Update as of July 2021:
The following toolkit is archived; information regarding state and local guidelines was accurate to the date of publication. In July of 2021, Governor Hogan lifted the Directive and Order referenced below. However, other information provided in this toolkit will continue to be relevant throughout the pandemic. For questions regarding current directives and orders in Maryland, visit Maryland’s COVID-19 Pandemic: Orders and Guidance web page.
NOTICE: All licensed healthcare facilities and healthcare providers may resume elective and non-urgent medical procedures and appointments at 7 AM, May 7, 2020, provided all the required measures are in place, as outlined by this Directive and Order from the Maryland Department of Health, released May 6. Take these requirements seriously; non-compliance is punishable by both fines and prosecution. Please note that not only must your practice meet the requirements, you must also certify it to the Maryland Department of Health by email, and post a copy of that self-certification in your practice. MedChi, The Maryland State Medical Society, has drafted a sample self-certification. Self-certifications should be submitted to firstname.lastname@example.org.
This toolkit is also available in a printer-friendly format.
In this toolkit…
- About this toolkit
- About reopening
- Comply with governmental guidance
- Make a plan
- Open incrementally
- Institute safety measures for patients
- Ensure workplace safety for clinicians and staff
- Implement a tele-triage program
- Screen patients before in-person visits
- Coordinate testing with local hospitals and clinics
- Limit non-patient visitors
- Insurance considerations
- Establish confidentiality / privacy
- Consider legal implications
- Financial considerations
- Staffing considerations
The following is a reprint of guidance published by the American Medical Association titled “COVID-19: A Physician Practice Guide to Reopening”. Montgomery County Medical Society has added, under each section, supplementary resources to provide additional support for implementation or to elucidate matters relevant to medical practices at the state and local level. All rights to this publication are reserved by the American Medical Association.
Additional sections on financial preparedness and staffing considerations have been added as a supplement at the end of this document. It is drawn primarily from the California Medical Association’s “COVID-19 Best Practices for Reopening,” with some additions.
Please also note, that this toolkit is not an endorsement or encouragement to reopen medical practices at this time. Physicians must use their clinical judgment in determining whether it is appropriate to open, and on what scale. The AMA has provided guidance on the ethics of practice reopening.
The information and guidance provided in this document is believed to be current and accurate at the time of posting. This information is not intended to be, and should not be construed to be or relied upon as, legal, financial, medical or consulting advice. Consider consulting with an attorney and/or other advisor to obtain guidance relating to your specific situation.
As public health experts determine that it is safe to see patients and stay-at-home restrictions are relaxed, physician practices should strategically plan when and how best to reopen. The American Medical Association believes that four signposts must exist before state and local governments relax stay-at-home orders:
- Minimal risk of community transmission based on sustained evidence of a downward trend in new cases and fatalities
- A robust, coordinated and well-supplied testing network
- A public health system for surveillance and contact tracing
- Fully resourced hospitals and healthcare workforce
The Centers for Medicare & Medicaid Services (CMS) has published a Phase 1 guide for reopening facilities to provide non-emergent, non-COVID care. Building upon that guidance, the AMA suggests using the following checklist to ensure that your medical practice is ready for reopening:
States and the federal government have outlined guardrails that should be in place before reopening. On the federal level, the White House has published guidelines for “Opening Up America Again.” At the state level, governors have begun to detail what reopening will look like. These state and city guidelines should be closely reviewed and followed. The AMA has also developed a chart and fact sheet detailing state-specific delays, and where applicable, resumption of elective or non-urgent procedures.
“Maryland’s Roadmap to Recovery,” released by Governor Hogan on April 24, outlines a sequence for reopening in Maryland. Stage one has, in practice, been broken into multiple steps.
