handling patient calls

[ctts]

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I am in a solo practice situation, two office locations, 4 medical assistants. No nurses, NPs, PAs.

So all patient phone calls regarding clinical matters are forwarded to me through the MAs. This includes routine med refills, opioid refills. Also calls like medication did not help or could not tolerate, can I try something else? Or last injection did not help, what is the next step? Or I had my MRI, can the doctor review it and let me know what the next step will be? Or last treatment helped and I was great for the past few months, but I have a severe flare-up of pain, can hardly get out of bed, and I cannot get an appointment to come in for 3 weeks, and I cannot wait that long, what can I do? And the list goes on and on.

For more straightforward communication, especially if there was already a plan B in place, then I can have my MAs execute plan B. But a lot of the more complex phone calls involving decision making take quite a lot of time to handle. I find myself probably working an extra hour per day on average, but often more, just handling these situations. I try to avoid calling patients back and try to communicate through my MAs, but some situations seem best handled if I call the patients directly, so I do when necessary. Part of the problem is that I am stretched thin between two locations, so appointment availability is limited. Often times, the next available appointment is not for 2-4 weeks, and in some cases patients are not able or not willing to wait that long. It's not about the money, but it also does not seem quite fair that we have to do all this extra work without any way of being compensated.. Just curious to know if anyone else is out there in a similar situation and how your handle it. Or if you are not in a similar situation, what suggestions you may have. I am thinking I may need to consider adding an NP or PA, even though I don't think our practice is really set up to easily accommodate one, not to mention that I doubt the additional revenue they bring in could bring in would cover their salary.

 

[DOctorJay]

hire another physician (not a midlevel)
work the patient in on the next day for an office visit if you're changing meds or need to evaluate for a different procedure
set up a telemedicine visit over your lunch or at the end of the day

if you don't do this then yes you're doing a lot of care for free

 

[Laryngospasm]

No free care.. you need someone to turf this crap to but the general answer is office visit. No.. I won’t review your mri,, come up with a plan discuss over the phone.. talk about risk blah blah blah. Your time is not free.. you are only as valuable as you make yourself. Tell patients if a medicine doesn’t work or they have bad side effects to stop and you will discuss at the next visit.

 

[ctts]

Hire another physician... I get what you are saying. I just don't know that we have to patient volume and referral numbers to sustain another physician. I think I am in a situation where it is just a little more work than I can handle alone, but not enough work to support another physician. Whether or not that is true, I don't know, but that is my impression of where I have been for quite some time now.

Work the patient in...I do that already sometimes, especially for urgent procedures. I also do work in extra telehealth appointments during lunch. I just feel I am near my max capacity and will drown if I add on more than I already add on.

To larngospasm...if you tell patients to stop the med and discuss at next visit, how long of a wait to see you on average?

There are so many situation where I would like to say, wait to discuss until next visit...but for example, let's say patient has to wait 2-4 weeks to get in to review MRI, then if injection is planned, another 2-4 weeks to get prior auth and schedule injection...the timeframe of waiting gets to be ridiculous from the patient perspective. If I schedule some of these patients in just to discuss meds, that takes away potential appointment slots for higher priority patients that need injections scheduled... I feel so stuck. But thanks for your responses, as I think it will help reevaluate my situation, and perhaps reconsider the possibility of trying to hire another physician.

 

[Ronin1]

these kind of calls are mostly handled by my nurse. I think you may need to upgrade your staff to save your sanity. Your time is priceless

 

[ctts]

these kind of calls are mostly handled by my nurse. I think you may need to upgrade your staff to save your sanity. Your time is priceless

How about in the relatively basic scenario of patient stating medication does not work or having side effects, is there something else they can try. Does the nurse discuss other medication options and send the prescription without having to come to you? (I am meaning non-opioid meds for the purpose of this discussion.)

 

[Ferrismonk]

You have just a few options here:

1. Hire more clinical staff, either another doc or an APP to handle routine clinical stuff.
2. Do less medical management, especially opioids.
3. All of the questions that you feel you must answer personally before the patient's next scheduled appointment get a telehealth visit. Don't give away free phone calls.
4. If it's an emergency, that's why there is emergency rooms.

