Optimize Your Practice

Transcription

1 Optimize Your Practice Billing and Coding, the Role of Fellows and Physician Extenders, Band Adjustments and Diversifying Strategies to Increase Revenue Philip Clark, MBA, CMPE Business Manager, Duke Metabolic and Weight Loss Surgery

2 Managing the Revenue Cycle

3 Billing and Coding: Revenue Cycle Op. Notes Coding Payment Accounts Receivable Surgery Referral Evaluation Pre-Verification Appeals Patient Balance New Patient Visit Pre- Determination Pre- Authorization

4 Physician Involvement + = =

5 Pre-Operative Revenue Cycle If you waited until you received the denial notification to deal with the insurance company, you left it to late! Front End Management is Key to Successful Revenue Cycle Optimize all processes prior to the bill being sent Determine Bariatric Benefits (prior to delivering any services) [Optimize Convert to Self Pay] Match Medical Evaluation Phase to Fit the Insurance Benefits [Optimize Personalize the evaluation process to the patients insurance benefit] Get the right surgical authorization [Optimize add all potential procedures to the authorization] Documentation in Pre-Evaluation Phase and in the OR [Optimize make sure that medical decision making and assessments match the actions of the encounters, template where appropriate]

6 Accounts Receivable Denial Reason Write Off Billing Correction / Documentation (Billing) Appeal (Physician) Authorization required X Services not Covered X Coverage Terminated X Medical Records X More Documentation / Info X X Medical Necessity X X Missing / Invalid CPT X X Coordination of Benefits X Untimely Filing X

7 Negotiating Self Pay Package Negotiate with Hospital Negotiate with Ancillary Providers Create Self Pay Contract Hospital Prices based-on cost, including overhead and risk Negotiate with other Professional Providers Collect Cash up Front Hospital will want new contract for every patient (particularly for low volume procedures) Remember market value

8 Physician Based vs Hospital Based

9 Billing and Coding

10 ASMBS Sleeve Gastrectomy Coverage Map ASMBS Sleeve Gastrectomy Coverage Map

11 Why E&M Coding Matters Recovery Audit Program [RAC] CMS: Medicare Fee-for-Service Recovery Audit Program Myths December 17,

12 E&M Coding Estimate E&M Coding: 14% - 20% of Total Surgeon Income Documentation should include: Reason for encounter and relevant history, physical exam findings and prior diagnostic tests Assessment, clinical impression and diagnosis Medical plan of care Date and legible identity of observer If you do not understand E&M Coding, get educated.

13 Pre Surgical Evaluations Pre-Operative Visits E&M visits conducted for pre-operative clearance are part of the global period of the surgery, even if they occur 2 7 days before the surgery. E&M visits prior to the surgery are only payable if directly for the decision for surgery

14 Global Period 1 Day or Greater Before the Surgery Pre-evaluation visits for surgical clearance are part of the global period SURGERY 90 days after the surgery Part of the global period, unless unrelated to the surgery 91 Days after the surgery Out of global, part of medical long term follow up

15 Assistant Surgeons Modifier Title Use Qualifications % Fee Schedule 80 Assistant Surgeon Assistant Surgeon must assist through the entire procedure Assistant Surgeon must work under direct supervision of Primary Surgeon and be involved in procedure Primary and Assistant must use same CPT Code, with Assist appending Modifier Minimal Assistant Surgeon 82 Assistant Surgeon [No Qualified Resident] Assistant surgeon has limited or minimal involvement in the case Physician assistance during only part of the procedure A clinical situation requiring more than one physician assistant In a teaching facility, may be used when a qualified resident surgeon is not available to assist M.D., D.O., D.M.D, D.D.S., D.P.M. M.D., D.O., D.M.D, D.D.S., D.P.M M.D., D.O., D.M.D, D.D.S., D.P.M 16% 13% 16% AS Assistant at Surgery Used for non-physician surgical assistants primarily APN / PA Must have training in the surgical procedures being performed Must be present for the entire procedure and perform operational assistance under the direct supervision of the Primary Surgeon C.N.S, N.P., A.P.R.N., A.P.N., R.N.F.A. 13.6%

16 Deploying Fellows and Physician Extenders

17 Physician Extenders and Fellows B = Billable : X = Non-Billable

18 PA / NP Income by source

19 Strategies for Deployment Pros Clinical Fellow Can provide most support to the surgeons. Actively take call, see patients under supervision, assist in surgery Least costly, usually come with at least partial grant funding Most flexible, can work longer hours Can act independently to provide general surgery services Physician Assistant Can provide technical support across all environments, much like a fellow, but less qualified Generally less costly than an equivalent NP Can act independently and bill in clinic and act as Surgeon Assistant Nurse Practitioner Provide great support for long term follow up care for patients Can bill for work in the clinical setting Great for patient education Cons Can only bill in absence of qualified resident as Assistant Surgeon [81] Can be a hindrance more than a help, need training and require closer supervision Service inconsistent new fellows every year Want to be in the OR more than the Clinic Hard to find well trained surgical PA Some can perform procedures and can be in the OR, but surgical NP is extremely hard to find Tend to be the most expensive NOTE: RULES ON PHYSICAN ASSISTANT AND NURSE PRACTIONER BILLING AND SCOPE OF PRACTICE VARY BY STATE CHECK BEFORE PROCEEDING