All licensed healthcare facilities and healthcare providers may resume elective and non-urgent medical procedures and appointments at 7 AM, May 7, 2020, provided all the required measures are in place, as outlined by this Directive and Order from the Maryland Department of Health, released May 6. Take these requirements seriously; noncompliance is punishable by both fines and prosecution. Please note that not only must your practice meet the requirements, you must also certify it to the Maryland Department of Health by email, and post a copy of that self-certification in your practice. MedChi, The Maryland State Medical Society, has drafted a sample self-certification. Self-certifications should be submitted to email@example.com.
Pre-opening planning will be vitally important to the success of your practice reopening. Sit down with a calendar and chart out your expected reopening day and, ideally, a period of “soft reopening” where you can reopen incrementally. Assess your personal protective equipment (PPE) needs and alternatives such as cloth masks, what stockpile you have currently and will need in the future, and place the necessary orders. As much as possible, have supplies delivered in advance before you reopen so that sporadic deliveries and other visitors do not disrupt the order of your daily plan. Plan in advance how you will handle staffing and cleaning if an employee or patient or visitor is diagnosed with COVID-19 after being in the clinic. Develop guidelines for determining when and how long employees who interacted with a diagnosed patient will be out of the clinic.
In Maryland, meeting the requirements for operation outlined in the May 6 health directive, must be given the highest priority.
- CDC Guidance for Outpatient and Ambulatory Care Settings
Consider a step-wise approach to reopening so that the practice may quickly identify and address any practical challenges presented. Identify what visits can be done via telehealth or other modalities and continue to perform those visits remotely. Begin with a few in-person visits a day, working on a modified schedule. Direct administrative staff who do not need to be physically present in the office to stay at home and work remotely. Consider bringing employees back in phases, or working on alternating days or different parts of the day, as this will reduce contact. Communicate your weekly schedule clearly to the practice’s patients, clinicians and staff.
- AAFP Checklist to Prepare Physicians Offices
- MGMA Medical Practice Reopening Checklist
- Medical Mutual Liability Insurance Society of Maryland’s Practice Reopening Checklist
- Doctors’ Choice Medical Services: Strategizing Reopening
- MCMS Practice Reopening Readiness & Preparedness Webinar – On-Demand
To ensure that patients are not coming into close contact with one another, utilize a modified schedule to avoid high volume or density. Designate separate waiting areas for “well” and “sick” patients in practices where sick patients need to continue to be seen (much like many pediatric practices have longtime used). Consider a flexible schedule, with perhaps a longer span of the day with more time in between visits to avoid backups.
Limit patient companions to individuals whose participation in the appointment is necessary based on the patient’s situation (e.g., parents of children, offspring, spouse or other companion of a vulnerable adult). Consistent with U.S. Centers for Disease Control and Prevention (CDC) guidance, practices should require all individuals who visit the office to wear a cloth face covering. This expectation should be clearly explained to patients and other visitors before they arrive at the practice. To facilitate compliance, direct patients to resources regarding how to make a cloth face covering or mask from a household item if needed, such as the CDC web page. Visitors and patients who arrive to the practice without a cloth face covering or mask should be provided with one by the practice if supplies are available.
Consider safety for patients in the whole building, even if your practice maintains a single suite. Talk to your landlord or facilities manager about safety measures such as:
- Installing hand sanitizers/stations in common areas
- Increasing janitorial/day porter services to continually clean high touch surfaces and common areas
- Working with their HVAC vendors to ensure that operating systems for optimal capacity for fresh air and filtration are in place
- Encouraging social distancing in lobbies separating and/or removing furniture and added signage for the elevators
- Surveying the properties for enhancements like auto sensors for toilets, water faucets, door openers, foot pulls, microbial surface protection and temporarily covering public water fountains
- CDC Infection Prevention and Control Recommendations in Healthcare Settings
- ASAM Sample Workflow for Infection Control – Includes waiting room guidance.