 

[ctts]

2. Do less medical management, especially opioids.

Of course especially with regards to opioids, but how about non-opioids? What if there are reasonable medication options to try? Especially when non medication options have been exhausted? I really wish I could tell all my patients that I am not going to prescribe any medications because I don't want to, but that is hard to do if putting patient care first, when there are medications options that have the potential to help, regardless of whether or not I personally believe that medications are that helpful. Not expecting a response to this, but just putting out my thoughts. I suppose everyone has to find some balance between the two extremes of prescribing something to everyone or not prescribing at all.

 

[Agast]

If you ordered an MRI on the patient there should be a follow up appointment to discuss it, and your MA tells them to wait until that appointment. I put my MRI patients at 2 week follow ups. Injection patients follow up in 2-4 weeks depending on how catastrophizing they looked in office. Get a sense of who needs to see you sooner rather than later and it cuts down on the number of patients needing to be forced into a different date. I run my clinic with 3 MAs and my lead MA handles phone calls throughout the day and is authorized to force patients onto the schedule if they need it.

 

[ctts]

Agast, 2 weeks FU after MRI certainly is reasonable for relatively non-urgent pain. How about the patients that are in "severe" pain? When they come in 2 weeks later to review MRI and are still in severe pain, and next step is injection, do you do it on the same day? Or do they have to wait another 2 weeks to schedule an injection? I find they generally don't take that too well, so I try to do injection on same day when possible. Of course if insurance requires prior auth, doing injection on the same day is not even possible... so then they say something to me like, I had to wait 2 weeks (or more) to see you just to get my MRI results and now I have to wait another 2 weeks (or more) for insurance approval and scheduling my injection?! But I am in pain NOW, so what can you do in the meantime? Then of course that's when I have to discuss medications we can try in the meantime, hopefully non-opioid, but not always. I think part of my problem is just trying to keep all my patients happy, which is impossible. Sometimes I think I just need to care less, but that's hard for me to do.

 

[Ronin1]

She kind of does the initial conversation with the patient. The she sends it in to me if needed. She’s been with me 10 years so she has a good knowledge base. Sometime I review a scan and she will call the patient to schedule for intervention if no authorization is required otherwise they need a visit. But she saves me a lot of time and aggravation.

 

[Ronin1]

“Sometimes I think I just need to care less,”

secret to happiness just not good patient care though

 

[DOctorJay]

Agast, 2 weeks FU after MRI certainly is reasonable for relatively non-urgent pain. How about the patients that are in "severe" pain? When they come in 2 weeks later to review MRI and are still in severe pain, and next step is injection, do you do it on the same day? Or do they have to wait another 2 weeks to schedule an injection? I find they generally don't take that too well, so I try to do injection on same day when possible. Of course if insurance requires prior auth, doing injection on the same day is not even possible... so then they say something to me like, I had to wait 2 weeks (or more) to see you just to get my MRI results and now I have to wait another 2 weeks (or more) for insurance approval and scheduling my injection?! But I am in pain NOW, so what can you do in the meantime? Then of course that's when I have to discuss medications we can try in the meantime, hopefully non-opioid, but not always. I think part of my problem is just trying to keep all my patients happy, which is impossible. Sometimes I think I just need to care less, but that's hard for me to do.

Tell them they can pay cash and you’ll do it that day, otherwise their insurance dictates their care. Yeah you will need to prescribe some meds if they decide to wait.

I typically review my patient MRIs and have my nurse review my findings and I offer them a choice between a procedure or an office visit to review imaging first and discuss the options before setting up the procedure.

Telehealth imaging reviews, especially where you can share your screen and images, might make sense.

You’re a conscientious doc trying to do right by your patients in a system that fights against this.

 

[Laryngospasm]

When an injection is planned do it as quickly as insurance/schedule allows. Make sure patients understand this or alternatively they can do cash pay. If this is explained you very rarely will get grief.

 

[kstarm]

I am curious if people are running into more issues with phone calls with the CARES act and automatic release of radiology results to the patient? I have not yet seen much change, but have heard my oncologists colleagues having more difficulties with patients calling immediately after their scans/labs wondering what is going on before the doc has even had a chance to review it.

OP: Figuring out what is really urgent and what isn't is helpful. I get a handful of referrals for "urgent back pain patient needs to be seen in one week" on chart review the first 6 diagnosis are psych related and the urgency is that the referring provider doesn't want to work with the patient. I don't double book those or move them up. Some I will just say I don't have space for at this time if they truly do not look appropriate for our pain program. Lots of patients I do overbook which is easier with telehealth. I purposely leave a couple open slots in my schedule to allow for flexibility. They always fill, but with patients I need to get in sooner for some reason or another, not what someone else thinks is urgent. Also if you are at max capacity you may need to change your template to allow more follow-ups and less new patients until you clear out some people and then switch back to your current.

