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Implementing Policies and Procedures into your Medical Practice

As a child, my mother always stressed the importance of being neat and organized. She told me that I should be able to walk into my house in the dark and find anything that I need because I know exactly where it is. At the time, I didn’t know how those values would apply to not only my personal life but also my business life. With that being said, life gets in the way and there are days when my office or my house is in disarray. This reduces my productivity because I have to spend time searching for important documents at my office or my car keys at home.

I place a lot of emphasis on maintaining a neat and organized medical practice for all of my clients because it will make their life easier for numerous reasons. The best way to maintain a neat and organized medical practice is to implement policies and procedures that you and your employees must strictly follow. These policies and procedures can range from physical security of the facility, security of HIPAA protected information, employee time-keeping, janitorial services, medical substances and pharmaceutical drug internal audits, etc.

Everyone on the staff should be held accountable for the tasks that they perform or fail to perform. As the owner of the practice, you should periodically review the procedural tasks to make sure that everyone is performing their duties adequately and on-time. It only takes one missed log entry for a crisis to arise. This brings me to my next point, you should implement a policy where everyone on your staff must sign off on or use a unique identifier and password that only they have. This is important so that you can trace most of the activities that occur in your practice. Providers have to play “big brother” and watch over their practice because as you let things slide so will your staff and certain policies and protocols will be abandoned.

It is not unusual for a provider to contact me after a regulatory authority, such as the Florida Department of Health (“DOH”) or the Centers for Medicare & Medicaid Services (“CMS”) has contacted them about a potential violation within their practice (i.e. billing). Typically, these regulatory bodies make certain requests for documentation in their correspondence. I am often surprised by how unorganized the medical practice’s files are and the lack of adequate policies and procedures within the practice. As I mentioned earlier, I understand that life gets in the way, but being organized and having policies and procedures in place to maintain organization should be a priority. Lack of time will not be a valid excuse for the regulators. In fact, there are several state and federal record-keeping requirements that a medical practice must strictly adhere to or run the risk of receiving fines and penalties. Take one day or weekend and work alongside your staff to clean up those files and perform an audit of your inventory.

The following is a sample of some of the steps that I would take to ensure that my medical practice is neat and organized:

  • Create a formal policy and procedure manual that every employee must sign and adhere to.
  • Document everything and save it on-site as well as off-site on a cloud-based service and limit employee access to those documents.
  • Maintain employee files, including, but not limited to, emergency contacts, termination letters with reason for termination, professional and drivers licenses, periodic drug test results, personal and medical history, progress reports, professional and academic performance evaluations etc.

In the event that you have to self-report or if any state or federal regulatory authorities contacts your practice for a potential violation of a law or rule you should be as prepared as possible. Implement policies and procedures into your medical practice that will protect you and will ensure that your practice runs efficiently and smoothly. A healthcare attorney can assist you in creating a fully functioning policy and procedure manual specific to your practice.

My DEA Number was Stolen by an Employee and Used to Buy Controlled Substances

Most doctors have various licenses that provide them with unique identification numbers. If any of these identification numbers find their way into the wrong hands it can be detrimental to the healthcare provider’s practice, their patients, and the public. Doctors hire support staff to run their practice efficiently by perform tasks that they don’t have time to do or don’t have the training to perform. This employer-employee relationship requires a certain level of trust from both parties because a bad act by either party can have a negative impact on the other party’s license, privileges, or reimbursement for services. Some of the support staff working in a doctor’s office may have access to HIPAA-protected information and a doctor’s unique identification numbers, such as his NPI and DEA numbers. What should you do if one of your employees steals your DEA number and uses it to self-prescribe controlled substance through e-prescribing or traditional prescription pads? What if they use your DEA number to order controlled substances for the practice without your knowledge or consent? Doctors should also be concerned with their potential liability for the unauthorized use of their DEA number.

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