Communicate personal health requirements clearly to clinicians and staff. For example, the employee should know that they should not present to work if they have a fever, have lost their sense of taste or smell, have other symptoms of COVID-19, or have recently been in direct contact with a person who has tested positive for COVID-19. Screen employees for high temperatures and other symptoms of COVID-19. Records of employee screening results should be kept in a confidential employment file (separate from the personnel file). Minimize contact as much as possible. This includes during the employee screening process, as employees conducting temperature checks have been the potential sources of spread in some workplaces. Consider rearranging open work areas to increase the distance between people who are working. Also, consider having dedicated workstations and patient rooms to minimize the number of people touching the same equipment. Establish open communication with facilities management regarding cleaning schedules and protocols regarding shared spaces (e.g. kitchens, bathrooms), as well as reporting of COVID-19 positive employees in the office building. To learn more about health care institutions’ ethical obligations to protect health care professionals, see this piece from AMA ethics.
- CDC Criteria for Return to Work for Healthcare Personnel with Suspected or Confirmed COVID-19
- CDC Strategies to Mitigate Healthcare Personnel Staffing Shortages
- MCMS OSHA Compliance Plans and Digital Trainings
Depending on a patient’s medical needs and health status, a patient contacting the office to make an in-person appointment may need to be re-directed to the practice’s HIPAA-compliant telemedicine platform, a COVID-19 testing site or to a hospital. Utilize a tele-triage program to ensure that patients seeking appointments are put on the right path by discussing the patient’s condition and symptoms. If the practice had already engaged a tele-triage service to handle after-hours calls pre-COVID, contact this service to see if the service can be expanded to tele-triage daytime calls, or consider redeploying the practice’s own clinicians or staff to manage this service.
- CDC COVID-19 Phone Advice Line Tools and Triage Algorithms
- Tele-Triage Sample: UCSF Health COVID-19 Ambulatory Adult Remote Triage
Before a patient presents in the office, the practice should verify as best it can that the patient does not have symptoms of COVID-19. Visits that may be conducted via telemedicine should be. For visits that must take place in person, administrative staff should contact the patient via phone within 24 hours prior to the office visit to 1) review the logistics of the reopening practice protocol and 2) screen the patient for COVID-19 symptoms. Utilize a script for your administrative staff to follow when conducting these calls. (See the sample script the AMA has
developed below.) Once the patient presents at the office, the patient should be screened prior to entering. Some practices may utilize text messaging or another modality to do such screening, subject to patient consent and relevant federal and state regulations. Others may deploy staff in a designated part of the parking lot or an anteroom of the practice to screen patients before they enter the practice itself. The practice should strictly limit individuals accompanying patients but, in instances where an accompanying individual is necessary (e.g. a parent of a child), those individuals should be screened in the same manner as a patient.
- AMA Pre-visit screening script template
- In-Person Triage Sample: UCSF On-site Workflow for Adult NON-Respiratory Screening Clinics
There will be instances where your patients require COVID-19 testing. Contact your public health authority for information on available testing sites. Identify several testing sites in your catchment area. Contact them to ensure that tests are available and to understand the turnaround time on testing results. Provide clear and up to date information to patients regarding where they can be tested and how the process works. Some health systems have instituted the practice of testing all patients who are being scheduled for elective or high-intensity procedures (such as outpatient surgeries or services requiring close contact). Depending on the nature of your practice, you may consider doing the same.
- The Maryland Department of Health is maintaining a list of non-office based testing locations updated on a rolling basis. View the list of locations.
- For testing done by the Maryland Department of Health, refer to instructions provided in their latest clinician letter.
Clearly post your policy for individuals who are not patients or employees to enter the practice (including vendors, educators, service providers, etc.) outside the practice door and on your website. Reroute these visitors to virtual communications such as phone calls or videoconferences (for example, a physician may want to hold “office hours” to speak with suppliers, vendors or salespeople). For visitors who must physically enter the practice (to do repair work, for example), designate a window of time outside of the practice’s normal office hours to minimize interactions with patients, clinicians or staff.