 

[Ferrismonk]

Of course especially with regards to opioids, but how about non-opioids? What if there are reasonable medication options to try? Especially when non medication options have been exhausted? I really wish I could tell all my patients that I am not going to prescribe any medications because I don't want to, but that is hard to do if putting patient care first, when there are medications options that have the potential to help, regardless of whether or not I personally believe that medications are that helpful. Not expecting a response to this, but just putting out my thoughts. I suppose everyone has to find some balance between the two extremes of prescribing something to everyone or not prescribing at all.

We don't do much chronic medical management in my current office, but I did a ton in my previous job. If you look into it, aside from insurance issues, 99% of your patient problems are likely from medication management issues.

"Lyrica only helps when I take 4, so now I'm out early."
"The flexeril didn't work, but I took a friend's Soma which worked great, can I try that?
"I didn't take the motrin because I read the side effects and got scared. Yes, I still smoke." etc etc

That being said I will make recommendations for OTC medications (voltaren gel, etc) and will sometimes do a gabapentin, etc, but it's clear that I am the consultant and not the primary medication person. What the patients need from me is my specialty care, an accurate diagnosis and a treatment plan that includes appropriate therapy, lifestyle modification, and interventions. Nobody is being saved by adding baclofen or elavil and anyone with an NPI can handle this.

Agast, 2 weeks FU after MRI certainly is reasonable for relatively non-urgent pain. How about the patients that are in "severe" pain? When they come in 2 weeks later to review MRI and are still in severe pain, and next step is injection, do you do it on the same day? Or do they have to wait another 2 weeks to schedule an injection? I find they generally don't take that too well, so I try to do injection on same day when possible. Of course if insurance requires prior auth, doing injection on the same day is not even possible... so then they say something to me like, I had to wait 2 weeks (or more) to see you just to get my MRI results and now I have to wait another 2 weeks (or more) for insurance approval and scheduling my injection?! But I am in pain NOW, so what can you do in the meantime? Then of course that's when I have to discuss medications we can try in the meantime, hopefully non-opioid, but not always. I think part of my problem is just trying to keep all my patients happy, which is impossible. Sometimes I think I just need to care less, but that's hard for me to do.

You should be reviewing every imaging study that comes across your desk as it becomes available. If it's an urgent thing, either call the patient or have them come in for an appointment ASAP (Yes, double book). Otherwise they wait until their normal diagnostic review visit. You will likely need to evaluate them in office, with review of imaging, before you can schedule your procedure anyway. I don't do same day injections because you won't get paid for either the procedure or the office visit. Nobody should expect you to do work for free.

Yes, patients will complain about the delays and rightly so. I make 100% sure they are aware this is the insurance company's fault and give them both the insurance's number and the contact info for the State's Insurance Commissioner. If they don't want to wait for the insurance's MRI auth, they can go to Basha and get their MRI tomorrow for cash. If they want an injection urgently, I offer to get them in the next day (yes, double book if needed) if they wish to pay out of pocket. Every single person grumbles about the insurance company and waits their turn, but they don't blame me. It's not me delaying them

For people who state they are in "pain NOW, so what can you do in the meantime?" I sympathize and tell them we'll do everything we can to get them in for their procedure as fast as possible. If it's truly a severe AND acute issue (hot radic, etc) that you cannot call the insurance company and get emergency auth for, you can always give IM steroids and/or a Medrol Dosepak. You can also do a freebie ESI if you're so inclined.

If you go with the short-term opioid path without clear cause of the pain, you'll often find that "only that percocet you gave me worked for my pain" and they'll expect you to continue. If you don't, they'll blame you for their pain. Opioids aren't for chronic pain flareups, they're for broken bones and after surgery.

 

[deleted875186]

Picking up a patient phone call is rolling the dice, even if it sounds straightforward, they’ll hit you with a thousand extra questions, frequently hard to get off the phone. I think fielding phone calls is good patient care, but until it is made billable I try to avoid anything on the phone.

I’m split about what to do for MRIs, I like to call people, I think they appreciate it if yojr waiting on imaging, but almost everything can wait until follow up.

 

[painfree23]

We don't do much chronic medical management in my current office, but I did a ton in my previous job. If you look into it, aside from insurance issues, 99% of your patient problems are likely from medication management issues.

