Urgent Care Policies and Procedures: Think Before You Cave

As reality sets in that you are now the proud owner of an urgent care clinic and you’re down to the nuts and bolts of the operation—the urgent care policies and procedures—many owner operators begin to ponder what type of boss they want to be.

One of the hardest things about being an owner-operator is knowing how to balance good business decisions with being fair and considerate of the staff’s needs and wants. After all of the effort that goes into hiring and training, the last thing you want to do is a have high staff turnover due to things you deem easily adjusted; such as allowing staff flexible lunch periods or personalized floating schedules.

Many decisions may seem to have little impact initially, so we modify policies to accommodate the requests of our staff without proper thought or research into future operational or legal ramifications. Do you know how far your state laws allow you to bend the rules?

It is not always a matter of kindness on your end but more a function of what is dictated to you as an owner by state and federal regulations. So before deciding what type of manager you want to be and what policies you are willing to alter, learn more on where you state and federal employment boundaries lie.

By playing the nice guy’ boss, you may be in violation of employment laws without even realizing it. The U.S. Small Business Administration has recently published a report siting the most common ways employment laws are broken. Below is a quick glance at 5 ways the report determines owners may be breaking the law unknowingly.

1. Flexible lunch breaks
While federal law doesn’t require employees be given lunch or coffee breaks, certain states require that non-exempt employees get 30-minute lunch breaks, plus breaks for hours worked during the day. Laws even stipulate when the break must be given. In California, a meal break must be provided no later than the end of the employee’s fifth hour of work. So giving employees the option of skipping lunch to get out of work early is a law-breaker. Again, refer to your State Labor Office for more information.

2. Letting employees decide which hours and how many they want to work each day
State laws restrict the number of hours an employee can work without payment of overtime. If you have a flex-time policy that lets employees work longer days but fewer of them, you’ll need to follow the rules to ensure you don’t incur overtime or back-pay along with penalties. Check what laws apply in your state regarding pay and scheduling.

3. Giving employees loans and deducting repayments from their pay checks
You may think you’re being a generous boss, but most states don’t permit employers to deduct anything other than pay and benefits from employee paychecks. Instead, have the employee sign a promissory note with the oversight of a lawyer and arrange a regular schedule of repayments.

4. Classifying employees as independent contractors
This is an area of the law ripe for litigation, which can also land you in trouble with the tax man. Your worker may be happy to be considered an independent contractor until money and benefits such as paid leave, workers’ compensation and disability become issues. For more insight into this thorny topic, as well as the role the IRS plays and why you need to be aware, read Independent Contractors vs. Employees.

5. Classifying all employees as exempt, whether they are or not
An exempt employee is typically someone who is paid a specified amount of money, regardless of the number of hours worked a week. Under both state and federal law, these positions may be exempt from overtime requirements, as well as meal and rest breaks. Other positions may only be exempt from overtime.
Employees who don’t qualify for one of the exemptions are considered nonexempt and subject to overtime and meal breaks.

Problems arise when employers assume it’s easier to pay everyone a salary (or treat them as exempt), rather than dealing with meal and rest breaks, overtime, and time sheets. Many employers are sued for failure to provide meal and rest periods for nonexempt employees improperly classified as exempt.

Remember there is a fine line between being a nice flexible boss and being an uninformed owner.

How to Handle A Narcotics Scam in Urgent Care

Scam Your Doc: Website Teaches Abusers How to Get Drugs with a Narcotics Scam.

A former drug addict has posted online a step-by-step guide on how to run a narcotics scam using urgent care centers and emergency departments to get narcotics. Urgent Care Consultants, turns the tables by offering their own instructions using the blogger’s steps as a guideline.