To ensure that clinicians on the front line of treating COVID-19 patients are protected from medical malpractice litigation, Congress has shielded clinicians from liability in certain instances. As the practice reopens, however, there may be heightened risks caused by the pandemic that do not fall under these protections. Contact your medical malpractice liability insurance carrier to discuss your current coverage and whether any additional coverage may be warranted. As much as is practicable, you should protect your practice and your clinicians from liability and lawsuits resulting from current and future unknowns related to the COVID-19 pandemic. The AMA is also advocating to governors that physicians be shielded from liability for both COVID treatment and delayed medical services due to the pandemic.
- Medical Mutual Liability Insurance Society of Maryland has published a web page for COVID-19 updates, in addition to announcing flexibilities for policy holders. Contact them for additional details.
- MedChi Insurance Agency created a checklist of insurance related concerns for practices to consider. They have also offered complimentary policy review to our practices. They can be reached at 410.539.6642 or firstname.lastname@example.org.
Institute or update confidentiality, privacy and data security protocols. Results of any screenings of employees should be kept in employment records only (but separate from the personnel file). Remember that HIPAA authorizations are necessary for sharing information about patients for employment purposes. Similarly, coworkers and patients can be informed that they came into contact with an employee who tested positive for COVID-19, but the identity of the employee and details about an employee’s symptoms cannot be shared with patients or co-workers without consent. While certain HIPAA requirements related to telemedicine are not
being enforced during the COVID-19 public health emergency, generally, HIPAA privacy, security and breach notification requirements must continue to be followed. Answers to frequently asked questions are provided at the end of this document.
- CMS FAQs on Telehealth and HIPAA during the COVID-19 nationwide public health emergency
- MedChi Sample Consent for Telemedicine and Telephone Services During COVID-19
- AMA Privacy and Confidentiality During COVID-19 FAQ
New legal issues and obligations may arise as the practice reopens. For example, some practices may not have had to make decisions about paid sick leave (per the “Families First Coronavirus Response Act”) because they were on furlough; as the practice reopens, these sorts of employment obligations should be considered and decisions about opting out or procedures for requesting these leaves communicated to employees. The AMA has additional resources for physician practices related to employees and COVID-19. Lastly, coordinate with your local health department as provided for by law; provide them with the minimum necessary information regarding COVID-19 cases reported in your practice, and stay informed of local developments.
1) Consider the Capital Needs of the Practice and Available Funding Sources
As practices reopen, revenue and patient volume may increase slowly and unevenly. Physicians should carefully consider their capital needs for reopening, and all available funding sources, both private (bank loans) and public (such as SBA loans or government grant funds).
For more information about financial resources that can support practices, please see MCMS’s Financial Relief Resource Page. ACP has created a financial calculator, available for download on left hand side of this page. It includes sections for…
- Projected Revenue
- Practice Financials
- Summary of COVID-19 Financial Impact
2) Address Accounts Payable
Organize your accounts payable and develop a plan to repay any vendors in which you deferred payment including rent, utilities, vendors, Centers for Medicare and Medicaid Services (CMS) advanced payments or any other payor advanced payment or loans. Maintain open lines of communication with payors and vendors on payments due that you may need to defer.
3) Plan to Meet Existing Obligations
Practices should review contractual obligations from managed care payors, such as timely filing limits for claims and appeals, or submission of any encounter and/or quality data required. It is also a good idea to check employment agreements, vendor contracts and lease agreements. Reviewing these agreements and contracts for any clauses regarding termination, late payments, late fees, interest, etc. can save bigger headaches down the road. Maintain open lines of communication with payors and vendors on reporting or other obligations that you may not meet.
4) Develop a Monthly Budget
This will help on a go forward basis as things move to normal business. Practices can identify what costs the most on a monthly basis and adjust as necessary.
5) Talk to Vendors
If vendors know that the office is reopening, and will have revenue again, they may be willing to negotiate reduced rates, deferred payments or other considerations. Practices should contact vendors and see what they are offering to help with startup of the medical practice.
