Anesthesia Business Consultants: Communique fall06

ANESTHESIAANESTHESIA
BUSINESSCONSULTANTSBUSINESSCONSULTANTS
CUSTOMER SERVICE – GET IT YOURSELF! . . . . . . . . . . . . . . . . . . 1
SURGEON SATISFACTION: A 360 DEGREE PERSPECTIVE . . . . . . . . . 2
ASSESSING OPERATING ROOM EFFICIENCY . . . . . . . . . . . . . . . . . 7
COMPLIANCE CORNER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
2007 MGMA AAA ANNUAL CONFERENCE . . . . . . . . . . . . . . . . 12
EVENT CALENDAR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Continued on page 4
FALL2006VOLUME11,ISSUE3
➤ I N S I D E T H I S I S S U E :
Customer Service – Get it yourself!
That was the headline in last Sunday’s
paper here in my Southwest Florida com-
munity. This community is burgeoning
with population growth and still recover-
ing from last year’s hurricanes. There are
not enough workers to meet the demand
and any breathing creature can obtain a job
in the service and construction industry –
but what is the work ethic and profession-
alism of that worker?
Customer service – let’s look at our
everyday lives. Whether booking a hotel
reservation, questioning a bill, trying to get
the TV-cable repaired, or working with
your bank – just think of how difficult it is
to speak to a person – typically the “cus-
tomer” the guy who’s spending the money
with the option of taking business else-
where, is directed to voice-mail; hears,
“push one for this”; “push two for that”; or
best yet, must pay additional fees to speak
to a person – How Do You Feel, When You
the Customer are Treated That Way?
In healthcare we speak a lot about “the
customer and providing customer service”.
Several of my hospital clients have
“Customer Relations Specialists” – I think
these individuals are intended to assist
patients with service related issues, howev-
er I’ve never really been able to understand
what these specialists really do. In other
instances, my hospital clients have
“Physician Liaisons” – these individuals are
intended to assist physicians based at a
ABC offers Communiqué in electronic format
Anesthesia Business Consultants, LLC (ABC) is happy to announce that Communiqué will
be available through a state-of-the-art electronic format as well as the regular printed
version. Communiqué continues to feature articles focusing on the latest hot topics for
anesthesiologists, nurse anesthetists, pain management specialists and anesthesia
practice administrators. We look forward to providing you with many more years of
compliance, coding and practice management news through Communiqué. Please log
on to ABC’s web site at www.anesthesiallc.com and click the link to view the electronic
version of Communiqué online.
CUSTOMER SERVICE –
GET IT YOURSELF!
By Jerry Ippolito, Vice President & Principal
The Surgery Management Improvement Group, Inc.
CommNEWS_Fall06v6.qxd 11/30/06 3:33 PM Page 1

Why has surgeon satisfaction become
as important to health care leaders as clin-
ical and financial outcomes? Each year,
health care facilities throughout the world
spend hundreds of thousands of dollars
on surgeon satisfaction surveys in an
attempt to arrive at the elusive answers to
what truly satisfies a surgeon? The
thought being that if the surgeon is satis-
fied, then the patient will be satisfied and
business will be good. Practically every
American industry, to include healthcare
and business, is brimming with thousands
of articles, theories and studies about the
critical importance of customer satisfac-
tion in steering organizational success.
The dilemma is that the act of satisfying is
in as much a subjective action as it is a
subjective assessment. To satisfy, and in
turn be satisfied, is a personal perspective
that can typically be shared and appreciat-
ed, but likely not universally scripted and
accepted. In many ways, customer satis-
faction follows the simple Golden Rule;
treat others as you want to be treated.
Where the customer satisfaction
waters in the health care have become
muddied is that the traditional customer
(the patient) has joined an ever growing
list of customer stakeholders to include
THE COMMUNIQUÉ FALL 2006 PAGE 2
In our competitive society we all
want to know how we are doing. Few of
us are so confident in our endeavors as to
not want some kind of feedback or
approbation, especially those of us in the
service business. The challenge is know-
ing what sources to trust. Too often,
ulterior motives or our own naiveté
cloud reality, making it hard to distin-
guish the important from the trivial.
How often do we only hear what we want
to hear? At least in our business we have
some objective measures of success. So
long as we keep growing and our clients
maintain their franchises we are happy.
The question is, what makes for success
in an anesthesia practice? The persistent
dissonance and drone of life in the oper-
ating room tends to dull one’s senses to
everything but the matter at hand. When
the case goes well all is right with the
world, or so it seems. How often, though,
is the rising tide a harbinger of a major
storm? Perhaps more often than most of
us would care to admit.
Our clients used to obsess about
their collections. A good month was
defined simply in terms of a high
deposit. Heaven forbid we came in below
expectations, though. Little did I know
that those were the good old days! Now,
we are all so focused on the underlying
factors that generate those collections
that the actual numbers on the reports
are almost anticlimactic. The world of
anesthesia practice management has def-
initely evolved from its cash-based
accounting roots to an accrual-based
model of cost accounting. Sometimes I
feel like a stockbroker: even a hint of bad
news can send clients in paroxysms of
anxiety. Disaster seems ever-present. As
an organization we spend more time
than ever helping our clients formulate
strategies that will turn adversity into
opportunity.
The entire vocabulary of practice
management has changed in the past
few years. Discussions of gross and net
collections rates have given way to talk
of manpower and
staffing models. We
hear much more about productivity and
benchmarking than we do about
Accounts Receivable management per-
formance. But if there is one topic
which defines the new era by virtue of
its novelty and lack of understanding; it
is customer service. As each topic unfolds
across the country it is ever more clear
that we must all be constantly updating
our toolset if we want to succeed and
thrive in the years ahead.
As always, we hope you find our
authors’ treatment of these new frontier
topics timely and informative. We go to
great lengths to tap into those industry
observers who we believe have their fin-
gers on the pulse of the market. May you
find ways to put these invaluable ideas to
effective use in your practice!
Tony Mira, President & CEO
WHAT MAKES FOR SUCCESS IN
AN ANESTHESIA PRACTICE?
SURGEON SATISFACTION:
A 360 DEGREE PERSPECTIVE
By Hugh Morgan, CMPE
Director, AtlantiCare Anesthesiology