Here’s the scenario: The drug-seeker comes into your clinic with a complaint that is difficult to clinically prove or disprove, such as back pain or jaw pain. Like most urgent care visits, this is most likely the first time you have been visited by this patient, so you have no patient history to red flag your suspicions. The patient is asking for a narcotic such as Vicodin or Norco. Here are the steps the blogger recommends and how you can safeguard yourself against being scammed:

Scam Step 1: Get an appointment with a doctor, preferably one who doesn’t know you.
What to do: Have a good EMR and use it. An EMR is a vital tool in safeguarding yourself against drug fraud because you can use your EMR to thoroughly document patient encounters. Proper documentation will help you notice patterns of recent visits for nebulous complaints such as shoulder injuries, tooth aches, or jaw injuries that resulted in prescriptions for narcotics. Be sure every member of your clinic staff thoroughly documents all of their patient encounters because without documentation, these kinds of patterns will not emerge.

If you’re using a good drug-dispensing system, you can also safeguard against drug fraud by using your dispensing system to document the prescriptions you’ve written for all of your patients. This is especially helpful for practices with multiple locations. If the physicians in your urgent care practice are vigilant in their documentation, you’ll be able to see if a patient has visited other locations recently and received prescriptions for narcotics. You’ll notice red flags much more quickly while generating revenue for your clinic by prescribing in-house.

Scam Step 2: Determine what your complaint is and make yourself believe it.
What to do: Don’t let the patient experience get in the way of being a good doctor. Many scammers are good at acting like they are truly in pain, but no one wants to make the mistake of not treating a patient with a legitimate complaint. No doctor wants their patients to suffer, and no one wants to build a reputation for being a bad doctor. Because of this fear, many doctors slip into the let’s just take care of them mode and write up the prescription. Don’t let this fear stop you from being smart about doing proper assessments.

Remember to look for certain signs that will indicate a patient is not legitimately in pain. If you’re doing neurovascular checks, make sure the motion elicits the appropriate pain response. Watch the patient’s behavior; did a patient who is complaining of a pain level of 12 out of 10 jump onto the bed with no problem? Does the mechanism of injury match where he says the pain is? And remember: always follow your gut. If something seems amiss, it probably is. Just as you don’t want to have the reputation for being a bad doctor, you definitely don’t want your urgent care center to have the reputation for being the 7-Eleven of narcotics.

Scam Step 3: When the nurse comes in to see you, don’t give her any more than a brief and general explanation because she’s not important.
What to do: Foster good communication among your staff. If you foster good communication among your staff, both clinical and ancillary, this is really where you could effectively catch a scammer in the act. With Internet resources like WebMD and Wikipedia readily available, it’s easy for drug-seekers to look up a condition and learn exactly what they should complain about in order to appear legitimate. However, while most scammers are really good at keeping up the act in the clinic, they usually don’t carry through with the act in the waiting room or parking lot. Your staff is your eyes and your ears. When you foster a teamwork approach in your clinic, your staff will voluntarily notify you of a suspicious situation. Your receptionist may let you know that the patient who couldn’t bend over in the exam room bent down to get a pop out of the vending machine, or one of your nurses may tell you that the patient who couldn’t even get up onto the exam table dove right into their car when they left the clinic. A teamwork approach will make fraud of any kind difficult to execute at your clinic.

Scam Step 4: Use the time you’re waiting for the doctor to prepare answers to the doctor’s questions in a way that does not arouse suspicion.
What to do: Learn to play the game. Most scammers come prepared with tactics to deceive you, so look at the overall patient and play the game if necessary. Go through the proper assessment steps to ensure the patient is getting the treatment he needs. If a patient is going through two Vicodin every four hours, why refill it for him? If you suggest an MRI or a referral, a scammer will head straight for the door. A patient who is legitimately in that much pain will work with you to determine the cause. Above all, trust your diagnostic skills.

Scam Step 5: When you see the doctor, keep your story consistent and be sure to tell the doctor you have already tried taking over the counter pain killers.
What to do: Look for alternatives to drugs. Better living through chemistry isn’t always the answer, nor is selecting a lesser narcotic. Are there alternatives to writing that prescription? Are there other modalities you could suggest for this patient? Does your facility do physical therapy or have ties to physical therapy? Perhaps ultrasound, hot/cold therapy, E-stim, or other forms of PT can treat the patient’s pain in lieu of drugs.

