Physician practices managing patients during the COVID-19 pandemic are confronting new and unique operational and business challenges. This checklist provides high level guidance for practice owners and administrators. Check the AMA COVID-19 resource center to stay up to date and for additional resources.
1. Implement a process for rapid decision-making and planning
It is imperative to establish a clear chain of command and rapid response process to ensure swift, decisive action. Communicate to your employees that your response team is in place and evaluating the situation on a daily basis and that the highest priority is that practice patients, clinicians, and staff remain safe. And, as much as possible, think ahead so your response team does not have to navigate issues in real time; for example, what to do if a clinician or patient tests positive for COVID-19, what notifications must be made and to whom, given applicable privacy laws, and how that occurrence may impact your daily operations.
The AMA has a resource on health care leadership during COVID-19.
2. Understand your insurance coverage
Your practice may or may not be protected by its business insurance policy for COVID-19 related liabilities, and ascertaining your risk is a key element to making other business and operational decisions. Practices should contact their broker for a complete copy of all of insurance policies, refer to actual government emergency orders or decrees (to the extent that they impact your practice operations), and track your losses and expenses as you will need a record to make a claim.
Consult legal counsel on how to exercise your options under your existing policies, and in light of government orders, which may restrict or govern your business operations. You may need to notify professional liability carriers in the event practice providers are called upon to assist with emergency care, including outside of their normal clinical service arrangements.
Note that the Secretary of the U.S. Department of Health and Human Services has issued a declaration providing liability protection for certain COVID-19 related activities and medical countermeasures.
3. Evaluate ongoing financial obligations
Revise financial plans to ensure ongoing liquidity of your practice in the event of less clinical revenue (e.g., due to cancelled elective surgery; fewer outpatient visits) and whole or partial closure of practice locations. Develop a contingency plan based on estimates of minimum cash flow to stay afloat. Review existing loan documents and financial covenants to determine if a slow-down of business or collections could trigger a default situation.
Proactively communicate with these third-parties, such as vendors, landlords and creditors, to discuss reasonable accommodations for cash flow disruptions. Seek legal counsel as appropriate.
4. Make a financial contingency plan
Manage cash to the best extent possible and consider delaying payment of discretionary bonuses or other discretionary payments. Consider asking lenders and other creditors for forbearance, forgiveness, or a standstill and agree to a process of keeping them informed over time. Also, monitor resources available through newly emerging economic relief packages to try to help businesses and workers affected by the outbreak.
The U.S. Small Business Administration (SBA) has begun to administer low-interest loans funded by numerous states, counties and municipalities. Other organizations, like the United Way, have also created COVID-19 relief funds which may provide additional funding.
5. Assess current and future supply needs
The pandemic has created worldwide shortages of essential medical supplies including personal protective equipment (PPE) and respirators. Take stock of what supplies your practice has now and what cash flow should be devoted toward trying to stock up for the months ahead. A reduction in in-person care will reduce the number of encounters requiring PPE.
While your business may be interrupted, you may also be called upon to triage patients outside of your normal workflow, so contact your supply vendors and, if necessary, your state and local health authorities to ensure that you are in the queue to receive necessary supplies. Read more perspective about the global supply problem from two former AMA presidents.
6. Understand how to continue business operations
Many states and localities are issuing emergency and “shelter in place” orders which may impact your business operations. Many of these orders designate medical practice as “essential operations” or within “critical infrastructure industries,” but there can be a rush to understand the underlying policy and how impactful it will be to your practice and other businesses which are tangential to yours (for example, your office building).
If publicly available guidance is unclear, and especially if an essential employee refuses to work, consult with local counsel early so that you can quickly ascertain the reach of such orders and how to apply them to your practice. You may need to provide a form letter to the employee explaining the essential service that the employee provides in jurisdictions where a “shelter in place” order is in effect.
The AMA developed two non-jurisdiction specific template letters for physician practices that can be modified to suit the needs of each practice in consultation with the practice’s legal counsel. The Employee Essential Business Certification letter (DOCX) is a multistate template letter for practice employees to have on hand if they are stopped by authorities on the way to work. The Essential Critical Infrastructure Notice letter (DOCX) is for the practice to send to employees describing how the employee’s employment is considered an essential service under the order and they should report to work.
7. Consolidate administrative resources, including coding tools
Although operations may be interrupted or delayed, many businesses, include payors, will be operating remotely. If not already in place, office administrators should compile a “quick guide” of essential resources for meeting immediate needs while working remotely. It is likely that clinical and non-clinical personnel will still be required to adhere to practices (record keeping etc.) consistent with the standard of care, absent waivers.
Consider and put in place means to maintain documentation during a full or partial shutdown to obtain payment, including processes for collection of accounts, claims submission and other activities. The AMA has developed resources on CPT reporting (PDF) and scenario planning guidance (PDF) during COVID-19.