the community, hospital administration
and surgeons. Our challenge isn’t in
understanding and accepting the ideas
and principles of customer satisfaction,
but rather in defining who we are sup-
posed to satisfy? In recent years, a great
deal of customer satisfaction endeavors in
health care have been focused around the
surgeons or the “revenue producing” cus-
tomers. The shift in health care from
patient-centric satisfaction to what I
would refer to as “macro” satisfaction has
placed operational burdens and unjust
expectations on the specialty of anesthesi-
ology. The industry is strewn with
defeated anesthesiology groups who often
times are forced to succumb to adminis-
tratively supported surgical expectations.
How then is it possible for an anesthesiol-
ogy practice to survive and thrive in an era
of surgeon-centric satisfaction?
First and foremost, an anesthesiology
practice must define the diverse satisfac-
tion stakeholders for who they are
responsible to include patients, nursing,
administration and surgeons. The group
should seek to understand both the com-
mon and unique expectations of each
stakeholder group through personal
meetings and feedback surveys which ulti-
mately produce the satisfaction criteria
and goals. Although hard to believe,
patient’s seem to have become the least
arduous to satisfy. Typically, patient’s
simply expect to be treated with compas-
sion and respect and to receive the highest
quality and safest medical care with the
best possible outcome. Administration is
a little more challenging to satisfy in that
they usually expect anesthesiology prac-
tices to infallibly provide anesthesia
services and meet fluctuating clinical cov-
erage requirements without pause or
cancellation and within the most finan-
cially insolvent manner possible. Fairly
straightforward expectations, right? The
quandary is that administration’s satisfac-
tion expectations are often directly
associated, if not embedded, with that of
surgeon satisfaction expectations result-
ing in a tag-team of operational and
financial burdens for an anesthesiology
practice. The key is to concurrently
address the administrative and surgical
satisfaction expectations so that there is a
clear understanding by each stakeholder
as to how satisfaction expectations can
directly impact anesthesiology’s ability to
effectively satisfy at the expense of group
operations. It is essential to arrive at a set
of reasonable, achievable and mutually
beneficial administrative and surgical
expectations so that the satisfaction crite-
ria are universally known and not subject
to whimsical modifications. Although
some satisfaction expectations are some-
what broad and inherently subjective such
as, “adequate coverage” and “immediately
available” it is usually more evident to
notice and hear about the absence rather
than the presence of satisfaction. How
often have we heard that if all is quiet,
things must be good?
An important facet in achieving sur-
geon satisfaction is the ability of an
anesthesiology practice to be duly recog-
nized by administration and surgeons as
medical colleagues of the surgical staff.
Too often, anesthesiology is viewed as a
hospital “service” and not as a medical
practice with a critical role in the overall
safety and care of the patient. Although
anesthesiology touches numerous clinical
environments throughout a hospital, per-
haps the most important and visible
involvement is within the Perioperative
arena. From the preoperative assessment
through post surgical recovery, anesthesi-
ology plays a vital role in the customer
satisfaction of the various perioperative
stakeholders, most notably the surgeons.
Anesthesiology is the third cog, the others
being nursing and surgery, in the wheel
that effectively spins perioperative/surgi-
cal services. Like a tire, if any one of these
preoperative “cogs” experiences problems,
the tire goes flat and unfortunate acci-
dents can occur. It is important then for
each of the preoperative disciplines to be
accountable to each other for a variety of
satisfaction criteria to include patient
safety, clinical competency, professional
behavior and workflow efficiencies. The
challenge is to develop the mutual periop-
erative satisfaction criteria and
Continued on page 11

hospital with service related issues.
Humorous as it may seem, as an anesthe-
siologist have you ever been approached
by the Physician Liaison at your hospital
and asked, “how are we doing” – probably
not. However in my world of Operating
Room Management Consulting I do
encourage OR Team Leaders and
Directors of Surgical Services to take on
that duty – “how are we doing?”. The phe-
nomena however is that we talk a lot
about customer service and we have cus-
tomer service specialists of every species,
BUT HAVE WE DEFINED WHO THE
CUSTOMER IS? According to Webster
the customer is:
1. one who purchases a commodity;
2. one with expectations of outcomes.
Some years ago I participated in a CQI
(Continuous Quality Improvement) pro-
gram where the second definition was more
commonly used; in fact the second defini-
tion, in my mind, is the most appropriate.
We all have needs and rely on performance
and fulfillment of expectations by others –
WE ARE ALL EACH OTHER’s CUS-
TOMERS.
In the world of the operating room we
typically regard the surgeon as the customer.
Ironic as it is, we seldom consider the
patient first. As a consultant I have the
opportunity to work with several dozen
hospitals each year in many communities
around the country – indeed the patient is
the primary customer (even more ironic in
today’s world is that the payor is beginning
to usurp this position). As I sit in restau-
rants, ride on planes, read local papers I’ll
continuously hear / read about residents’
perceptions of the local hospital. I’ve had
the honor of working with several very pres-
tigious community medical centers around
the country; if physicians are not on staff at
these centers, they can not build or sustain a
practice – if they are not on staff at these
centers, they are not considered quality doc-
tors – THE PATIENT IS HIGHLY
SELECTIVE, and rightfully so!
In the world of OR we often speak of
the three or four legged stool – the four cus-
tomers; the four constituencies with
expectations; even here we forget about the
patient – aren’t there really at least five cus-
tomers:
1. Patient – Expectations of: Quality
care; Hospitality; Affordability;
Accessibility
2. Hospital Administration – Expecta-
tions of: Increased business;
Increased Margins; Decreased Costs;
Maximized utilization of resources
3. OR Staff / Nursing – Expectations of:
Ability to deliver quality patient care;
Competitive compensation;
Reasonable working conditions; Job
satisfaction; Reliable and predictable
work schedules
4. Surgeons – Expectations of: Quality
patient care; Sufficient OR access to
meet practice needs; Maximized /
efficient use of time; Experienced OR
staff who can anticipate case needs;
Equipment and technology meeting
procedural needs; Ability to generate
a livelihood comparable to similar
specialists
5. Anesthesiologists – Expectations of:
Quality patient care; Optimized uti-
lization of time; Competitive
compensation and lifestyle;
Predictability of schedules.
CUSTOMER SERVICE – GET IT YOURSELF!
Continued from page 1
Surgeons
Anesthesiology
Administration NursingPatient
Surgeons
Anesthesiology
Administration NursingPatient
COMPROMISE IS KEY TO OPTIMIZING
CUSTOMER SATISFACTION & MAINTAINING
A PATIENT FOCUSED PROGRAM
Without
Compromise the
Patient Stands
Alone

