Responses on time management for prosthetists

Responses on time management for prosthetists

Jessica Longoria

5/22/2018

I received many request for the responses I received. Below is my initial
question to the list serv and the three responses I received. And thank
you to the three prosthetists who took the time to respond. I appreciate
it!

Prosthetists,

Can you share your daily/weekly schedule that you manage throughout the
week? What time do you start work, leave work, lunch break? How many
patients do you typically see a day? How long for each appointment type
(fitting, casting, eval, follow up)? Do you order your components? When
do you modify, do patient notes, order parts etc? And how much time do you
alot for these items and tasks?

Thanks for your feedback!

Response 1.

I will skew your results...I am a one man facility. 99% prosthetics. I
start my day btwn 6&7am & end it sometimes at 3p & other times at 6p. Avg
escape time is 4:30p. M-F. I work 60% of Saturdays- 0-2pts on Sat. 3
out of 5 days I take my wife to lunch; a 1hr break. Other days I barely
sit down for lunch or eat while typing my notes. Since I do all my own lab
work, except laminations, I see avg of 4pts/day. Typical appts are for
1hr. Some fittings we stretch to 1.75hrs as I work a great deal on
fundamentals for prosthetic gait. Initial consults/eval are also 1hr
sometimes more if pt &/or family have a lot of questions. Typical follow
ups 45min-1hr as I gather as much info about what they are doing with their
device (function & wear time), problem solve, make adjustments PRN, touch
on gait mechanics & sock management. I find that you get more truthful
info when you're just chatting with the pt vs drilling them with
questions. Yes, I order everything. There is no set time or day for
ordering. Usually happens when I am in the test socket phase; I ensure
that I have the needed liners, socks & components for the test fittings &
castings currently in the system. Modifying happens when I have time-
usually btwn pt visits the day after casting or Saturdays if casted Th or
Fri. Same with forming test sockets. Ideally I get my notes done ater
each pt. Realistically that doesn't happen that often. I write notes 1st
thing in morning, over lunch, at end of pt visits & sometimes at night
after I have dinner.

Response 2.

My typical schedule or the one that I think is ideal is working daily
from 9 to 5. I have scheduled the office to be closed on Wed afternoon and
all day Friday. This gives me time to take care of paperwork, lab work,
etc.

I am a one-person shop, with a part time tech who comes and helps when I
have a lot to do. He has been coming about 4 days per week lately to keep
up.

Since I am listed as a business with Custom Prosthetics in the CMS
application, I am exempt from the 36 hour minimum requirement to be open to
the public. With this status of being Custom Prosthetics I can go so far
as having By Appointment Only on the door, or put whatever hours I want
to have, as long as it matches what I have submitted to CMS on my
application. I put on CMS application that I am open Mon: 10-12, 2-3:30
Tues: 10-12, 2-3:30, Wed: 10-12 Thur: 10-12, 2-3:30 Fri: closed.

This is now the only time that a CMS auditor/inspector can drop in and hold
me accountable to these hours. IF I am out of the office for the week, I
just have to put a sign on the door that I am closed from time/date until
the time/date when I will be back. If an inspector comes and sees this
sign, and the door is locked, I am ok. IF he comes and the door is locked
when I am supposed to be open, THEN I can lose my Medicare number. You
have to be really careful with this, I know that CMS has taken some
provider numbers away because they were not open when they were supposed to
be open.

 As for how to manage my time.... that depends on the day, where I am with
the patient progress, etc. Some days I spend basically 8 hours in the lab
modifying casts, making check sockets, laminating sockets, etc. There are
other days, like today, a Friday, where all I am doing in paperwork (my
least favorite part of the process). I have sent about 5 letters to
doctors asking them to please send me the chart notes with the exact
language and information to support medical necessity for a prosthetic leg.
I even write an example for them to use to write in their chart notes
about the patient, their daily activities, how the prosthetic leg will help
them, also noting the K-level of the patient which was determined by a
Physical Therapist, etc. I also send the prescription with this letter
for them to sign and return. A LOT of the time, we only get the signed
prescription back, and NO chart notes. I sometimes have to call 3-4 times,
and then I get the patient involved and ask them to talk to their
physician, explain to them that their leg is READY to get, but they cannot
get the leg until I get the chart notes from the physician. That usually
does the trick, the physician does not want to be seen as the bad guy who
is standing in the way of them walking.

