Taming your telephone.
Long states, "The American Medical Association estimates that between 5 percent and 10 percent of all health care expenditure is unnecessary....Estimates by consumer activists are twice those of the AMA."* To put this statement into perspective, let us assume that the quality management system approves 85 percent of reviewed procedures and 15 percent are referred to the physician executive. Also, let us assume that the physician executive does not approve one-third to one half of these requests. Simple arithmetic tells us that the overall denial rate is somewhere between 5 and 7.5 percent. The two above statements are in agreement and are probably correct.
The next logical questions are: "Who generates these request?" "Why are they created?" "What are the reasons behind this type of behavior?" and "Why are requests made for inappropriate and/or unnecessary procedures?" Let us examine provider characteristics.
The Authority Position. Many providers believe that only they can make decisions about their patients because "the patients belong to them". They feel that what they perceive is final. They think that they are not held accountable to the local, national, or professional standards.
Precommitment. Often the provider has made a judgment and has told the patient that the procedure needs to be or must be done. This request is processed and, when it is not approved, the confrontation begins. It is difficult for the provider to accept the task of convincing the patient that it was not necessary or appropriate.
Altered Perception. Mark Twain stated, "To a man with a hammer, a lot of things look like nails that need pounding". This behavior pattern is not foreign to providers. In this regard, I would cite the problems of the coronary angiogram and the colonoscopy, which are considered by select groups to be the gold standard. This standard may be perceived, depending on the point of view, as the highest priced procedure or the best procedure for the patient. Some providers have blinders that prevent them from seeing a global view of a case.
More Is Better. Certain providers are famous for "megabuck workups." They are obvious by their cost-ineffective behavior. It is nice to know everything about everything, but totally impractical. This does not reflect high-quality behavior.
Supersafe Physicians. This characteristic is common and accounts for great financial loss. It is driven by the legal system and is known as defensive medicine. It will not be solved until some system of tort reform is developed and adopted.
Disadaptability. This is the pattern of rigid habits of practice. The usual response is, "I do not do it that way!" Standards and workflow patterns of medical practice are in constant and dynamic change. There is usually more than one route to a given diagnostic solution.
WNDITWB, "We Never Did It That Way Before." Old habits die hard. Probably the most well-known habit is represented by the statement, "Once a c-section, always a c-section." Fortunately, the collective medical community is now beginning to accept the concept of limited resources and is reexamining some of these old patterns.
Institutional Benefactor. An increasing problem in medicine is economic credentialing. The provider is required to admit a certain number of patients to an institution to maintain admitting privileges or gain certain procedure privileges. Most institutions will deny this practice. However, it is a very powerful inducement to overutilize. This is not good for patients or medicine. It leads to unnecessary care and procedures.
Personal Benefactor. This characteristic may be very difficult to evaluate. This group of providers is clever and has financial gain at stake. They will be identified by computer methods evolving from databases. Fortunately they are a minority.
This last characteristic is totally under the control of the provider. In many conversations, it is difficult to identify the mixture of elements involved. When talking to a provider, the physician executive needs to be aware of the complexity of the forces motivating the provider.
Why the Phone Is Chosen as the
The physician executive requires different skills from those acquired in the training of a physician. In medical school and practice, the physician deals in depth with the nuances of histories, physical examinations, and arriving at a diagnosis and treatment plan. The length of this encounter is limited only by the curiosity and diligence of the physician.
The physician executive reviews data extracted and summarized from a chart or a computer screen. When the physician executive places a call to the provider, he or she uses telephone skills, along with accumulated training, experience, and demonstrated competence. He or she must make accurate and correct decisions in a rapid fashion without compromising quality of care.
Lets consider the advantages of phone versus face-to-face encounters.
* It is easier to say "No."
* It is much quicker than person-to-person negotiation. The longer the conversation, the more likely the real issue will be obfuscated or manipulated.
* It is more direct. During a phone conversation the parties tend to stick to the point and are more impersonal.
