Ideas for Improving Management Approaches to Billing / Paperwork
Mark Ragins MD
Many programs have spent a great deal of energy over the years working on increasing staff billing
hours, but we aren’t clear about what works and what doesn’t, or perhaps more precisely what
management practices we’d need to implement persistently to sustain billing.
My view is that 1) everyone is not a problem, only a small portion of staff account for most of the
inadequate billing, and 2) that some staff have occasional problems – probably mostly because of time
off or case load issues – and some staff have persistent problems. I recommend that supervisors focus
intensive efforts on the few staff who are persistently problematic instead of designing global “one
size fits all” approaches that burden everyone. Here are my ideas for a series of management steps to
achieve this:
First, the supervisor would need to review a longitudinal series of billing productivity reports looking for
chronic underperformers and review it for possible inaccuracies or extraneous issues to identify the
names of persistently problematic staff.
Second, the supervisor would create a collaborative correction plan that includes daily billing
supervision. If a given supervisor has more than a few persistently problematic staff on their team, it is
likely that supervisor is contributing to the problem and their supervisor will need to make a
collaborative supervision plan with them.
Third, identify the major source(s) of each staff’s deficiencies. I believe there are two common sources
of deficiencies: 1) Some staff are quite responsible in creating relationships with their clients and
providing billable services and may even be responsible to their team mates contributing to the
program’s functioning and many client’s services, but they do not feel responsible for the overall
departmental needs. They may feel disconnected from administration, with an “us vs. them” mentality,
and are often critical of management. In their view, billing demands take them away from providing
valuable services and management will figure out what to do about funding somehow. “ It’s not my
problem.” 2) Some staff are not actually providing high amounts of legitimately billable services. They
may be actively serving only some of their clients, not serving them in billable ways, or not being
assertive enough in outreaching clients, or not serving other clients in the program besides their own,
not “helping out”. They may feel very productive and satisfied and be well liked by clients and staff
despite any of these deficiencies.
Within each of those two sources there are some staff who are not motivated and engaged in improving
and some staff who are lacking skills and/or supports needed to improve.
For each persistently problematic staff identify which of the four sources apply:
1) Lack of motivation / engagement with improving department billing goals
2) Lack of skills / supports to improve department billing goals
3) Lack of motivation / engagement with increasing providing billable services
4) Lack of skills/ supports to increase providing billable services
For staff with multiple sources of problems, try to identify the primary barrier to focus on first. In
general, if there are problems with both motivation / engagement and skills/ supports in one area begin
with motivation / engagement since they aren’t likely to utilize skills and supports if they’re not
motivated / engaged.
Fourth, create an individualized correction plan that includes daily supervision for as long as it takes to
sustain needed billing habits (probably at least 6 months). Here are some ideas for each of the four
sources:
1) Lack of motivation / engagement with improving agency billing goals
Improve relationships with administration: Assign these staff to shadow some administrative staff and
have administrative staff shadow them (ASOC staff could target going out with these staff since they are
valued in their service responsibilities and deficient in their administrative responsibilities). They should
be assigned to some administrative committees to build working relationships and appreciation for
administrators.
Improve understanding and respect of administration: These staff often have the perception that their
criticisms of administration are not being heard and they may well be right. They should have a regular
meeting with an administration partner to have a channel to express their criticisms and learn more
about how administration works and have legitimate ideas be carried forward.
Improve alignment with administration: Steve Jobs said that the difference between Apple and
Microsoft and IBM was that Microsoft and IBM were run by sales people rather than product people.
The CEOs emphasized revenue and stockholders, market trends, and efficiencies and left the product to
the engineers, while he built the sales around the details of product development. Much of DMH’s
administrative communication and reports emphasize our equivalents of sales – billing efficiencies, new
funding opportunities, health care reform changing the market – with little about product details –either
quality of life or recovery. This set of valued staff who are disconnected with administration should be
given direct ongoing input into the MHA-LA vision and direction. For example, they could be
encouraged along with their grateful clients to submit article to the department newsletter.