Yesterday I spent 4 hours on the phone with Anthem trying to get them to
re-process a claim for an upper extremity iTouch hand. They approved it in
the beginning and now are saying that I am not in the network to provide
this service. BUT we have all of the documentation stating that I AM in
the network and it was all approved before I started.

So, I never know from day to day what my schedule has in store for me.

Ideally I would like to be able to see 3-4 patients per day, have time to
do the chart notes when I am finished with the patient, and keep up that
way. It does not always work that way.

Today, I have 2 more of these example letters to send to the doctors, NEW
patients, which takes me about 1 hour per patient to write the example and
including WHY they need this leg, etc.

I wish I had someone who understood what must be in these chart notes to
write these notes to send to the physician to put into their chart notes.
That would save me a LOT of stress and problems. But I would have to have
TOTAL confidence and trust in this person. This is critical to have it
perfect so that I will get paid, and also pass any audit that will happen
down the road.

I have been audited on hundreds of claims, LITERALLY!!! Two years ago, I
was getting audited on EVERY claim, K-1 , K-2, 3 4, it did not matter!!!
They seemed determined to find at least ONE error in my charting and my
documentation so that they could screw me out of some money. They audted
EVERY claim, and I passed EVERY claim!!! I have the system down to a
science, and have the paperwork that I know will pass.

I have the patient see a PT to do the Amp No Pro evaluation. This PT has
NO connection with me, my business, etc. They make a totally unbiased
decision on the K-level.

Then I send this in a letter to the physician, the patient is K-whatever
level, he/she can do the language exactly from CMS, ability to negotiate
uneven terrain, or whatever.

Then I get the chart note from the physician, I make sure they wrote
EVERYTHING perfectly that will pass an audit, explaining WHY they need a
leg.

Then I make sure MY notes are specific in what I have provided, what the
patient is capable of doing, including my assessment of what K-level they
are (which will agree with the PT evaluation, which is always does).

The patient signs the delivery ticket with the serial numbers, part numbers
or whatever included on the invoice/delivery ticket.

With all of this information, I will pass any audit, and I have done so now
since Medicare has been doing these audits.

I hope this is not too much information for you. But my point is that
getting all of this information, making sure it is all perfect, and calling
the physicians to beg for them to write the notes, and WHY they need to do
this... It is not MY policy or rule, but this is Medicare and EVERY
insurance company that is following Medicare guidelines. I am now getting
audits from United Healthcare, also from Anthem, and another insurance.
They require a prior auth, and then after it is all done, they want the
SAME paperwork again to approve payment for this limb. It is crazy, and
TIME consuming.

So, based on that, NO day is every the same, NEVER as planned, and I have
to be totally flexible. As much as I want and NEED Wed afternoon off, to
take care of my own stuff, house stuff, school stuff for my son, etc., I
hardly EVER get to take the afternoon off, I am here working, and even
seeing patients who claim that this is the ONLY time they can come to see
me due to the driver's work schedule. So, I will go ahead and see them
when I want to be closed. I am just not tough enough to tell the patient
too bad you have to come when I am open....

I spend about 6 hours doing paperwork and lab work, for every 1 hour I
spend with the patient. I see them maybe 4 times (cast, check socket,
delivery of limb, follow up....4 hours.) Then I spend at least 24 hours
on the phone getting pre auth, or doing the lab work, laminating even when
I have my part time tech, I still have to be there to make sure it is done
RIGHT.

Response 3.

Goal of 5 hours out of 8 scheduled in a day.
Cannot affect ratio of those patients being seen for new prostheses VS
maintenance, works itself out.
See established patients for 1 hour follow up every 3 months. None of that
call me if you have any problems. Some of those appointments are
non-billable as no labor was performed. Part of good care and developing
relationships.
Casting/ eval =1 1/2 hr
Test sockets= 1 hr
Dynamic alignments and fittings= 1 1/2 hr
Practitioner codes, modifies, puts parts into cart and chart. Tech fills
cast and fabricates, works closely with prosthetist.
Goal is charting done in 24 hrs.
Ratio is about 60/40 pt care to documentation. If takes more than 8 hours/
day, it is prosthetist's responsibility to complete. Reasonable to expect
50 hr workweek. Many weeks are less. We have ability to do EMR at home,
but most finish before going home.


*Jessica Longoria, CMF*


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