Scam Step 6: Get your prescription.
What to do: Be cautious with your prescribing techniques. According to the blogger, running this scam has gotten him anywhere from 100 Norco to 15 Vicodin. Without an established relationship with the patient, it’s difficult to justify prescribing as much as100 Norco. Physicians should be very careful with their prescribing techniques to ensure they are only prescribing what is necessary to appropriately treat the patient’s chief complaint. The prescription for 15 Vicodin is more realistic in this situation, and patients with legitimate pain will be appreciative and will follow up with you if the pain does not improve. Drug-seeking patients will typically become irritated by such a small prescription and may even become argumentative, citing the excuse that they can’t get in to see their primary care doctor, so they need a larger prescription that will last until they can get an appointment.

You’ve caught a scammer. Now what?
Despite extreme vigilance, a scammer might still slip through your safeguards. If you wrote that prescription for 100 Norco, let it be a lesson to you to take a few more precautions before doling out narcotics. Otherwise, regardless of how much you prescribed, you can alert your area pharmacies not to fill the prescription for that patient. For chains, this is relatively easy since calling one Walgreens/CVS/Target/etc. hits them all. You’ll have to call the local pharmacies individually, so decide exactly to what extent you want to go to prevent this patient from filling his prescription before investing the kind of time it will take to contact the smaller local pharmacies.

If you dispensed, for example, #20 Vicodin, and the patient is already out the door, the most you can do at this point is document the incident so you’ll be red flagged if this patient returns. The patient lost out on the deal anyway because most likely they had to pay a copay for the visit and $10-$15 for the Vicodin itself, so it’s best to cut your losses. Keep in mind you should not red flag the patient as someone to turn away if he returns with a legitimate complaint, like strep throat or a broken bone. Your top priority is still to provide good healthcare.

More Information
The Journal of Urgent Care Medicine (JUCM) published a thorough article on this topic titled Prescription Drug Abuse and the Drug-Seeking Patient in their May 2008 issue. It’s a great resource for background information on how this problem emerged and what urgent care physicians can do to prevent patients from scamming them. Visit www.jucm.com to view an archived version. Subscriptions are free for physicians and clinical staff.

Does Your Urgent Care Business Qualify for the Healthcare Tax Credit?

Is your urgent care business center losing out on the Small Business Health Care Tax Credit? Not sure if you’re eligible?

The IRS has recently posted a quick Q & A to better explain the credit. According to the IRS.gov a qualified employer must have fewer than 25 full-time employees or a combination of full-time and part-time (for example, two half-time employees equal one employee for purposes of the credit); the average annual wages of employees must be less than $50,000, and the employer must pay at least half of the insurance premiums. The employer must also pay premiums under a qualifying arrangement. See the What expenses count question on the Calculating the Credit page.

Read more on who qualifies at www.irs.gov.

Urgent Care Growth Expected From Newly Insured Under ObamaCare

Recently, the Supreme Court ruled in favor of upholding the Affordable Care Act better known as ObamaCare. While ObamaCare’s main target is the 16.3% of the population that was uninsured last year, this decision will ultimately impact ALL Americans.

What does that mean to you as the healthcare consumer? That means that an additional 49.9 million Americans could be seeking medical care. Alluding to extended wait periods to see your practitioner. Can your allergy ridden child wait three weeks to be seen? How about your fractured arm? Can you wait two weeks for your splint?

If your answer was NO, than you’re in luck.

Currently, there are about 9,000 urgent care clinics seeing cases like this on a daily basis. This equates to about 160,056,000 patients per year. And the industry isn’t slowing down. With an estimated 4.4% urgent care growth between now and 2017, the number of urgent care clinics could soon reach 11,000+ facilities. These clinics are, and will continue to be, staffed with physicians and other providers prepared to take on new patients for all of their non-emergent healthcare needs. And the best part? It’s all on an as needed walk-in basis.