8. Manage workflow
Certain governmental agencies or health care payers have issued guidance, for example the Centers for Medicare & Medicaid Services (CMS) issued recommendations that adult elective surgeries and non-essential medical services be delayed during the COVID-19 outbreak. Refer to these recommendations when reviewing your practice’s calendar and deciding whether to reschedule, cancel or proceed with visits and procedures.
This will protect clinical staff and patients requiring essential services, conserve PPE and other supplies, reduce variation in responses to patient queries, and reduce the safety and liability risk to your practice.
9. Utilize digital health tools
Digital tools such as telehealth and remote patient monitoring can enable your practice to function outside the confines of a physical office in a potentially safer environment than the in-office setting during outbreak. The AMA has developed a quick guide to telemedicine practice to help physician practices utilize telehealth during the COVID-19 pandemic, including insights on COVID-19 flexibilities for telehealth practice and reimbursement.
The Federation of State Medical Boards has a resource which tracks state emergency declarations and licensing orders. Prepare clear communication to your employees and patients regarding the use and availability of digital health tools.
10. Communicate guidelines for employees
Many employees are concerned about their own health and workplace safety; institute interim guidelines to assist employees with making the best health decisions for themselves and their families and to provide a safe workplace. For example, advise employees concerning circumstances under which they should not report to work, identify whom they should contact if they need to be absent for a COVID-19 related reason, and specify any leave available to them in the event of a COVID-19 related absence.
The U.S. Centers for Disease Control and Prevention (CDC) has an Interim Guidance for Businesses and Employers with information in this regard. The federal government and states have also implemented COVID-19 related leave and benefits for employees; for example, the U.S. Office of Personnel Management has provided this guidance for federal employees.
11. Plan ahead for employee furloughs
Depending on cash flow challenges or external factors beyond your control, your practice may need to furlough or terminate non-essential employees. Consult qualified legal counsel to understand your practice’s obligations in this regard, understand legal requirements regarding communication of employment status, and identify workflow changes in advance which may be required to keep the practice functioning properly.
Health care staff and clinicians will be sorely needed during the COVID-19 pandemic, so communicate with your local health care systems and authorities to identify external opportunities for furloughed or terminated staff.
12. Stay abreast of new care delivery flexibilities
Federal government and states are waiving regulatory hurdles to patient care during the COVID-19 emergency on a daily basis. In this swiftly moving environment, real time knowledge of what is being done external to the practice will help you manage and protect the business of the practice. To avoid non-essential email traffic, task one administrative staff member with signing up for and disseminating alerts from your Governor’s office, state and local departments of health, and payors.
Your legal and financial obligations may change as the status of your locality changes (e.g. those practices in states who have declared a state of emergency may have unique rights to not satisfy contractual obligations), and other government or payor notices may provide needed flexibilities to enable patient care.
The AMA COVID-19 resource center has daily updates on transmittals related to COVID-19.
13. Prepare for exposure incidents
Physicians and other clinical staff are on the front lines of caring for patients with confirmed or possible infection with COVID-19 and have an increased risk of exposure to the virus. Health care professionals may minimize their risk of exposure when caring for confirmed or possible COVID-19 patients by following the CDC’s Interim Infection Prevention and Control recommendations for: Patients with Suspected or Confirmed COVID-19 in Healthcare Settings.
Review whether any engineering or administrative controls, safe work practices, and/or personal protective equipment may limit potential exposure.
14. Identify and implement COVID-19 specific clinical protocols
As the COVID-19 crisis evolves, many practices are being tasked with developing clinical protocols in the absence of guidance. Issues such as how to clinically evaluate symptomatic persons, triage and surveillance, infection control and isolation practices, communication with and reporting to public health authorities, and facility access and security should be top of mind and will help arm your practice against business and legal risks.
The AMA has a COVID-19 FAQ which answers key questions on the virus for patients and physicians and gives tips on best practices. You can also sign up to receive the AMA Physicians Guide to COVID-19. The AMA has also developed resources to help private practices and physicians navigate non-essential care during COVID-19.
Share your ideas and experiences about the financial and business challenges during COVID-19 with the AMA by emailing us. The AMA remains committed to ensuring quick dissemination of ongoing strategies to support physicians and care teams. Your learning and experiences will help other organizations better support their care teams during this time.
Disclaimer: The information and guidance provided in this document is believed to be current and accurate at the time of posting, but it is not intended as, and should not be construed to be, legal, financial, medical, or consulting advice. Physicians and other qualified health care practitioners should exercise their professional judgment in connection with the provision of services and should seek legal advice regarding any legal questions. References and links to third parties do not constitute an endorsement or warranty by the AMA and AMA hereby disclaims all express and implied warranties of any kind.