The overall mangement message to these staff shouldn’t be a punitive one. Instead we should
emphasize that we value them and they’re responsible enough to be let in on the department’s
concerns, to “sit at the adults’ table” with the expectation that they will “Share in the chores willingly” if
they’re really included and understand what’s needed.
2) Lack of skills / supports to improve agency billing goals
This is the area we’ve focused the most effort on including for example, hiring auditors to review notes,
charting trainings, creating quiet areas for charting, blocking off for time for charting, “paper work
parties”, daily logs in calendars to increase recall of billable services. For some staff these efforts have
already worked. For those who are still persistently problematic, they will need daily oversight until
they can sustain new habits. We need to include “Sustaining” stage of change supports along with
“action” stage of change supports. Giving up, because “nothing works for me” isn’t an option.
3) Lack of motivation / engagement with increasing providing billable services
The vast majority of staff are providing good, billable services to some clients at least at some times or in
some settings and that the challenge is to motivate / engage them in expanding these strengths. The
supervisor can evaluate a longitudinal series of individual billing reports that tell us what members each
staff is serving and billing on and what members they aren’t. Together with the staff, they should be
able to pull out the patterns of who is being served and who is not being served. For example, the staff
provides more services in the office than in the field, or more services to people who don’t abuse drugs,
or take their meds, or have less active symptoms, or who don’t have personality disorders, etc. Cross
referencing the billing reports with the MORS adds a recovery based differentiation – the staff serves
mostly their 3’s or 7’s or whatever it happens to be. Staff can be engaged in both increasing the range
of members they serve and in serving other members on the team who are within their usual focus on
other staff’s caseloads.
Sometimes the issue is that staff don’t’ sufficiently differentiate their services according to member
need and find that the services they excel at are only welcomed and working for some members and so
withdraw from serving others. Supervision can focus on service planning for individual members that
the staff isn’t serving much. Intentional, billable services can be built on 1) pursuing outcomes, 2)
pursuing flow and graduation, 3) pursuing client-driven goals, or 4) pursuing an improved recovery
narrative for their life. Individual staff may find one or more of these approaches more accessible to
them to increase their engagement / motivation in providing more intentional, billable services.
4) Lack of skills/ supports to increase providing billable services
Here is where there is the most potential for substantial overlap between the program’s service goals
including enhancing recovery based evidenced based practices and DMH’s need to increase billable
services, rather than the more usual perceived conflict between those set of goals. If we implement the
in vivo clinical supervision ideas included in the Recovery Oriented Supervision workshops from the
University of Kansas to collaboratively increase the skills and supports of every staff, then we will have a
structure to improve the skills and supports of the persistently problematic staff without singling them
out and while improving the team’s clinical skills. From a management point of view, the skill and
support development should be driven from the line staff’s motivation / engagement in their own
development in a “bottom up” way instead of being driven by management and committee generated
“areas of need” in a “top down” way. The function of higher management is to provide access to
information, experts, trainings, and individual mentorship for whatever areas of skill / support
development staff identify for themselves.
For both groups 3 and 4, the emphasis should be first on improving services and secondarily on
improving billing. The presumption is that some staff’s billing will improve just because they are
providing more intentional billable services and some of them will be converted into 1’s and 2’s and
then need help documenting better the improved services they’re now delivering. If we don’t begin
with service improvement with these staff, we run the risk of them becoming staff who still don’t
provide enough good services, but their paper work looks good. That’s an undesirable outcome. Even
though we may not get in trouble doing that for a long time, and frankly it may seem like the best “harm
reduction” strategy for an unproductive staff who we don’t want to confront, it does increase the risk of
being charged with fraudulent billing as well as not helping people in need. Even though administration
can’t directly track services, direct supervisors can and should. Every staff should have some time where
they are working alongside their supervisors, observing each other. Persistently problematic staff
should do so frequently. In my view that’s the most powerful way to deliver the message that what staff
actually does with clients is what is most important to us.