resources

¨       Consents for Treatments – Informed consent policy; Development process for consent forms; Brochure for patients; Procedures requiring informed consent; Procedures for obtaining informed consent; Procedure consent form; Refusal of treatment form, AMA Policy and Procedure; HIV testing; consent and payment procedures; Interpreter's statement; Consent for immunizations; Consent for photography during a surgical procedure; General Consent for surgery; anesthetics and other medical services formats; Consent for sterilization form; Consent for Oral Contraceptives (the pill); Prostate Needle Biopsy consent form; Rubber band ligation; hemorrhoids; Telemedicine consent form; DNR/withholding of treatment order form; Gastroscopy form; PEG consent

¨       Office Services Management Toolbox – Office Services Management; Patient-centered care model; Brand Name Identify/Welcome Letter; PacifiCare Welcoming Letter; Welcome calls; HIPAA summary, HIPAA web sites, HIPAA checklist; Sign-in sheets;  

 Access for Non-emergency Care; Group visits; Access to Care and Access Time for Appointment Standards; Auditing access times; Wait Times Policy; After Hours Services; ‘On Call’ Policy and Procedure; Frequent callers: a high risk group for utilization of care; Telephone log; ‘Walk-in’ Patient Triage;  Time Allocation for Routine Primary Care Visits;

        Address for All Adult Patients and Visitors; Chaperone in Exam Room for Pelvic Exams; Messages; MDHub.com; Communication with Hearing Impaired Patients; Communication with Patients and Visitors – Limited English Proficiency; Transport of Patients to Area Hospitals; Admitting Process: Office to Hospital; Vital Signs and Weights; Ambulatory/Office-based Surgery;

        Telephone Access and ‘Hold’ Time; Telephone Calls from Patients; Smoke-free Environment Policy; Appointment Scheduling Policy; Missed or ‘No Show’ Appointment Policy; Reschedule Notification Letter format; Appeal process for missed appointment charge;

Patient Registration; Registration Form; Payment policy and Assignment of Benefits,  Acknowledgment form; Insurance payment (or nonpayment) release agreement form; Handout for Medicare Patients (re: nonparticipating provider); Waiver of liability/Financial Responsibility statement, general, form; Waiver of liability for Medicare statement, form; Collection policy; Lien attachment form; References for former employees; Shred for confidentiality; Locum tenens physicians - billing; credit cards;

Patient Rights and Responsibilities; Advanced Directives; ‘Living Will’ Declaration; example; Physician Request for Transfer of Care; Discharge of terminated patients presenting for medical care, P&P; Nursing Services policies and procedures; Billing for 'Incident to' Services; Billing for ‘Concurrent’ Inpatient Services;  Outpatient surgery instruction sheet; Document retention – P & P; Median number of ambulatory encounters per physician, by specialty; Major reasons for outpatient visits, all US , 2000; Medical Practice Web Site – an essential tool; Medical Management/Practice Web Sites ; Scribes – Non-physicians acting as scribes for physicians; References and resources for Office Management

Unsnarling Patient's Medical Bills

Emergency Care Overview; Emergency Care Committee; ACLS Certification; Emergency ‘On-site’ Triage Policy; Emergency Telephone Triage; Office Emergency/Code Blue Policy and Procedure; Code Blue; Evaluation of Code Blue Response; ‘Stat Nurse’ Call; Electrocardiograms; Physical Abuse Policy;

Emergency Equipment; Adult Crash Cart: Required Content List; Crash Cart/Defibrillator Check List; Urgent Care Flow Algorithm; Specialty Referral by UCC Physician Algorithm; Priority Care Appointment following UCC Visit; UCC Patient; Disposition Algorithm; Pre-Admission Function/ER Algorithm; 

¨       Office Pharmaceutical/DME Policies and Procedures –  Introduction; P & T Committee; Formulary; Drug Samples; Procedure for Stock Drugs; Procedure for Samples; Distribution and Storage of Schedule II Drugs; Outdated Drug Inspection and Removal; Orders for Medications; Tests and Treatments; Pharmaceutical Standards; Controlled Substance Reorder/Refill Guidelines; Referral to UCC for Parenteral Medication Administration; Administration of Injection; Ordering Provider not Present; Treatment of Mild Reaction to Any Substance; Treatment of Anaphylaxis; Preparation and Administration of Antineoplastic Agents; Mandatory Therapeutic Substitution Example; Altered/falsified Prescriptions P & P; Peak Expiratory Flow Meters - to monitor asthma care at home; Tamper-Resistant Prescription Policy for Medicaid;

¨       Risk Management and Safety – Risk Management; Safety and Infection Control: Master Policy; Facilities and Environment; policy; CPR Training Policy example; Tracking Significant Abnormal Diagnostic Results; Facility Disaster Plans; Bomb Threat Emergency; Earthquake Safety; Electrical Emergency; Fire Emergencies; Fire Safety; Risk Manager/Patient Relations Manager Responsibility Policy; Safety Standards Policy; Customer concern form