If any one customer’s or constituent’s
expectations are fully satisfied (the 100
percent level) then fulfillment of other’s
expectations will suffer.
I hope we’re now all agreed that the
patient belongs in the center of our uni-
verse as professionals in the field of
healthcare. Let’s move on to the “nuts-
and-bolts” of developing customer
satisfaction in the OR. Let’s first talk
about the surgeon as we always hear that
the surgeon is the customer. Typically the
surgeon (or medical staff in general)
wants to be regarded as a patron or cus-
tomer of the hospital; the customer
maintains the option to shop elsewhere.
The hospital-business will not survive
without the physician (and patient) cus-
tomer(s). As in the retail environment
the physician-customer maintains an
expectation that the vendor (hospital)
delivers a quality product. However,
unique to the hospital setting is that the
product is truly a service vs. a tangible
product; physician-customers place pri-
mary emphasis on the hospital meeting
their service oriented expectations.
Physician-customers typically “Want what
they want, when they want it”. The physi-
cian customer typically forgets that even
in the most service oriented, traditional
environment (whether Ritz Carlton,
Nieman Marcus or Lexus dealership)
hours of operation, dress codes, pricing
strategies, rules of conduct, (etc.) exist
and are required to effectively and reliably
meet the majority of customers’ expecta-
tions. Too frequently physicians /
surgeons expect the administrative team
(and anesthesiology) to meet 100 percent
of expectations 100 percent of the time on
terms established by the physician-cus-
tomer at any given point in time. This
mind-set, if allowed, diminishes the abili-
ty to optimize service to the other
customers (patients, nursing, anesthesiol-
ogy, administration). Compromise is key.
Now what you’ve been waiting for –
does anesthesiology ever get to be the cus-
tomer and what role does anesthesiology
play in meeting customer service / satis-
faction requirements? Surgeons will grav-
itate to those hospitals and ASCs where a
superior level of anesthesiology care is
provided – where there is choice. Patients
are generally unaware of the level of care /
expertise provided by the anesthesia serv-
ice and really don’t make decisions based
on this factor. Doctors, I know this is
going to hurt, but I now have to drop the
bomb – in my nearly thirty years in
healthcare and fourteen years in consult-
ing, I can not site an instance where an
anesthesiologist referred a case to a hospi-
tal (pain management or a personal
referral aside). Indeed, quality anesthesi-
ologists and CRNA (AA’s) are in short
supply these days and do have numerous
job / practice opportunities, but typically
anesthesiology’s decision of where to“per-
form / take a case: requires a career and
geographic move – very different from the
surgeon’s opportunities. Doctors, we just
have to “bite-the-bullet” and deal with
reality. I spend a sizeable amount of my
time in consulting and interviewing anes-
thesiologists around the country and all
too frequently I’ll hear: “My income is
decreasing because they (meaning hospital
administration) have lost the outpatient
business”. In polite terms I’ll ask, “What
role did anesthesiology play in retaining
that business?” Generally I’ll continue
with the anesthesiologist and ask, “Do you
consider yourself a consulting specialist? “
Almost universally the anesthesiologist
responds “Yes” – well then, don’t consult-
ing specialists need to garner referrals;
develop and protect referral sources? It
then begins to sink in. In the old days and
still in some pockets of the country, anes-
thesiologists teamed up with surgeons and
followed the surgeon all around town pro-
viding anesthesia for the surgeon’s case.
The surgeon was treated as a customer or
client of the anesthesiologist; the anesthe-
siologist was expected to provide a certain
level of service (I know I’m rubbing salt in
the wound – sorry). Today the model has
greatly changed and rightfully so due to
the economics of healthcare – one sur-
geon’s practice can not support an
anesthesiologist at today’s reimbursement
levels. So then, the anesthesiologist, all the
more, needs to expand and further devel-
op the practice base – the anesthesiologist
requires more clients / customers to gen-
erate the expected livelihood; the
anesthesiologist needs to: “Market to the
Customer; Build the Business”.
As we wrap this up, let’s focus on anes-
thesia’s role in customer service in the
operating room as well as anesthesia’s posi-
Continued on page 6

