Ten years have passed since the U.S. was attacked on September 11, 2001 and six since Hurricane Katrina slammed into the Gulf Coast. And, while disasters of that magnitude are rare, hundreds of smaller-scale disasters occur every year, including tornadoes, blizzards, fires, earthquakes, airline crashes and chemical spills.
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September 2011Whether it is confined to your building or involves your entire community, any unforeseen event could constitute a disaster for your otolaryngology practice, according to Owen J. Dahl, FACHE, CHBC, president of Owen Dahl Consulting in The Woodlands, Texas, and author of the eBook The Medical Practice Disaster Planning Workbook. Consider a lightning strike that ignites a structural fire, a speeding car that plows into a building, a shooting that turns a business office into a crime scene or a biological disaster such as a pandemic flu.
Two reports, “Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations,” issued by the Institute of Medicine (IOM) in September 2009, and “A Management System for Integrating Medical and Health Resources During Large-Scale Emergencies,” prepared by the U.S. Department of Health and Human Services in September 2007, have highlighted the need for health care organizations to plan proactively. A disaster plan provides an otolaryngology practice with a template to maintain or restore business operations, no matter what the crisis.
“The medical practice manager of an ENT practice has a responsibility to ensure that a disaster plan is in place,” said Kenneth T. Hertz, FACMPE, a principal consultant in the MGMA Health Care Consulting Group who is based in Alexandria, La.
Whether you start small and add a new piece to the plan each month or schedule a retreat to draft the entire plan in one sitting, it is important that you distribute the plan to every employee and review and revise it regularly—when you change clocks in the spring or fall, for instance.
“Practices at risk of hurricanes could review the plan the last week of May, while those at risk of tornadoes could review it in February,” Dahl suggested. “But every practice should pick a date and put it on the calendar.”
Prepare Yourself
Otolaryngologists must first prepare themselves for the prospect of a disaster, said Dan Hanfling, MD, an emergency medicine physician at Inova Fairfax Hospital in Falls Church, Va., who serves as special advisor in emergency preparedness and response for Inova Health System and is also a clinical professor in the department of emergency medicine at George Washington University School of Medicine in Washington, D.C. Dr. Hanfling participated on the IOM’s Committee on Guidance for Establishing Standards of Care for Use in Disaster Situations. Because otolaryngologists could be first responders, he suggested keeping emergency kits containing basic supplies such as suture materials, an intubation set, backup batteries and a pulse oximeter that could be taken to help support care at the hospital.
Key preparation for otolaryngologists is offered through the American College of Surgeons’ Advanced Trauma Life Support course and the American Medical Association’s online National Disaster Life Support Program, added G. Richard Holt, MD, MSE, MPH, MABE, professor emeritus in the department of otolaryngology-head and neck surgery at the University of Texas Health Science Center at San Antonio and author of a paper on making ethical decisions in patient care during disasters (Otolaryngol Head Neck Surg. 2008;139(2):181-186).
These programs “give an otolaryngologist the kind of preparation that goes well beyond general experience,” Dr. Holt said. “There are so many issues to consider. A SARS outbreak would be different from a tornado, which would be different again from an explosion at a chemical plant.”
Develop a Communications Strategy
The welfare of family, staff and patients is the next priority in disaster planning, so communications are key. Compile a list of emergency phone numbers for physicians, staff and family members, then create a detailed phone tree and store it in a secure location. Use your website as a message board where you can post updates about office hours and provide contact information for staff and patients, Dahl suggested. Use text messages or create an online chat group in a secure area of your website to distribute schedules and arrange meetings. Notify media contacts at the local television station, radio station and newspaper about the status of your office.
In the event of a major disaster, you’ll need an integrated strategy that might include a combination of landlines, voice over Internet protocol (VoIP) access, remote toll-free numbers and walkie-talkies, Dahl noted. Ensure that physicians and key staff members have car chargers for their cell phones in case power lines go down, and consider adding a satellite phone to your emergency equipment in case cell towers are down.
Develop evacuation procedures in the event of imminent danger during business hours, such as a fire in the building or a tornado alarm, and practice these drills every year. Dr. Hanfling suggested coordinating your emergency plan with your local public health department, which networks with the federal Medical Reserve Corps to engage local providers in disaster planning.
You’ll also need to communicate with your community hospital, because otolaryngology is a critical specialty when mass casualties occur.
“There may be opportunities for otolaryngologists to volunteer at their hospitals, which are the primary sites where teams leave to care for patients or receive them,” Dr. Holt said. He serves on his hospital’s disaster response team to establish a comprehensive strategy, including deciding the most effective use of resources.
“When you think about a very busy hospital that’s being taxed because of a catastrophic disaster, the general surgical skills of ENT doctors extend far beyond what might be required for airway management,” he said, potentially including general surgical procedures and basic orthopedic care.
Consider Tools, Equipment
Next, examine the potential impact of a disaster on your equipment and inventory. For insurance purposes, maintain an updated record of medical and office equipment and keep a running inventory of medical and office supplies, including refrigerated drugs. Following a disaster, you may need to discard many supplies as a precautionary measure because of contamination risk.