* It is easier to make a quick exit on the phone than in face-to-face negotiation.
* Listening becomes an art. Once you have stated your reason for calling, listened to the physician's logic, and rendered your decision, you become mute. The provider may talk compulsively, which could give you information that was not previously provided. Every statement that the physician executive makes gives the provider more information to challenge the decision. Therefore, continually reevaluate your "listen-to-talk" ratio.
Suggestions for Phone Efficiency
Preparation for the call is critical. The physician executive must plan ahead, much as one plans ahead for a formal presentation or a board meeting.
* Be a caller and not a callee. The party placing the call has the "high ground." If the provider has the details of all the questions that the physician executive will ask, the provider will be forewarned and will have the answers the physician executive wants to hear. This is why many physician executive calls are diverted to a secretary, a scheduling assistant, an insurance clerk, the business office, a physician's assistant, or "whoever." The "whoever" is only interested in getting the procedure approved.
If a physician calls another physician in a review scenario, it is only courteous for the called physician to respond. It is also good business, because the exasperated physician executive is less likely to certify a case after spending a long time on the phone with sequentially less knowledgeable personnel.
* Plan and prepare. Decide if your answer will be yes or no, unless there is additional information. Someone once said, "If you fail to plan, you plan to fail." You may not know the exact track the conversation will take, but you will have an idea of the possible responses. You should be prepared with several counter points. Your checklist before placing the call should include a notation based on the information provided:
* Prepare the key reasons given for the procedure. This would include history, physical examination, laboratory results, x-ray results, probable diagnosis, procedure, and medical necessity for the procedure
* Run through conversation mentally. This can be done in seconds.
* Have all the facts in front of you. This should be in your mind or in written form for quick reference. If the attending physician feels the physician executive is hesitant and uncertain, the physician executive has given up the high ground.
* Concentrate without distractions. Distractions include other incoming calls and persons fumbling around on the desk for papers. The physician executive cannot carry on two conversations at one time.
* Summarize. If you approve the request, everyone will be happy. If you do not approve the request, tell the physician that you cannot approve it. Human nature creates selective hearing. The mind does not hear what it does not want to hear.
* Place calls early. The attending physician staff will be more receptive to early morning calls. Early calls are perceived by the staff as requests for information from helpers or expediters rather than those late afternoon calls from frustrating antagonists. Remember that answering services are paid to be polite and expedient.
* Don't tell the physician how to practice medicine. The ego structure of the physician is a topic for a book.
* Don't be intimidated. When the physician executive's decision is contrary to the provider's expectations, it is not uncommon to elicit a series of well-known behavioral responses.
* Return calls promptly. Return incoming calls as promptly as possible after you have collected the information needed. Procrastination does not set the stage for sound negotiating. Deal with issues while they are fresh and clear in your mind. You can always tell the attending physician that you will have to consult with your panel of experts and will get back. If you try putting off the call, the attending has a way of sensing it, and this leads to needless confrontation.
* If the attending physician hangs up while you are on another incoming call, call back immediately. The attending physician doesn't like waiting on the line any more than you do. Call back as soon as you can, and apologize by explaining that you were on another call. The attending physician will understand.
* Be an expediter. Try to anticipate associated problems in reference to the case and clear them with one phone call. The attending physician's office staff may have used the wrong code, used the wrong name for the procedure, or requested an inappropriate length of stay. Give the attending an answer at the time of the original contact rather than in repeat calls. It will be appreciated.
Guidelines for a Successful
Time and frustration can be minimized by using certain guidelines that are common to all negotiations:
* Take the high ground. When you call, state your name, your employer, and the problem. Request the clinical history and logic for the requested procedure. Do not allow yourself to become engaged in a challenge about your credentials, your specialty, or the fact that the provider is, or is not, an expert. Do not allow yourself to be drawn into a position of making statements that you will have to defend.