"Lyrica only helps when I take 4, so now I'm out early."
"The flexeril didn't work, but I took a friend's Soma which worked great, can I try that?
"I didn't take the motrin because I read the side effects and got scared. Yes, I still smoke." etc etc

That being said I will make recommendations for OTC medications (voltaren gel, etc) and will sometimes do a gabapentin, etc, but it's clear that I am the consultant and not the primary medication person. What the patients need from me is my specialty care, an accurate diagnosis and a treatment plan that includes appropriate therapy, lifestyle modification, and interventions. Nobody is being saved by adding baclofen or elavil and anyone with an NPI can handle this.


You should be reviewing every imaging study that comes across your desk as it becomes available. If it's an urgent thing, either call the patient or have them come in for an appointment ASAP (Yes, double book). Otherwise they wait until their normal diagnostic review visit. You will likely need to evaluate them in office, with review of imaging, before you can schedule your procedure anyway. I don't do same day injections because you won't get paid for either the procedure or the office visit. Nobody should expect you to do work for free.

Yes, patients will complain about the delays and rightly so. I make 100% sure they are aware this is the insurance company's fault and give them both the insurance's number and the contact info for the State's Insurance Commissioner. If they don't want to wait for the insurance's MRI auth, they can go to Basha and get their MRI tomorrow for cash. If they want an injection urgently, I offer to get them in the next day (yes, double book if needed) if they wish to pay out of pocket. Every single person grumbles about the insurance company and waits their turn, but they don't blame me. It's not me delaying them

For people who state they are in "pain NOW, so what can you do in the meantime?" I sympathize and tell them we'll do everything we can to get them in for their procedure as fast as possible. If it's truly a severe AND acute issue (hot radic, etc) that you cannot call the insurance company and get emergency auth for, you can always give IM steroids and/or a Medrol Dosepak. You can also do a freebie ESI if you're so inclined.

If you go with the short-term opioid path without clear cause of the pain, you'll often find that "only that percocet you gave me worked for my pain" and they'll expect you to continue. If you don't, they'll blame you for their pain. Opioids aren't for chronic pain flareups, they're for broken bones and after surgery.

What do you mean by “don't do same day injections because you won't get paid for either the procedure or the office visit.”
If u get the auth before hand u may?

 

[deleted875186]

What do you mean by “don't do same day injections because you won't get paid for either the procedure or the office visit.”
If u get the auth before hand u may?

100% for one service, and 50% for the second service, even if covered or no PA required.

 

[Agast]

Agast, 2 weeks FU after MRI certainly is reasonable for relatively non-urgent pain. How about the patients that are in "severe" pain? When they come in 2 weeks later to review MRI and are still in severe pain, and next step is injection, do you do it on the same day? Or do they have to wait another 2 weeks to schedule an injection? I find they generally don't take that too well, so I try to do injection on same day when possible. Of course if insurance requires prior auth, doing injection on the same day is not even possible... so then they say something to me like, I had to wait 2 weeks (or more) to see you just to get my MRI results and now I have to wait another 2 weeks (or more) for insurance approval and scheduling my injection?! But I am in pain NOW, so what can you do in the meantime? Then of course that's when I have to discuss medications we can try in the meantime, hopefully non-opioid, but not always. I think part of my problem is just trying to keep all my patients happy, which is impossible. Sometimes I think I just need to care less, but that's hard for me to do.

The follow up is 2 weeks after I’ve ordered the MRI - that gives them time to schedule it, radiologist to read it, usually I get the results 2-3 days before their appointment. Put yourself in the shoes of the patient - a lot of the pain is driven by anxiety and fear of the unknown. You would be surprised how many patients think “bad back pain” = “if I move the wrong way I will be paralyzed.” Start them on gabapentin or Lyrica if they need something, muscle relaxant at night if they can’t sleep, around the clock NSAIDs. A lot of people who ask for something for pain don’t mean they want you to give them narcotics. They want to feel like there’s some sort of plan they can follow and that you care. If they really need something 20 tabs of Tylenol codeine if they’re sweating or hydrocodone if you’re feeling soft-hearted. Think about how you’d want your family to be treated.

I can’t do same day injections. Usually 3-7 days. I’ve only had one person flip out on me for not doing it on the same day.