If your practice is housed in a dedicated building, consider purchasing a propane generator for emergency power. If you’re located in a flood zone, install the generator on the roof of your building instead of in the basement, Hertz said.
Consider developing a reciprocal arrangement with an otolaryngology practice on the other side of town or in a neighboring community, Dahl added. In the event one practice is damaged or destroyed, those otolaryngologists can temporarily use the other practice as a patient care center, treating their patients after hours and on weekends until their office is repaired or reestablished. “You don’t know which side of town might be affected by a disaster, so both groups must be open to the idea,” Dahl said.
Also consider the impact on your support services. If your bank floods, how will you manage accounts payable? How will you process your accounts receivable and daily deposits? What’s your backup plan if you lose access to your lockbox? If mail service is disrupted, how will patient payments be routed to your practice? If you change locations, even temporarily, how will financial institutions and vendors find your office? Your disaster plan should address these issues.
“After Katrina, it took months—years, in some cases—to reestablish the financial and postal connections,” Dahl noted.
Back Up Critical Documents
Finally, ensure that you’ll have access to patient and financial information if your physical plant is damaged or destroyed. Back up your electronic medical record or clinical and billing data at least weekly—preferably daily—and store the information on a remote server, preferably in another state. An on-site server or backup tapes will be of no value if your practice burns to the ground or washes away.
Secure a copy of the network schematic of your hardware, Hertz said, as well as software disks and documentation so that you can restore your system if your network crashes. Gather vital documents, insurance policies, service contracts, leases, warranties and vendor contacts, for instance, and store them off site or maintain them in a waterproof emergency box that would leave the practice with the last person out the door. Develop a chain of command for that responsibility, Hertz advised.
Consider adding business interruption insurance to your business or property policy to cover the loss of revenue if your operations are curtailed or suspended during an insured loss, Dahl suggested. (See “Include Managed Care Contracts in Your Plan.”) If your practice were damaged by fire or water and needed to close for several weeks, business interruption insurance would cover your operating profit, salaries and fixed expenses during that time, he explained. A rider called “extra expense coverage” would pay for the cost of rental space, enabling your practice to remain whole following the loss.
Like most insurance policies, business interruption insurance may include a waiting period, deductible and limitations based on how the policy defines a disaster. The goal is to make sure “you don’t have to lay off your employees or have your physicians go without a paycheck,” Dahl said.
Once your disaster plan is complete, laminate copies of the basic steps and place the template throughout your office, including the physician and staff lounges, so that the information becomes ingrained, Dr. Holt advised.
“Disasters can be very small and personal, so don’t think it can’t happen to you,” he said. “Physicians are in the business of being prepared. Why not prepare for disaster, too?” ENT TODAY
Include Managed Care Contracts in Your Plan
During an emergency, medical practices must maintain payer contracts so they can continue to bill for the clinical services they provide. If your otolaryngologists are providing life-sustaining care to victims in the wake of a disaster or if the practice site has suffered devastating physical damage, meeting the administrative requirements of your managed care agreements will be a low priority. As the community returns to normalcy, however, those details could create new burdens for your practice, according to James G. Fouassier, Esq., associate director in the department of managed care at Stony Brook University Hospital in N.Y.
If the federal government declares your community a disaster area, the Centers for Medicare and Medicaid Services may issue a waiver relieving health care providers of certain documentation and technical submission requirements for claims related to Medicare and Medicaid, Fouassier said. A government agency also may suspend credentialing and licensing requirements for physicians from other states who travel to the disaster scene to assist with patient care.
There’s no guarantee, however, that the government will take either of these actions, and private payers won’t necessarily be obligated to do the same. By adding language to your managed care contracts to address disaster scenarios, you can require payers to pay for services, even if you’re temporarily forced to suspend standard billing practices, Fouassier said.
The ideal time to incorporate such language is during contract negotiations. Choose language that defines precisely when a disaster or emergency is considered to have occurred. The usual description refers to an official declaration by a government agent or authority, but you should press for more limited situations in which an isolated incident, such as an explosion, destroys or seriously damages the building containing your practice.
“Contract language shouldn’t be so specific that it can’t be flexible,” Fouassier said.
Contract language related to disasters should suspend specific time frames and formats for claims submission. You won’t have time to document during an emergency, so you’ll likely face problems coding those claims properly. A simple accommodation allows commercial plans to accept any government decree that affects Medicare or Medicaid, Fouassier suggested.
Seek relief from requirements for preauthorization or notification for admissions, treatment and discharge, he added, as well as suspension of concurrent utilization reviews. Although it’s reasonable for payers to ask for some evidence of medical necessity once the disaster has ended, seek language that allows alternatives, such as physicians’ affidavits or copies of X-rays.
Don’t be dissuaded by a payer’s claim of protection by a standard force majeure clause, which typically states that the contract doesn’t anticipate war, natural disasters and other “acts of God.” Given the lessons of 9/11 and Hurricane Katrina, combined with this year’s unusually severe blizzards, flooding, tornado outbreaks and fires, today’s practices are hard pressed to argue that they could not anticipate virtually any large-scale disaster.
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