tion as a customer. In general, customers’
expectations, regardless of who the cus-
tomer is, will not be met unless
expectations are reasonable and clearly
defined. Most frequently for anesthesia
this is defining how many sites are staffed
by hour of day and day of week; this CAN
NOT be a moving target if customer serv-
ice is to be effectively delivered.
Only as a few examples, as a customer,
anesthesia should be able to rely on:
• Development of clearly defined and
agreed to expectations with regard to
sites staffed;
• Competitive compensation and
lifestyle for services rendered deliver-
ing to expectations (potentially
requiring a hospital stipend);
• An OR committee (or governance
body) having developed effective
scheduling policies and procedures
and further, consistently enforcing
them;
• Surgeons’ offices effectively commu-
nicating with OR scheduling;
• Surgeons effectively communicating
with anesthesia with regard to diffi-
cult cases or sick patients;
• Nursing effectively implementing
preadmission screening protocols
that have been developed jointly with
anesthesia;
• Charts being complete on the day of
surgery;
• Patients being appropriately prepared
for surgery in either a Day-surgery
unit or on the hospital floor;
• Ability to transport the patient to the
OR in a timely manner in order to
have on-time case starts;
• Surgeons reporting to the OR on time
for on-time case starts;
• Experienced OR staff and appropri-
ately set-up cases in order to reduce
case times;
• Experienced charge nurses working
with anesthesia to run the day’s
schedule;
• Experienced PACU staff who can
function with relative independence;
• Lots of other stuff...
In providing customer services anesthesia
should be expected to:
• Be current in state-of-the art anesthe-
sia care with an emphasis on
ambulatory anesthesia;
• Maintain reasonable flexibility with
regard to agreed expectations – main-
tain an attitude of meeting or
exceeding expectations;
• Assure consistent and reliable staffing
for all anesthesia sites agreed to;
• Collaborate with nursing to develop
state-of-the-art preadmission guide-
lines; agree as a group to established
guidelines;
• Screen all ASA III and above patients
and visit with all inpatients prior to
the day of surgery;
• Develop processes to administer
anesthesia consults for the preadmis-
sion unit;
• Call patients on the evening prior to
surgery;
• Be as familiar as possible with
patients’ conditions prior to the day
of surgery;
• Review patient charts at least the day
prior to surgery;
• Proactively work with nursing in
schedule planning and management;
• Begin reviewing the schedule with
nursing several days prior to surgery;
• Facilitate getting patients into the OR
for on-time case starts;
• Facilitate expediting turnaround
time;
• Maintain an effective medical direc-
tion model where CRNA direction is
based on case complexity, patient
acuity and CRNA skill level;
• Be promptly available to CRNAs dur-
ing on-going cases;
• Be promptly available to CRNAs cases
to expedite induction and emergence;
• Develop a staffing model and service
agreement model whereby anesthesia
staffing requirements of OR-periph-
eral sites does not disrupt OR staffing;
• Develop a Q/I and education model
for all anesthesiologists, CRNAs and
hospital staff (RNs; RTs) where
appropriate;
• Assign lead individuals to foster skills
and business development in key
services such as cardiac / vascular,OB,
ambulatory, pain (potentially neuro,
trauma, pediatrics);
• Play a key role in developing and sus-
taining YOUR OWN BUSINESS by
focusing on what is required to devel-
op a marketable and financially viable
surgical program with increasing case
volume;
• Focus on delivering the highest level
of patient care with respect for the
patient’s time; provide hospitality;
• Focus on defining expectations and
then exceeding those client / customer
expectations and your business / anes-
thesia practice will flourish (1).
(1) Depending on expectations, payor mix and
OR efficiencies / case times there may always be
a need to approach hospital administration for
a subsidy payment to deliver on expectations.
CUSTOMER SERVICE – GET IT YOURSELF!

The measurement of
operating room effi-
ciency used to be one
of those arcane sci-
ences reserved for a
special breed of con-
sultant with experience
in balancing the political and practical
requirements of the daily management of
a suite of operating rooms, but not any
more. Given the impact of inefficient
operating room management on anesthe-
sia coverage and call requirements, O.R.
utilization is rapidly becoming a key factor
in an anesthesia practice’s need for finan-
cial support. While the causes of
inefficient operating room utilization tend
to be complex and directly related to a
hospital’s need to compete for surgeon
allegiance in increasingly competitive
markets, it is not uncommon for anesthe-
siologists to be invited to join the fray. The
concept of an anesthesiologist or an anes-
thesia department designee playing some
role in O.R. management is not new. Many
practices have had a “floor person,”
“Clinical Day Director,” or “Captain of the
Ship” for years. Typically, these have been
ombudsmen providing a customer service
rather than aggressive managers empow-
ered to actively modify surgeon behavior.
The problem is simply that for all their
experience in the arena, most anesthesiol-
ogists have yet to develop the necessary
tools and strategies to make them effective
agents of change.
From an anesthesia perspective all
discussions of operating efficiency ulti-
mately hinge on the economics of
coverage and call. This takes some over-
eager practitioners right to a discussion of
profitability. From a management per-
spective, however, an exploration of
benchmarks and metrics may be more
useful in the strategic positioning of anes-
thesia as a contributor to the solution of
declining productivity. Establishing a
common vocabulary of performance uti-
lization is deceptively complex. It is not
uncommon to hospital administrations to
view any data from the anesthesia practice
with a healthy dose of skepticism. As in so
many exercises in change, management
time must be spent educating all the stake-
holders so that they agree on the problem,
accept the metrics and share some owner-
ship for the process.
Most observers would agree all met-
rics should be viewed and tabulated by
anesthetizing location. Let us further
assume, for the sake of this discussion, that
an anesthetizing location is an actual or
virtual location that requires dedicated
anesthesia personnel for part or all of a 24
hour period. By this definition each oper-
ating room is an anesthetizing location, as
is the delivery suite, the Cystoscopy room,
or any other physical space where anesthe-
sia services might be required. The
definition becomes a little less clear when
the dedicated personnel are required to
provide a variety of non-operating room
services. Each practice must work through
its own definition of N.O.R.A. (Non-
Operating Room Anesthesia)
ASSESSING OPERATING ROOM
EFFICIENCY
By Jody Locke
Continued on page 8

requirements.
One school views operating room
efficiency through the absolute lens of a
particular metric such as cases, units or
minutes per anesthetizing location day.
There is considerable discussion across the
country as to appropriate points of refer-
ence. There is some data to support an
optimal number of cases per location day,
but as even the most casual observer of the
specialty will note not all cases are of equal
acuity or duration. Others prefer to focus
on total ASA units billed per location per
day (base, time, modifier and incidental
units) and will site the magic number 50
as an ideal productivity benchmark. Still
others prefer to measure and monitor
minutes. Actual anesthesia time has the
advantage of corresponding, more or less,
to the operating room time captured by
the hospital staff. Discussions of anesthe-
sia time can take a number of directions
depending upon how important it is to
identify when activity occurs. It has been
suggested that an operating room that
generates 6 hours of anesthesia time
between 7 AM and 3 PM is running at
optimum efficiency. Obviously, all bench-
marks and standards must be adjusted to
meet the particular requirements and
challenges of the facility.
Proponents of such metrics argue that
while they may not be a perfect measure-
ment of every situation at least they
provide a consistent frame of reference.
They lend themselves to an objective com-
parison of facilities. An operating room
that consistently generates 40 ASA units
per location day is clearly less efficient
than one that generates 50 or more units.
Inevitably, the question arises: Which
metric is best? “Best” is a relative term
because all valid data has some value if it is
applied judiciously. A determination of
the most appropriate metric or approach
for a particular setting should hinge on
two separate issues: reliability and credi-
bility. Many anesthesiologists put great
stock in measuring total ASA units per
location day, because they know how they
get paid for anesthesia, but such an
ASSESSING OPERATING ROOM EFFICIENCY
Hours per Location Day Versus Hours Per Location Dayshift
6.011030596 5.944845679 5.964393939 5.90016835 5.973765432
4.215288462
4.031243032 3.951185897 3.96497669 3.914597902 3.963269231 3.855992196 3.880512821
6.193117284
5.723054214 5.664907407
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06
Avg Hours per Location Day Avg Hours per Day Shift Location