¨       Infection Control – Infection Control Committee; Exposure Control Plan; Universal Precautions; Training program with exam; Infection Control Policy – Ambulatory Care; Bloodborne Pathogens; Universal precautions; Infection control records, form; Infection control personnel policy; In-service acknowledgement form; Designation of Clean and Not-Clean/‘Dirty’ Patient Care Items & Equipment; Air Decontamination; Dirty-Clean Work Flow Policy; Refrigerator: Maintenance/Monitoring Policy; Linen: Handling; Storage; Transportation and Processing; Soap/Lotion Containers; Cleaning Examination Rooms; Cleaning toys; Handwashing; Biohazard Medical Waste Management; Waste Management: Authority and Responsibility; Enforcement of the Waste Management Plan; Decontamination; Disinfection and Sterilization of Equipment; High Level Disinfection Policy; Glutaraldehyde Potency Testing Policy; Autoclave Sterilization Policy; Autoclave: Biological Monitoring; Cleaning and Servicing; Autoclave Recall and Outdate Procedures; Storage of Sterile Supplies; 

Communicable Disease: Managing Known or Suspected Patients; HIV: Post-Exposure Evaluation; HIV: Testing/Release of Information; HIV Test: Information and consent form; Authorization: release of information related to HIV testing; Communicable Disease: Reporting; Hepatitis B Vaccine Declination forma; Hepatitis B Vaccination: Post-exposure Evaluation; Hepatitis B: Informational pamphlet; Hepatitis B Vaccine: Informed Consent Form; Tuberculosis Control Plan; Creutzfeldt-Jackob Disease (CJD)/v CJD with other Transmissible Spongiform Encelphalopathies; Skin disinfection to prevent catheter-related blood-stream infection; Screening for Methicillin Resistant Staph Aureus (MRSA); VRSA (Vancomycin Resistant Staphylococcus Aureus); VRSE (Vancomycin Resistant Staphylococcus Epidermidis); VISA (Vancomycin Intermediate Staphylococcus Aureus); VISE (Vancomycin Intermediate Staphylococcus Epidermidis); Vancomycin Resistant Enterococcus (VRE) Detection; Reuse of Disposable Items – Policy; Blood borne pathogens – exposure determination record; Animal guests in the medical environment; Infection Control: References and Resources

¨       Quality Improvement Toolbox – Patient Satisfaction Surveys (Service Evaluation - forms to use); Risk Management/Patient Relations Policy; Ethics Manual - link; Health care apologies/Medical error admissions; Skilled vs. Custodial (non-skilled) Levels of Care Services; Custodial Level of Care: Informational Hand-out sheet; Home Health Referral Procedures; Mammogram follow-up tool; Clinical Performance Measures, ‘Pay for Performance’ and Gain-sharing programs; Physicians Office Quality Improvement Tool Kit; Sentinel events reporting - P&P; Quality-related web sites; Quality references and resources; Norton Healthcare Physician Office Quality Monitor.

¨       Case Management – Introduction; CM policy; CM: SNF; CM: Home Health and Hospice Services; Discharge Planning – policy and procedure; Homebound program; High risk screens; New patient screens: Indicators; trigger; action; CM Outcome Measures; High risk case detection; Congestive heart failure CM; Hospital Director; CM Services; position description; Case Manager; position description; Discharge Planner; position description; Screening case manager candidates; Case Management duties; CM References and other resources.

¨       Utilization Management/’Back Office’ Toolbox – Major challenges for UM cost control; Medicare is targeting costly physicians; Capitation fundamentals; Benefit and eligibility determination verification; Financial Responsibility Guarantee Form; Eligibility FAQs; Waiver of Co-payments P & P; Appeal of Denial Policy; Grievance Tracking P&P; Authorization approval notification form; Authorization denial notification form; Outpatient Surgical Procedures Authorization; Transitional Care Center Policy; Diagnostic Referrals; streamlined process; Diagnostic radiology referral form for streamlined process; Authorization of special services; Submission of encounter data and claims; Coordination of benefits; Third party liability; Sanctions and Fines – Utilization Management; UM Committee Meeting Attendance Requirements; Quarterly Primary Physician Dinner Meeting Attendance Requirement; Specialty Pre-Admission Authorization; Primary Physician Notification; Utilization check lists; Common reasons for denials; Appeals process and procedure; Provider Sanctions and Fines: QI Committee; Fine Notification Form; The Hippocratic Oath

¨       Concierge or Retainer Practices - Introduction, financial models; History; State insurance regulators; Ethical guidelines, (AMA); Considerations before launching a retainer practice; Processes necessary to establish a retainer practice; Core issues in a retainer agreement or contract ; Guests, relatives and friends; Example letters to patients; Example letter to professional colleagues; Brochure example.

      ¨       Financial Management Benchmarks - Medical Practice Administrative Costs 

¨   References, Resources, Links – inserted throughout the manual following most sections.

¨  Appendices - Business/Clinical medical records retention guidelines; Health-law links; OIG alert; Provider alert – Physician involvement in diagnostic clinics; Disability certifications;.  

E-mail apollomanagedcare@cox.net to request example pages from the preceding 'Contents List' that are of particular interest to you or your organization.

 Medical Group Practice Policies and Procedures is a 465 page loose-leaf manual accompanied by the entire contents on CD. The price is $275.00 plus $15.00 shipping and handling. Checks, Visa and MasterCard are accepted for payment. 

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