Taming the paper tiger: Covering the cost of filling out forms

Physician practices inundated by patient requests to fill out paperwork may decide to start charging for the service. The key, experts say, is making your policies clear to patients.

By John McCormack, amednews correspondent — Posted Oct. 15, 2007

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Deluged by miscellaneous forms -- the sports physical, return-to-work, Family Medical Leave Act and other assorted patient-generated documents -- staff members at the Wichita (Kan.) Clinic, a 160-physician multispecialty practice, decided to figure out exactly how much it was costing them to process all this paper.

Their conclusion? It's an expensive endeavor -- to the tune of anywhere between $20 and $30 to fill out and return a single form, according to Terry L. Mills, MD, a family physician who works out of the practice's Newton, Kan., office. Dr. Mills figured the requests he handles ended up costing about $20,000 a year.

Like other practices across the country, leaders at Wichita wanted to figure out what they could do to control what was becoming an unwieldy beast.

Virtually all doctors agree that they must continue to provide this patient service. But to get a better handle on the paper juggernaut, they are considering whether to charge for the service, make the process more efficient, or combine both options.Regardless, practices are urged to pay more attention to communicating paperwork policies to patients and establishing effective paperwork workflow procedures.

To charge or not to charge?

For many years, doctors have filled out patient-generated paperwork on demand. "Historically, in medicine, these forms have always been filled out gratis and physicians have just found a way to fit the work into their day-to-day workflow," Dr. Mills says.

But in recent years, many doctors have challenged the status quo. Dr. Mills, for instance, says times have changed, and doctors cannot offer this service free for several reasons.

First, reimbursement from payers no longer provides much wiggle room. "In the last 20 years, the blood has been squeezed from the reimbursement turnip," Dr. Mills says.

Lisa Mangan, RN, administrative clinical manager at Ob & Gyn Specialists, PA, a 12-physician group based in Winter Park, Fla., agrees that changes in the reimbursement world are forcing physicians to focus on financial matters.

"If it was the good old days and we were getting the reimbursement like we used to, then we wouldn't have to consider charging. But we have to keep the lights on and the employees employed," Mangan says.

In addition, the amount of paperwork that an average physician receives has increased dramatically, Dr. Mills says. "It's no longer just one form a week. I can get 15 or 20 forms a week."

Physician practice experts, however, caution that before putting a price tag on paperwork processing, physicians should think through a number of issues, including:

  • Local market customs. If other medical groups in the area are charging for paperwork requests, then it's a good idea to do so, but if others are not, physicians might want to hold off, says Lori Foley, a principal with Gates, Moore & Co., an Atlanta-based practice management company.

Surveying what other practices are doing also could shed light on pricing.

"There is no rule of thumb on what to charge. You should look to the market to see what others are charging and then charge what is reasonable for the market and for your patient base," Foley says.

  • The work involved. "If it is a one-page form, then $10 might be appropriate. However, if it is a larger form, then you need to add on to the charge," she says.
  • Patient satisfaction. It's important to anticipate how your patients might react to a new set of charges, says Jerrie Weith, a practice management consultant with Health Care Management Alternatives, Belleville, Ill.

"Even if $15 doesn't come close to recouping your costs, practices need to realize that if they charge what it really costs them, their patients might have a cow," she says.

Setting consistent prices across the board also helps with patient satisfaction, Weith says. "If the patients know each other and someone finds out that they paid $15 for something that someone else got for free, you're going to have unhappy patients. The patient who was charged might also come back and say that being charged was a form of discrimination."

How much to charge?

While charging for paperwork is certainly not universal, many physicians have decided to recoup some of the costs associated with patient-generated paperwork.

According to the Medical Group Management Assn.'s Pediatric Performance Survey Report, about 30% of pediatric groups charge patients some fee to complete forms. Of those, 60% charge $5 or less; 20% charge $6 to $10; 13% charge $11 to $20; and 6% charge $21 or more.

Wichita Clinic, for example, now charges a flat fee of $10 to fill out and return various forms to patients -- a price that offsets, but falls well below, the actual cost of the service.

"Our policy is a compromise between those physicians who are uncomfortable doing this and those who want to cover at least some of the costs of doing this for the patients," Dr. Mills says.

Other practices have found other ways to compromise.

Tim Heilmann, MD, a family physician who practices at the Williamsport (Pa.) Hospital and Medical Center Family Residency Program, says his practice processes forms without charge if doctors have seen the patient within the last year, but charges a nominal fee if the patient has not been seen in the previous year.

In some cases, such as a student who had broken his arm in the past year and was now seeking a sports physical exam form, the practice will ask patients to come in for an office visit as a prerequisite to getting the form completed.

Telling patients

Once practices have decided to charge -- or even if they decide not to -- they should make sure patients understand the policy, experts advise.

Weith, for example, suggests that medical groups spell out paperwork policies in their practice brochures. In addition, front-office staff should ask patients if they need a form filled out. If so, the staff member should make sure the patient understands how much it will cost and how long it will take.

Ob & Gyn's Mangan emphasizes that it's important to make sure patients understand why, as well as how much, you are charging to fill out a form, or provide other paperwork.

"A lot of patients will come in and say, 'I just don't understand how you can charge me for my own records,' " she says.

When this happens, staff members explain that they are not charging for the information but for the time and cost involved with retrieving and copying it from the medical record.

To make charges more palatable, staff members work with patients to determine exactly what is needed. Beyond outside forms, patients, for example, sometimes will request their entire medical record when they need only a copy of the latest test results.

If patients still complain about the charges, Mangan explains that charges are authorized by Florida statute.

The time frame must also be explained. If the front-office staff clearly communicates that it will take a specific amount of time -- whether it be 72 hours, a week or a month -- to fill out and return forms, this help set expectations and avert misunderstandings, Weith says.

Perfecting the process

Although charging patients for forms can help practices recoup costs, more effective processes can also cut costs.

For example, a front-office employee could fill out the basic identifying info that makes up the majority of most forms, then hand it off to a nurse or doctor to complete the clinical components. Saving professional time will make it less expensive to complete the form overall, consultant Foley says.

Weith suggests that all requests for paperwork be processed through one staff member -- making it easier to track what has been done in what time frame.

"With a good organized process administered by one person, the practice will be able to keep track of what needs to be done, what has been completed, and what has been sent out," she says. "The record also documents what has been reported outside of the practice and could be used to comply with HIPAA regulations."

Some physicians are finding that computerized records can streamline the process as well. For example, Dr. Heilmann can consult the practice's electronic medical record to pull up the data required for each form.

"Rather than having to go to the file room and find the chart and then leaf through the pages to find what I need, I simply sit in one place and pull up the information and copy it down," he says.

"It makes it much easier and saves a lot of time."

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The cost of filling out a form

The Wichita (Kan.) Clinic charges patients $10 to fill out forms -- and that still doesn't cover the cost of the work, which the clinic says is $20 to $30. The clinic's process might sound familiar to a lot of practices.

  1. A patient or family member submits the form.
  2. A staff member pulls the appropriate chart.
  3. A nurse researches what is being requested and marks the appropriate information in the chart.
  4. The physician takes five to 15 minutes to fill out the form.
  5. The physician returns the form to the nurse.
  6. The nurse returns the form to the patient.

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