Continued on page 14
DAY Day of Week CASES CHARGES Units
Expected
Collections
Anes.
Locations
Units/
Anesthetizi
ng/
Location
Day
Expected Gross $ /
Location Day
1 Wednesday 25 $29,113.50 447.9 $15,005 12 37.33 $1,250.39
2 Thursday 28 $22,919.00 352.6 $11,812 12 29.38 $984.34
3 Friday 40 $37,128.00 571.2 $19,135 9 63.47 $2,126.13
4 Saturday 29 $25,148.00 386.9 $12,961 4 96.72 $3,240.22
5 Sunday 7 $5,512.00 84.8 $2,841 3 28.27 $946.93
6 Monday 5 $4,160.00 64.0 $2,144 12 5.33 $178.67
7 Tuesday 32 $24,687.00 379.8 $12,723 12 31.65 $1,060.28
8 Wednesday 32 $26,344.50 405.3 $13,578 12 33.78 $1,131.46
9 Thursday 28 $22,386.00 344.4 $11,537 12 28.70 $961.45
10 Friday 47 $40,703.00 626.2 $20,978 9 69.58 $2,330.86
11 Saturday 25 $23,965.50 368.7 $12,351 4 92.18 $3,087.86
12 Sunday 10 $7,228.00 111.2 $3,725 3 37.07 $1,241.73
13 Monday 4 $3,692.00 56.8 $1,903 12 4.73 $158.57
14 Tuesday 29 $26,955.50 414.7 $13,892 12 34.56 $1,157.70
15 Wednesday 27 $26,718.00 411.0 $13,770 12 34.25 $1,147.50
Anesthetizing Location Production Metrics for
Month of March 2005 (Based on DOS Data)
16 Thursday 39 $37,076.00 570.4 $19,108 12 47.53 $1,592.37
17 Friday 40 $32,922.50 506.5 $16,968 9 56.28 $1,885.31
18 Saturday 32 $29,428.00 452.7 $15,167 4 113.18 $3,791.68
19 Sunday 10 $10,991.50 169.1 $5,665 3 56.37 $1,888.28
20 Monday 8 $7,553.00 116.2 $3,893 12 9.68 $324.39
21 Tuesday 26 $24,017.50 369.5 $12,378 12 30.79 $1,031.52
22 Wednesday 32 $29,107.50 447.8 $15,002 12 37.32 $1,250.13
23 Thursday 14 $11,011.00 169.4 $5,675 12 14.12 $472.91
24 Friday 28 $21,671.00 333.4 $11,169 9 37.04 $1,240.99
25 Saturday 20 $18,359.00 282.4 $9,462 4 70.61 $2,365.49
26 Sunday 10 $8,495.50 130.7 $4,378 3 43.57 $1,459.48

Since the publication of the OIG
Compliance Guidance for Individual and
Small Group Physician Practices (here-
inafter the “OIG Guidance”) in 2000,
many anesthesia practices have had some
experience with compliance auditing.
The first of the seven compliance pro-
gram elements recommended by the OIG
is conducting internal monitoring and
auditing through the performance of
periodic audits. What does this entail
for an anesthesia practice? Although
physicians may not be legally required to
conduct internal audits and the fact
remains that the OIG Guidance is only a
set of recommendations, many experts
recommend that physician practices
should strive to conduct internal audit-
ing at least on an annual basis.
Conducting annual audits should
prove beneficial in assisting the practice
in identifying issues that should be
addressed or corrected thereby reducing
ongoing risks to the practice. By per-
forming an audit on at least an annual
basis, the practice should avoid messy sit-
uations such as identifying a significant
problem or issue that may have been
occurring for a significant time period
resulting in potential large overpayments
received by the practice. Such circum-
stances can raise significant questions for
the practice related to payback and dis-
closure obligations.
A common question facing anesthe-
sia practices when deciding to conduct
an internal audit (either by internal staff
or hiring an outside consulting group) is
“how many records should we review?”
While there is no exact right or wrong
number, it is reasonable for the practice
to limit the record review to a manage-
able and practical number for several
reasons including costs. In the OIG
Guidance, the OIG suggests that an
appropriate sample size may be five (5)
to ten (10) records per physician in the
practice. In many situations, a group’s
decision to audit between 5 and 10
records per physician would be reason-
able. Some outside consultants that have
an economic interest in reviewing many
records, may suggest too large of a sam-
ple size. The practice must keep this in
mind when hiring and coordinating an
audit with outside help. Outside con-
sultants can and do provide valuable
assistance and expertise for many prac-
tices, however, the practice should
maintain control of the process and not
simply allow the consultants to direct
and select the sample size. Given that the
auditors will typically identify problem
areas, it is also important for the practice
to conduct the internal audit under the
attorney/client privilege. This process is
not complicated and involves the prac-
tice’s attorney directing the auditors to
perform the audit under the
As part of our desire to keep both clients and
readers up to date, the Communiqué has been
printing compliance information since its
inception. In the Compliance Corner, we will
now formally keep you abreast of the various
compliance issues and/or pick out a topic that
would be of interest to most of our readers.
COMPLIANCE AUDITING: HOW MANY
RECORDS SHOULD YOU REVIEW?
By Abby Pendleton
Wachler & Associates, P.C.

