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I am 87 years old, with a problem of the prostate gland. Before I met Dr. Baum, I went to the bathroom every 30-60 minutes. After Dr. Baum's treatment on my prostate, I go only 5 times per day and only 1 time at night! You turned my life around. I am so very grateful!

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As we make the transition from fee-for-service to managed care there are several changes that are likely to occur with an almost predictable certainty. First there will be a trend towards capitation as the most common method of reimbursement. Second there will be more primary care physicians and fewer specialists. Third, doctors will need to see more patients in the same amount of time in order to maintain their incomes. Fourth, there will be more consolidation of physicians forming groups and integrated relationships. Also to be included in these predictions will be the presence of the practice audit from managed care organizations. You can be certain that this new era of health care will bring auditors into your practice to evaluate your practice on behalf of managed care plan's members.

Managed care plans have traditionally looked at three components when contracting with health care providers: scope of benefits, the provider's credentials, and premium costs. Now a fourth component, quality, will be considered. In order to assure quality, managed care plans will become increasingly interested in measuring our performance. This demand will come from those that are in the market to purchase health care, consumers, and those that already have contracted with us for our services. At the present time the driving force is cost--receiving the most services for the least expenditures of capital. Once managed care organizations drive the price so low that cost is no longer a marketing vehicle that providers can use to attract new plans, then accountability and high-quality service will be the distinguishing features. It is through the use of the practice audit that managed care plans will begin to evaluate accountability and quality of care that we provide our patients.

What the auditors will be checking?
The plan will begin by checking your office's accessibility and appearance. They will look to see that the facility is easily accessible and has clearly marked signage. They will check that your practice offers adequate parking facilities including handicapped parking and that your practice is handicapped accessible. When the auditor enters the office they will look for the cleanliness of the reception area and even the restrooms.

Next the auditors will evaluate the practice for safety. They will look for visible fire extinguishers and that they have an annual inspection certificate or stamp. A safe practice has smoke detectors, a fire alarm and a visible written evacuation plan with clearly marked exits. If your practice offers evening appointments, then adequate lighting of the parking lot, hallways and office will be checked.

The auditor will also evaluate various administrative services. This will include a review of the practice's appointment scheduling system. Questions that will be asked include "How long does it take for the patient to make a routine or follow up appointment?" (An acceptable interval is less than 30 days.) "How long for an urgent complaint? (Should be within 24 hours) How long for a non-urgent complaint?" (Within 7 days) Also included under the topic of administrative services are the method of triaging procedures for scheduling patients. Do you have in place a system for the receptionist or scheduler to evaluate which patients need to be seen immediately and which ones can be seen later. For example, a patient with hematuria or acute onset of testicular pain needs to be seen immediately. On the other hand a patient with incontinence or impotence can be seen on a non-urgent basis.

Auditors will inquire about after office hours calls and how they are recorded in the chart. For example, if a colleague is covering for you and makes a decision on your patient after hours or on weekends, is that information recorded in the patient's chart? You need to demonstrate that a system is in place to accomplish this.

The auditors will inquire about your staff, i.e., number of physicians, RNs, LVNs, physician assistants, receptionists, medical assistants, office manager and other office staff. Auditors will ask for records of the physicians continuing medical education and also what training and on-going education that the staff is receiving. They will examine your treatment areas recording the number of exam rooms, the presence of blood pressure cuffs, scales, disposable containers for biohazardous substances and needles and other sharp materials. They will check that each room contains gloves, sinks, water and soap.

The auditors will inquire about safety issues such as the presence of a crash cart in the office that has a check list that is periodically checked and a readily available source of oxygen. They will want to know if those individuals that have contact with patients have CPR training and certification.

For those that have a laboratory, the examiner will look for applicable state permits, evidence of daily calibration of lab equipment, and written procedures of obtaining and handling body fluids. (OSHA and CLIA standards). For those practices with on-site X-ray capability you will need to show state permits , posted radiation signs, and records of personal monitor badges and radiation measurements.

If your practice performs minor surgery, they will ask to see that consents are used for in-office procedures, that you have appropriate sterilization procedures, and that instruments are wrapped and dates.

Next will be the assessment of the office medications and samples. They will want to verify that all drugs are inaccessible to patients and that controlled drugs are kept in a locked cabinet. If you have narcotics in the office, you will have demonstrate that you use written control procedures that record the use of these controlled substances. The auditors will also check to see that you have a system for checking and disposing of expired medications.

Finally and probably one of the most important areas that will be evaluated will be the medical records. They will observe your office and practice style to be certain that the records are protected from public access and are secure from fire and theft. Several managed care member's records will be reviewed. (The auditors must have a signed release from the patients before they are legally allowed to look at a plan member's chart.) They will check a few charts to be certain that each page contains the patient name or identifying number, the date the patient was seen and that the records are legible. They will also evaluate that each record or document has been seen and interpreted by a physician before it is filed in the chart. Charts will be checked that missed or no-show appointments are recorded in the chart. The auditors will want to know if you have a policy for scheduling an appointment for patients whop have missed several appointments.

Before and after the auditor visits your practice
Those practices that take a proactive position regarding managed care audits will be those in the best position to pass the examination. I suggest you prepare a check list of those areas that are likely to be examined during an audit. If you identify areas that are deficient or absent, make the appropriate changes before the auditor arrives. After the auditor evaluates your practice, take corrective action on the deficiencies or on the suggestions and contact the managed care plan and notify them of your actions.

Managed care is resulting in rapid changes in the way we practice our profession. One of these changes will be the presence of the auditors checking the details of our office practice. Those that are prepared and are proactive about the audit will have no problems in passing this test.