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Medical Group Practice Policies and Procedures for Efficient
Operation - 2010 Update

Description:    477-page toolbox of ‘how-to’ policies and procedures for the efficient management of medical
                groups and other providers. Improve productivity, day to day medical practice management. Pay
                for Performance measures. Resources include a ‘how-to’ chapter on ‘concierge’ or retainer
                practices. Forms and other tools. Web sites. Authoritative references. Updated annually.

                A ‘how-to’ manual of creative, cost-effective, quality-driven policies and procedures for the efficient
                management of medical group practices and other health care provider offices. Improve
                productivity, day-to-day medical practice management procedures including infection control,
                medical record and consent policies and procedures. Designed for modification to adapt to local
                practices and contract terms. Numerous forms, examples and other helpful tools. Resources include
                example materials to establish and measure practice metrics including physician staffing (by
                population) and office staff (by physician) requirements, develop a 'concierge' or retainer practice;
                hospitalist programs, compensation strategies, health law, disability evaluations, HIPAA, meet site
                visit standards by accrediting bodies, and web links.

                These representative guidelines, policies and benefit interpretations are not intended to be
                construed or to serve as a certification and/or contractual agreement for payment or as a standard
                of medical care. Standards of medical care are determined on the basis of all of the facts and
                circumstances involved in an individual case and are subject to change as scientific knowledge and
                technology advance and patterns evolve.

                Guidelines are designed to assist medical care professionals by providing a framework for
                evaluation and treatment and are not intended to either replace professional judgment or to
                establish a protocol for all patients with a particular condition. These guidelines are not intended as
                a sole source of guidance. Rather, each is designed to assist clinicians by providing an evidence-
                based framework for decision-making strategies. Guidelines are not intended to replace clinical
                judgment or establish a protocol for all individuals and may not provide the only appropriate
                approach to diagnosing and managing a problem.

                Each payer will have specific limitations and exclusions in the member’s certificate of coverage that
                may vary from one contract to another. It is important to verify the current specific applicable
                benefits for any individual with the payer. Unless indicated otherwise, policies apply to all fully
                insured HMO, POS and PPO plans and to all other plans, unless a specific limitation or exception
                exists. Unless otherwise specifically excluded, Federal mandates will apply to all plans. With respect
                to Medicare and Medicaid members, policies will apply unless Medicare and Medicaid policies extend
                coverage beyond that in these example benefit interpretations.

                This manual is a toolbox of medical management policies and procedures provides a model
                structure for an efficient, physician-directed, medical care organization committed to cost effective,
                high quality care that will meet medical office accreditation and related standards. This manual has
                been developed to assist medical groups and hospitals in the implementation of successful medical
                management programs, particularly in relation to the delivery of outpatient managed health care
                services under ‘at risk’ health plan contracts. Unlike some other manuals, it cannot be taken ‘as is’
                and distributed with minimal explanation. Instead, it is a model format for a Provider’s Manual to
                be tailored for use by each medical organization. Not all policies and procedures will be applicable
                to any given provider’s office. The process of evaluating each P & P for applicability to a given office
                will lead to improved strategies for the delivery of care to both the fee for service and managed
                care environments of care. The effort to improve the cost-effectiveness and the quality of
                ambulatory care has only just started with the purchase of this manual.

Contents:       List of Contents

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

- 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; Physician compensation; Pay for
Performance (P4P); Primary Physician; Job Description and Work Standards - policy & procedure;
Mentor Policy; 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);

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;

 Address for All Adult Patients and Visitors; Chaperone in Exam Room for Pelvic Exams; Messages;; 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; 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;

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 ; References and resources for Office Management

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

- 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

- 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 – 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

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