measurement tool for which each of the
perioperative disciplines will be account-
able and to encourage global participation
as a means to achieving higher levels of
performance and satisfaction.
Earlier this year, with input from my
perioperative leadership colleagues at
AtlantiCare, I initiated the development of
a 360 degree Perioperative Satisfaction
Survey to purposefully achieve higher lev-
els of mutual perioperative satisfaction
and drive higher levels of perioperative
performance. The 360 degree approach
for survey and evaluation purposes is not a
new concept as business leaders have suc-
cessfully used 360 surveys as a means of
assessing leadership at every organization-
al level. Although surgeon specific
satisfaction surveys had previously been
attempted at AtlantiCare, the thought was
that a comprehensive 360 degree survey
would likely surface common satisfaction
and dissatisfaction themes affecting all of
the perioperative disciplines to include the
surgeons. The intent was to obtain defini-
tive feedback on the common satisfaction
and dissatisfaction themes so that the lead-
ership of each perioperative discipline
could address the universal issues of the
discipline rather than issues of isolated dis-
satisfaction. A set of mutually inclusive
satisfaction criteria with basic effective
scoring was developed and scoring that fell
above or below acceptable targets required
supportive elaboration so that dissatisfac-
tion could be effectively addressed. The
leaders of each perioperative discipline
were tasked with distributing the 360
degree survey to their respective col-
leagues. Each perioperative discipline had
the opportunity to survey each of the other
disciplines as well as their own discipline.
As with any feedback survey, it was impor-
tant to establish deadlines for survey
submission dates so that feedback is timely
and action plans for improvement can be
efficiently developed. The survey success is
completely dependant on the level of par-
ticipation or you will have developed the
best satisfaction survey with no feedback
to improve satisfaction or performance.
The key point is that to achieve higher
levels of surgeon satisfaction is to concur-
rently achieve higher levels of nursing and
anesthesiology satisfaction. Within the
perioperative arena, none of the disciplines
can achieve high levels of satisfaction with-
out the other disciplines also being
effectively satisfied. It comes down to a
mutual respect and understanding of the
critical roles that each discipline plays in
determining the performance, culture and
overall success of perioperative and surgi-
cal services. In the end, it becomes an
exercise in futility to attempt to satisfy one
discipline, namely surgeons, at the expense
of the other two perioperative disciplines,
nursing and anesthesiology.
SURGEON SATISFACTION: A 360 DEGREE PERSPECTIVE
attorney/client privilege.
In addition to the cost issues, if the
goal of the audit is early identification of
issues or patterns, a large volume of
records is typically not necessary. In fact,
many auditors will begin to identify
issues/patterns in the first 10 to 20
records. For example, in auditing anes-
thesia records, it usually does not take
many records to identify whether the
physicians are fully documenting med-
ical direction requirements or whether
anesthesia time is being rounded. In the
anesthesia setting, many auditors suggest
a review of a full day of cases in order to
perform a concurrency review in con-
nection with the audit. The practice will
have to make a determination as to
whether an independent check of con-
currency is necessary.
Accordingly, while there may not be
one “magic” number for compliance
auditing, your practice should take a rea-
sonable approach by selecting enough
records to accomplish the goal of the
audit, which in many routine compli-
ance audit situations is to identify areas
needing attention. For many practices,
selecting a minimum of 5 records per
physician will accomplish this goal. Of
course, once issues are identified, the
practice should perform specific focused
follow-up audits to oversee that correc-
tive action measures that were put into
place (e.g., educating providers or estab-
lishing new policies) are working.

We are pleased to announce that this
year’s MGMA AAA annual conference
will be held April 29 – May 2, 2007 at the
spectacular Four Diamond Sheraton
Hotel and Towers in Seattle, WA. For
those who have never attended this anes-
thesia practice management conference, it
is one of the best in the industry. This
year, due to popular member demand, we
added two half-days of pain management
specific practice management informa-
tion as a pre-conference on Saturday
afternoon and Sunday morning, in addi-
tion to offering a pain track throughout
the concurrent sessions of the main con-
ference. Typically attended by
approximately 300 administrators, physi-
cians, practice managers, billing service
owners, consultants and others involved
in advanced level anesthesiology and pain
practice administration, it also provides
an exceptional forum for networking and
information exchange. Early in the con-
ference we offer roundtable discussions
on specific issues of interest that allow
people to meet others in comparable
practices or with similar concerns. We
include a number of social events to pro-
vide further networking opportunities.
People who have attended this meeting
for many years develop friendships that
provide continuing networking support
throughout the year.
Once again, we have an exceptional
group of speakers lined up for this year’s
conference and pain management pre-
conference. The pain pre-conference is
scheduled to begin on Saturday, April
28th from 1:00 to 5:00 p.m. and Sunday,
April 29th from 8:00 a.m. to 12:00 p.m.
The keynote speaker is Doug Merrill, MD
from Virginia Mason Clinic located in
Seattle. Dr. Merrill, a leading physician in
the chronic pain management field, will
share his vision in “The Future of Pain.”
Other speakers include nationally
renowned healthcare attorneys Vicki
Myckowiak, Esq., and Jennifer Bolen, J.D.,
who will address fraud and abuse risk
areas and compliance concepts for the
pain management provider, respectively.
Also, nationally known speakers, Devona
Slater, CHC and Marvel J. Hammer, RN,
CPC, CCS-P, ACS-PM, CHCO will dis-
cuss pain management coding, billing,
and appeals. In response to member
requests, this information-packed pre-
conference was designed to meet the
specific needs of our members with pain-
management practices.
On Monday morning, physicians
who attend the conference are invited to
join Dr. Craig Johnson, ASA liaison to
MGMA AAA, and other colleagues for
breakfast. As in past years, this “physician
only” informal networking event gives
physicians an opportunity to discuss cur-
rent topics and exchange information
pertinent to their practices. Our keynote
speaker (special thanks to Tony Mira and
Anesthesia Business Consultants, LLC for
their generous sponsorship of this event)
is Jim Bergquist, president, BizFutures.
This Seattle-based consulting company
has been featured on National Public
Radio and has an impressive list of clients,
including Microsoft and Boeing. The high
energy and high impact presentation –
designed to inspire and motivate employ-
ees – is fun and educational.
Other general session speakers include
Mark J. Lema, MD, president, American
Society of Anesthesiologists, Norman A
Cohen, MD, American Society of
Anesthesiologists’ Committee on
Economics, and Alexander Hannenberg,
MD, Vice-President Professional Affairs,
ASA. Back by popular demand, national-
ly known health care futurist James E.
Orlikoff, Orlikoff & Associates, Inc.,
Chicago, will discuss “The Impact of
Technology on the Healthcare System.”
As usual, the concurrent sessions will
include many experienced speakers cover-
ing a great variety of new and timely
topics. This year we will be adding a
fourth option to the concurrent sessions
to provide a specific pain track in the main
conference as well as the pre-conference
offerings. Topics to be covered in the con-
2007 MGMA AAA ANNUAL CONFERENCE
PROVIDES EXCEPTIONAL EDUCATION AND
NETWORKING OPPORTUNITY
By Kelly Dennis
MBA, ACS-AP, CPC, President-Elect, MGMA AAA, Leesburg, FL