6) Tackle Accounts Receivables Slowly
As the office reopens, practices should continue or re-start collection activity and implement an internal process to follow up on outstanding claims. Office staff can pull financial reports (Insurance Aging, Patient Aging, Adjustment Report, ideally starting in the 60 day and older aging buckets).
The goal should be to make sure every claim has been followed up on patient schedules for the upcoming one or two weeks.
7) Verify Patient Contact and Insurance Information
When patients return to the office, their life circumstances may have changed. Office staff should confirm patient contact information, including address and phone number. Patient insurance eligibility and benefits should be checked to determine if eligibility is effective, or if copay and deductible amounts have changed. If patients have an outstanding balance, practices can offer payment plans. It is important to communicate with patients at the time of confirming appointments.
8) Analyze Revenue Streams
Billing staff should understand the Days Revenue Outstanding (DRO), which is the average number of days it takes to collect on the practice’s accounts receivable. It is important to have an accurate understanding of revenue streams as payments may have been delayed, compared to past revenue trends, or incorrect due to payor delays in implementing telehealth requirements or other related factors.
- MCMS Webinar: Short & Long Term Financial & Tax Strategies
- MCMS Webinar: Planning & Borrowing Options
- MCMS Webinar: COVID-19 Employment Law Q&A
- MCMS Webinar: COVID-19 Telemedicine Billing & Coding
- MCMS Webinar: Rapid Implementation of Telehealth
- MCMS Webinar: Remote Patient Monitoring
- MCMS Telemedicine Vendor Options
- MCMS Remote Patient Monitoring Vendor Options
- MCMS From Our RPM Speaker: Remote Patient Monitoring Implementation Guide
- Doctors’ Choice Medical Services Billing Cheat Sheet
- MHCC Telehealth Readiness Assessment (TRA) Tool
1) Right Size Physician and Staff Workforce
As noted above, practice revenue and patient volume may come back slowly, in cycles and unevenly. To prepare for this, practices should consider staffing adjustments, which may include bringing staff and physicians back in different waves. Personnel can be placed on rotating teams or via telecommuting for certain positions if possible.
Please note that if your practice recieved aid from the federal Paycheck Protection Program (PPP), that a PPP borrower is only eligible for loan forgiveness equal to the amount the borrower spent on the following during the eightweek period beginning on date of origination of loan (“Covered Period”):
- Payroll costs (at least 75% used for payroll and using same definition of payroll costs used to determine loan eligibility).
- Interest on mortgage obligation incurred in ordinary course of business and originated prior to February 15, 2020.
- Rent on a leasing agreement that originated prior to February 15, 2020.
- Payments on utilities, such as electricity, gas, water, transportation, telephone, and Internet.
- Learn more.
2) Consider Options for Vulnerable Staff
Working in health care immediately puts health care workers at risk and at higher exposure. The risk is even higher for vulnerable staff – those over the age of 60 or with pre-existing conditions. Having internal policies for these workers can help all employees feel safe while working. Workers in vulnerable populations may be shifted to different roles that minimize their risk of exposure. This may include various duties, such as consulting with younger staff, advising on the use of resources, keeping staff updated on most recent news, ordering of supplies for the clinic, working from home, phone triage of patients, helping providers and managers make tough decisions, or talking to patients’ family members.
3) Give Extra Care and Attention to the Emotional and Physical Needs of Staff
The pandemic has required physicians and many other health care workers to work long hours in dangerous conditions. As the health care system reopens, practices should pay extra attention for signs of exhaustion, depression, stress and other similar issues.
Consider starting the work day with a gratitude moment. Allow staff to take breaks and get outside in nature for their own meditative time. Thoughtful gestures and regular praise will go a long way to help your staff be committed in this challenging time.
- MCMS Mental & Physical Well-being Strategies During Crisis Overview
- MCMS Webinar: Short & Long Term Financial & Tax Strategies
- MCMS Webinar: Planning & Borrowing Options
- Planning and Borrowing Options Slidedeck with List of PPP Forgiveness Requirements
- MCMS Webinar: COVID-19 Employment Law Q&A