 

[callmeanesthesia]

OP, when I hit that point in practice, I hired a PA. Best decision I ever made. YMMV - It really depends on hiring a good mid-level who understands their place in the team. I don’t worry about packing his schedule and maximizing profit, because when a patient calls in with a flare up of pain, my MA can offer them a next-day appointment with him. If they don’t want to see him and only want to talk to the doctor, then clearly it wasn’t that urgent. Need to talk to the doctor right now!!!? That sounds like an emergency and you should probably go to the ER. We’ll make an appointment for you tomorrow to follow up on your ER visit. (We aren’t actually that callous with them, unless they are really rude and demanding). If it’s beyond my PA’s comfort level or he’s not sure what to do with the patient, he will come and ask me. He mostly sees follow-ups, but some new patients. Mostly old folks with arthritis who need an RF.
Very rarely do I call a patient for MRI results over the phone unless it’s a scheduled telemed follow up visit. Pretty much only for “go to the ER” findings. If it’s cancer I first try to have the MAs move the f/u appointment to same or next day as the results become available because I don’t feel like that should be delivered over the phone.
Meds aren’t working? Unless I’d pre-planned a next step that I can just e-Rx, they get a telemed follow up to discuss. I don’t manage opiates so that makes those much less common.
I try to arrange same-day procedures for acute disc herniations, insurance permitting. Otherwise they can generally wait. However, if they don’t require pre-auth or estimate (Medicare with a secondary), my scribe will schedule them before they leave. I also get some referrals for procedures from a local spine surgeon and fast-track them in - same day new patient appointment with my PA, followed by seeing me for the procedure the surgeon has ordered (he’s pretty sensible - rarely do I need to change anything).

 

[DesertDoc16]

I’m in my first year of PP. This thread is very helpful…. I have similar struggles. I have been very hands-on since I started, calling patients, accommodating with requests/visits/injections etc…. But that was only sustainable when I was slow and building my practice. A lot of those older patients were so impressed with the fact that doctor personally returned their phone call that they told all their retired friends and it helped significantly grow my practice quickly. So don’t discount the power of a personal phone call and it’s impact on the patient. Now that I am busier, I have had to be a little more selective in regards to these things, however I still try to return calls personally and it does take some extra time. But it pays dividends in ways you may not realize.

 

[DrMDAware]

Is it possible to call the patient (not FaceTime) at a random time (meaning not scheduled) and bill for it? Obviously you may talk about test results, prescribe a new medication etc…?

 

[afob100]

Is it possible to call the patient (not FaceTime) at a random time (meaning not scheduled) and bill for it? Obviously you may talk about test results, prescribe a new medication etc…?

Absolutely. Any time I open a patient's chart, there is a button to "create a now/immediate telemed encounter". I click that and then start documenting and bill normal office codes.

 

[DrMDAware]

Absolutely. Any time I open a patient's chart, there is a button to "create a now/immediate telemed encounter". I click that and then start documenting and bill normal office codes.

Thanks. Do some patients complain of a bill being created for “just a question”?

 

[RoloTomassi]

Absolutely. Any time I open a patient's chart, there is a button to "create a now/immediate telemed encounter". I click that and then start documenting and bill normal office codes.

I thought to bill a regular E&M office visit code it has to be a 2-way audio-visual, not just audio. I believe there are separate phone call codes that don't reimburse well.

 

[afob100]

Thanks. Do some patients complain of a bill being created for “just a question”?

If it's a simple question, my secretary will respond (she will send me the message in epic and I'll answer, then she will call patient ...no charge).

If it can be answered later, I tell her to schedule patient for clinic or telemed visit. If the patient demands to talk to the doctor now, then I add them myself for telemed at lunch usually.

I only had one patient complain about being billed - she called every other day for a week demanding to speak with me. I ordered an mri during these visits and went over them with her - and ordered an injection. I explained this to admin and they supported me in my billing. I can't document appropriately without creating an actual clinic/telemed encounter for this level of work.

 

[Laryngospasm]

If they complain ask them if their attorney gives them advice for free and when they say no tell them your training was over twice as long and you don’t either.

 

[Ducttape]

as long as you don't do this for medicare patients...

you cant just up and call a patient and bill them for the conversation out of the blue. they have to be agreeable. have your secretary call beforehand.

telephone encounters do have separate codes. 99441-99443. time based billing. pays like crap. like $14 for 99441 and around $41 for the highest level 99443.

if you do a telemedicine encounter via video - doximity or FaceTime or Skype - then you get to charge "regular" cpt codes 99211-99215