current sessions include: “Modifier Magic
for Pain Management Coding,” by Marvel
J. Hammer, RN, CPC, CCS-P, ACS-PM,
CHCO; “General Competency –
Communication Skills,” by Sara M. Larch,
MSHA, FACMPE, chief operating officer,
University Physicians, Inc.; “To EAR or
not to EAR - What you Need to Hear
Before Implementing an Electronic
Anesthesia Record,”by Phil Mesisca, MBA,
CMPE, CEO, University of Pennsylvania
Health System; “Pain Clinic Operations
and Profitability,” by Devona J. Slater,
CHC, CMCP; “Achieving Optimum Back
Office Productivity,” by Jody Locke, vice
president of anesthesia and pain manage-
ment services, Anesthesia Business
Consultants, LLC.
In addition to these excellent speak-
ers, many who are members of MGMA
AAA, roundtables will be moderated by
members, who facilitate discussion and
share their experiences on a variety of
issues of interest.
Social events run the gamut from
breakfast, lunch and networking recep-
tions to a golf tournament and casual
get-togethers by members. Each year, an
introductory session is held for new
administrators and a special reception is
held prior to the opening reception for
first-time attendees to help them meet
people and start networking right away.
Most of the key anesthesiology and pain
management vendors are “on hand” as
sponsors and exhibitors during the breaks
to demonstrate their products and servic-
es, answer questions and solicit feedback.
It provides a great forum to comparison
shop and evaluate products your practice
may need.
The Sheraton Seattle Hotel and
Towers, the location of our 2007 meeting, is
located in the city’s vibrant core and has
recently undergone a 14 million dollar ren-
ovation of the lobby, restaurants, guest
rooms and suites. Sheraton Seattle has
been the recipient of Meetings and
Conventions Gold Key Award for five con-
secutive years. It is conveniently located
next to the sights, sounds, and experiences
of one of the greatest cities in the northwest
and just steps from world-famous Pike
Place Market and the world-class shopping,
exciting nightlife and gourmet restaurants
that surround this magnificent hotel. The
hotel is located at 1400 Sixth Avenue in
downtown Seattle. For more information,
visit http://www.seattle.com/sheraton-
seattle/
To learn more about the conference,
view the brochure or to sign up yourself
and/or your administrator, visit
www.mgma.com/education/calendar/,
find the appropriate dates and click on the
MGMA AAA annual conference. Or you
can call 1-877-ASK-MGMA and request
to have a hard copy brochure mailed to
you. ASA members who sign up with
their administrator who is an MGMA
AAA member may attend at the member
rate. There is also a special rate available
for non-members to include purchase of
their initial membership and obtain the
membership price for the conference.
Please do not hesitate to contact me, kelly-
ddennis@attglobal.net or MGMA AAA
president Jack Beecher,
jack.beecher@yale.edu, should you have
questions or need more information
about the conference or any aspect of
MGMA AAA membership. We hope to
see you in April, 2007!!

approach may be viewed with great suspi-
cion by hospital administrators who do
not understand how anesthesia basic val-
ues and time units are determined. In
other words, if a particular metric does
not serve the goal of providing common
coinage for a discussion of management
options it will serve no practical purpose.
Another school of thought is more
concerned with the relationship between
coverage commitments and actual pro-
duction patterns. In this variation on the
theme actual hours of anesthesia time are
divided by total hours of staff coverage.
Such an approach factors in such issues as
call and distinctions between short and
long rooms. The advantage of such a per-
spective is that it can be customized to any
particular configuration of anesthetizing
locations. The disadvantage is that all
applications become relative.
Included below are examples of each
of the two approaches to the measuring of
operating room productivity. Not every
anesthesia practice will want to develop
the tools to generate such reports,
although more practices should probably
be exploring the possibilities than are cur-
rently doing so because too often it is the
initiation of a serious subsidy discussion
that triggers the need to look at productiv-
ity. Practices that have been monitoring
O.R. metrics over time have much greater
conversance with their applicability and
relevance. The fact is that as is true of the
administration of anesthesia, it is difficult
to manage what one does not measure.
While anesthesia practices have tradition-
ally focused on the measurement and
management of billings and collections,
more and more are beginning to realize
that the one piece of the equation they did
not choose to monitor is the one that has
the greatest impact on the income and
lifestyle of the members.
It has been said that you cannot man-
age what you do not measure.
Anesthesiologists know this intuitively,
because the availability of reliable physio-
logic data about a patient’s response to the
trauma of surgery and anesthesia plays
such a critical role in the consistent out-
comes of today’s practitioners. The
converse is also true: what you do not
measure, you cannot manage. Anecdotal
discussions tend not to support serious
change. If O.R. productivity is an issue for
your practice then an investment in the
tools and resources to capture the data and
monitor it closely is a small price to pay for
the opportunity to be part of the solution
rather than a victim of the problem.
ASSESSING OPERATING ROOM EFFICIENCY
27 Monday 6 $4,927.00 75.8 $2,539 12 6.32 $211.61
28 Tuesday 27 $28,073.50 431.9 $14,469 13 33.22 $1,112.97
29 Wednesday 35 $36,305.50 558.5 $18,711 14 39.90 $1,336.52
30 Thursday 38 $38,389.00 590.6 $19,785 15 39.37 $1,319.01
31 Friday 39 $37,050.00 570.0 $19,095 12 47.50 $1,591.25
Totals 772 $702,038 10,800.6 $361,819 298
629 $572,910 8,814.0 $295,269 270
143 $129,128 1,986.6 $66,550 28
24.90 22,646.37 348.41 8.76 36.24 $1,524.31
29.95 27,281.43 419.71 12.86 32.64 $1,064.33
Weekends
Overall Averages
Weekday Averages
Weekdays