* Control the agenda. Once the call has been placed and the initial control of the dialogue has been established, the physician executive needs to maintain control of the conversation. This is autocratic, but it is an efficient method of expediting phone calls. Follow the adage that "the one who controls the agenda, controls the meeting," but it must be applied in a fair and impartial manner.
* Be affirmative. When the decision is reached, be affirmative. If you project indecision, the provider will sense it and this sounds the bugle for the attack. Say "I cannot certify your request for the following reasons" and not "I don't think that I can approve your request."
* Avoid peripheral battles. Some attending physicians try to intimidate the physician executive by diverting the conversation. This pattern is an attempted detour of the conversation. Threats may take one or more of the following forms: inappropriate language, threat of legal recourse, patient retaliation, assertions that they are taking care of the patient and you are not, statement that you are a prostitute, assertion that you are trying save money for personal gain, statement that the provider is an expert and knows more than the physician executive, comment that the physician executive is to be pitied because he or she is not practicing medicine in the real world of medicine, threat to take it up with a specialty society, and so on.
If you try to respond to even one of these allegations, it becomes an ongoing verbal battle. At times, the physician executive must listen; however, he or she is playing the role of a psychiatrist. Simply state, "I am sorry that you feel that way, but it will not change my decision."
* Be as clear as possible. Some Physician executives have adopted the philosophy that they are required to "dance" or give an evasive answer. The answer should be honest, forthright, and as accurate as possible. If the physician executive announces the decision and reasons clearly, it will save time in appeals and correspondence.
* Say, thank you! Be sure to thank providers for their time and compliment them on how efficient their staffs were in handling the matter, even if it's not true. A simple thank you can totally disarm a provider who assumes that you are an adversary.
Pitfalls, or What Not to Do.
* Don't place calls at peak flow hours for the attending physician. If a physician executive has been in practice, he should remember that the provider's office staff becomes fatigued and even short-tempered as the day wears on. The worst time to place routine calls is in the late afternoon. The best time is early morning.
Some will contend that calls should not be placed with the answering service. However, the answering service is paid to take messages politely and transmit them to the office staff in a timely manner.
Primary care physicians usually are office-based and will tend to be available in the mornings. Specialty physicians usually are hospital-based and may not be as readily available in the mornings. Exceptions are allergists, dermatologists, and psychiatrists.
* Don't address the office staff of a female physician using male gender terms. If you do, they may become contentious, and your job becomes increasingly difficult.
* Don't accept calls from nonphysicians if you are certain that you will need to talk to the physician. Let the attending physician's office staff know in the initial call that you will need to talk to the physician. If it is implied that the physician executive will talk to other than the provider, the provider will not return the call. When a nonphysician calls back and cannot answer the physician executive's questions, the staff member may sense that he or she is not doing his or her job. The advantage has been lost, and time has been consumed.
* Don't have a person place calls for you if he or she is not clear, concise, and affirmative. This invites confusion and consumes time.
* Don't be casual about the wording of your statements. This applies to many points in a phone conversation. However, the best example might be the following:
"I am Dr. C. with XYZ Company, and I need to talk to Dr. ABC about Mary Jones. May I leave a message for him to call back, or is he perhaps available to speak with me now?" The office is usually receptive to taking a message.
Or, on the other hand,
"I am Dr. C with XYZ company, and I need to talk to Dr. ABC about Mary Jones. Is Dr. ABC available to speak now...?" Before you have finished the part of the sentence asking him to call back at his convenience, the person on the phone is defensive, and you will not get a call back until later.
The person on the phone heard a demand to speak to the doctor at that moment. The message is the same, but it is perceived in a totally different way, depending on the word order. Rehearse your calls and make sure that they are heard the way you want them to be heard. One word or phrase can change the outcome of a phone call.
* Long, H. "Economics and U.S. Health Care." In The Physician Executive: New Leadership in Health Care Management. Tampa, Fla.: American College of Physician Executives, 1988, p. 142.
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|Title Annotation:||developing telephone skills|
|Author:||Casebolt, John M.|
|Date:||Apr 1, 1995|
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