So while, the nation is watching ObamaCare for their next tax increase and fee penalties, the urgent care industry is gearing up to take care of America. From new facilities to awareness campaigns, urgent care is poised to meet the needs of the newly insured.

Non-physician Owned Urgent Care? All Eyes On Massachusetts

A recent article posted on the web-based Patriot Ledger announced that the State of Massachusetts was investigating the legitimacy of non-physician owned urgent care facilities within the state. Their focus is seemingly directed at the franchise group  Doctors Express  which currently operates two centers in Braintree and Springfield and has plans for seventeen others there and elsewhere in the northeast.

The bone of contention, according to State Law, is that for-profit health clinics such as Doctors Express, must be owned by a physician or group practice. This is commonly known as Corporate Practice of Medicine (CPOM) law and it prevents non-physician entities from engaging in the practice of medicine for profit. However, in the instance of franchising or as is the case in other urgent care ownership structures, the workaround is that a physician commonly owns the clinic while the non-physician group or management company is engaged to take care of all other functionality of the business. These other functions may include operations, staffing, billing and collections.

Currently, at least eight states have relatively strict CPOM guidelines and many others have language that often limits who may own or practice certain types of medical services. In fact, very few states such as Florida  have virtually open access to ownership and the practice of medicine, although recent efforts have been made to restrict the glut of pain management shops popping up on nearly every corner to limit the pill-mills that offer no medicine but simply rake in the cash.

So why are so many concerned about what impact this action by the General Counsel in Massachusetts might have on urgent care ownership and the overall industry?

The truth is that all eyes are looking to Massachusetts  perhaps even a good portion of the northeast- to see exactly how the rest of the U.S. is going to respond to ObamaCare. After all, Massachusetts is a case-study in what happens when you essentially open up access to healthcare without a game plan on how to administrate resources. In theory, making sure that all Americans have access to healthcare- both preventative and urgent/emergent is a very good thing; provided of course that you have the infrastructure to actually take care of the millions of patients showing up to your offices, clinics and emergency rooms.

Such is the case in Massachusetts. These folks basically woke up one morning after passing their new laws giving full healthcare access to EVERYONE and found out that their idyllic system of being able to see a primary care practitioner or specialist in a timely manner went the way of the dinosaur over night. These practitioners were overburdened with a flood appointments brought about by thousands of patients with insurance resources under the new healthcare laws. Hence the essential land-grab going on in the state; anyone with an ounce of entrepreneurship and an inkling of urgent care insight is realizing that a solution to the complaint of the middle-class masses over not being able to receive timely healthcare any longer is the provision of urgent care.

And so we have the current dilemma: the pressing need to meet demand accompanied by American free-enterprise butting heads with legal interpretation. (Are you scratching your head and saying didn’t this just happen in the Supreme Court a week ago?) But perhaps the real story here isn’t contained within a few short paragraphs. Just maybe one needs to look beyond the report and to the comments section to get a real feel for not only the motivation for this action but also how potential patients in the area are reacting.

Nearly every comment posted alluded to how the investigation into Doctors Express and their ownership structure must surely be due to hospital influence and the lack of profitability since urgent care might be taking the paying patients. Further, another comment suggested that insurance companies were also a likely culprit trying to stymie reimbursement or freeing up emergency rooms of non-emergent patients. One commenter even asked the obvious question of Why wasn’t the issue addressed prior to the opening of the first two centers?

Overall, each respondent seemed supportive of urgent care in general and there was a sense in their comments that they saw this move by the state as a means as one put it as More government intervention and micro management.

Whatever the outcome of this investigation, it would seem that there is still support for the continued growth of urgent care in the Massachusetts marketplace. Patients want convenience, competent care and reasonable costs for the delivery of that care. They don’t care whose name is on the ownership papers when they walk into the urgent care. Are they treated any better by the physician/owner than by an employed practitioner? After all, they know the physician they see when they’re lying in the emergency room doesn’t have any ownership stake in the hospital either.  Perhaps the true spirit of CPOM needs re-examined or at least enforced more fairly.

All eyes ARE on Massachusetts. Maybe now more than ever.