Coding CornerCoding Corner
Speakers at anesthesia coding sem-
inars often harp on the importance of
indicating the use of hardware when
documenting spinal surgery. The argu-
ment is that failure to indicate the use
of hardware will result in the loss of five
billable units. While it is useful to keep
this in mind when reporting spinal pro-
cedures, this is hardly the end of the
story. New surgical techniques make it
imperative that not only is the surgical
approach and location clearly indicat-
ed, but that the coders understand the
significance of each indication.
A case in point is a practice that
routinely reported a spinal procedure
indicated as “TLIF.” The indication
obviously made sense to the anesthesi-
ologists, but was not at all clear to the
coders. A review of various reference
materials indicated the following
options for which the corresponding
anesthesia basic values are indicated.
Another physician reported a pro-
cedure as“ACDF,”which was interpreted
as Anterior Diskectomy with fusion and
the coder selected CPT code 22554. A
review of a standard coder’s reference
indicated such a procedure does not
typically involve instrumentation. A
review of the surgical operative report,
however, clearly indicated the use of
plates and screws. This clarification
resulted in a base value of 13 instead of
10.
The bottom line is that the place-
ment or removal of plates, screws, rods,
cages or dowels during spine surgery
should be clearly noted together with
the level of the procedure. It is always a
good habit when providing anesthesia
for a procedure that is new to your
practice to confirm the best way to doc-
ument the surgery so that the coders
will be able to code it appropriately. For
ABC clients this is a standard part of the
service.
DOCUMENTING
SPINAL SURGERY
By Jody Locke,Vice President
Anesthesia Business Consultants, LLC
Thoracic Lumbar
8 units
Interbody Fusion
Transforaminal Lumbar
8 units
Interbody Fusion
Translaminar
Instrumentation 13 units
with Fusion

PROFESSIONAL EVENTS
DATE EVENT PLACE CONTACT INFO
Dec. 8-12, 2006 New York State Society of Anesthesiologists New York Marriott Marquis, www.nyssa-pga.org
Postgraduate Assembly in Anesthesiology New York, NY
Dec. 13, 2006 “Pain Managment 2007 Coding Update and Live Webcast and Audio Conference www.mgma.com
Common Coding Pitfalls to Avoid!” 2:00 p.m. to 3:30 p.m. EST
Speaker: Linda Van Horn, MBA Sponsored by MGMA
Jan. 18, 2007 Anesthesia Coding Updates Live Webcast and Audio Conference www.mgma.com
Speaker: Debbie Farmer Sponsored by MGMA
Jan. 26-28, 2007 Arizona Society of Anesthesiologists Scottsdale Resort and Conference www.az-anes.org
Annual Mtg. Center, Scottsdale, Arizona
Jan. 26-28, 2007 ASA Conference on Practice Management Pointe Hilton-Tapatio Cliffs Resort, www.asahq.org
Phoenix, AZ
Feb. 7-10, 2007 American Academy of Pain Medicine Ernest N. Morial Convention Center, www.painmed.org
Annual Meeting New Orleans
March 8-11, 2007 Society of Pediatric Anesthesia Pointe Hilton Squaw Peak, www.pedsanesthesia.org
Winter Meeting Phoenix, Arizona
April 19-22, 2007 32nd Annual Regional Anesthesia The Westin Bayshore Hotel, www.asra.com
Meeting and Workshops Vancouver, British Columbia, Canada
April 21-25, 2007 Society of Cardiovascular Anesthesiologists Palais des Congres de Montreal www.scahq.org
Annual Meeting and Workshops Montreal, Quebec, Canada
April 26-28, 2007 AUA 54th Annual Meeting Sheraton Hotel and Towers, www.auahq.org/annualmtg
Chicago, IL
April 29-May 2,2007 MGMA AAA Annual Conference Sheraton Seattle Hotel & Towers, www.mgma.com
Seattle, WA
May 16-19, 2007 Society of Obstetric Anesthesia and Perinatology Fairmont Banff Springs, www.soap.org
Annual Meeting Alberta, Canada
May 31- Jun 3, 2007 CSA/UCSD Annual Meeting & Clinical Sheraton San Diego Hotel & Marina, www.csahq.org
Anesthesia Update San Diego, CA,
Sept. 28-30, 2007 South Carolina Society of Anesthesiologists Grove Park Inn, Asheville, www.scanesthesia.com
Annual Meeting North Carolina
255 W. MICHIGAN AVE.
P.O. BOX 1123
JACKSON, MI 49204
PHONE: (800) 242-1131
FAX: (517) 787-0529
WEB SITE: www.anesthesiallc.com
PRSRT STD
US Postage
PAID
Holland, MI
Permit No. 45
ANESTHESIAANESTHESIA
BUSINESS CONSULTANTSBUSINESS CONSULTANTS

Anesthesia Business Consultants: Communique fall06

Recommandé

Recommandé

Contenu connexe

Plus de Anesthesia Business Consultants

Plus de Anesthesia Business Consultants (20)

Dernier

Dernier (20)

Anesthesia Business Consultants: Communique fall06