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. References are included. This product is updated for 2009.
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 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 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; 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; Brand Name Identify/Welcome Letter; PacifiCare Welcoming Letter; HIPAA summary, web sites, checklist; 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; 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; Lien attachment form; References for former employees; 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
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 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
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; Infection Control Policy – Ambulatory Care; Dirty-Clean Work Flow Policy; Refrigerator: Maintenance/Monitoring Policy; Linen: Handling; Storage; Transportation and Processing; Soap/Lotion Containers; Cleaning Examination Rooms; Handwashing; 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; 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