20 Recommendation on Extender Type Depends on program and needs: Academic program > Hire a fellow Non-Academic Program - Technical Assistance in the OR > Hire a PA Clinic support> Hire an NP OR and Clinic Support> Hire an PA

21 Incentive Plans for Fellows and Physician Extenders Fellow and extenders are assisting in the care of the patients that you have recruited, and should be incentivized. Flat Rate Incentive based on individualized targets ($3,000 - $5,000) Percent of Net Collections (5%) with a cap

22 When to Recruit a Physician Extender: Financial Modeling Considerations The recruitment decision is a decision based around opportunity cost: Opportunity cost is the cost of any activity measured in terms of the value of the next best alternative forgone (that is not chosen). It is the sacrifice related to the second best choice available to someone, or group, who has picked among several mutually exclusive choices Choice A: Physician Performs the Services and Collects the Income Choice B: Recruit an Extender to Perform the Services and Collect the Revenue, while Physician Does some Other Activity

23 Physician Extender Hiring Decision Scenario: Based on Real Data at Duke. Physician A perform 175 Roux-en-Y Gastric Bypass and 75 Gastric Bands Per Year The new evaluation conversion rate is 70% - so 100 new valuations have to be performed for every 70 patients Each patient receives 3 follow up visits in the first year Each band patient receives 3 adjustments in the first year Assumptions 5 surgical cases may require 2 OR Days 7 New Evaluations may require 1 Clinic Day 20 Established Patients / Band Adjustments would require 1 Clinic Day

24 Surgeon Financial Modeling The surgeon passes long term follow up to NP, giving up 750 Established Visits, and 250 band adjustments or 1 Clinic Day per week. Replaces with 1 day OR per week, he could reasonable complete 3 additional OR cases.

25 NP Financial Modeling Note: NP Reimbursement for Office Visits = 85% of Physician Provider (estimated at $63 per visit)

26 PA Financial Modeling

27 Diversifying Strategies to Increase Revenue

28 Diagnostic EGDs: Refer or Manage Refer: Can create goodwill with GI (although not a critical referrer of patients). Endo Suite scheduling not always convenient Need credentialing to perform Endo in the suite, high risk patients may need to be completed in the OR Manage: Additional source for professional fee income, if performed in the hospital setting $400 - $600 per patient for about minutes time Can be billed in the pre-operative phase if diagnosis supports (commonly GERD)

29 Ancillary Services in the Provider Setting Vitamin and Supplement Sales Pros: Can provide good nutritional support to patients, especially for those on malabsorptive diet. Income for practice, usually 50% mark up, or potential $15 20 per patient per month. $100 patient = $2,000. Cons: Can be difficult to administer in a large system make sure you get on consignment Transnasal Endoscopy Pros: Provides in office diagnostics for some bariatric complications, GERD, and Hernia [ disposable sheaths] Income for the practice can be reasonable, estimated at $260 per case, need to perform about 100 cases for break even on equipment and supplies Cons: Not well tolerated by patients, difficult to find suitable patients

30 Intra-Operative Services Intra-Operative EGD billing Usually considered part of the operative procedure, if used to check anastomosis Can be used for diagnostic if unrelated to primary procedure, common diagnosis esophagitis Medical Necessity must be documented Liver Biopsy Must document the reason for taking a liver biopsy Can be used for fatty liver

31 Post Bariatric Concierge Services Exercise Physiology Usually will involve employing the services of a exercise trainer with some medical background to develop individualized training regimens Nutritional Consulting Requires nutritional counseling on an ongoing bases from a dietician Focus Groups Provide long term support groups for the well being of the patients PROs: Great for long term patient satisfaction and can improve outcomes CONS: Hard to sell in a down economy, difficult for surgeons to make money need to pay the ancillary providers.

32 Hospital Revenue On Call Compensation Hospital Requirement (Bariatric Service) Per Call Day Rate Reimbursement Per Case for Uninsured/Underinsured Medical Director Stipend Reimbursement for administrative duties related to managing the program and participating in hospital required functions. Usually reimbursable at fixed annual rate [$25,000 - $50,000] Service Line Co-Management Reimbursement for managing the entire service line (surgical and related specialties) and includes much more involvement in business decisions related to the program. Contracts can be flat rate, and/or incentivized for improvements in efficiency, quality and financial metrics.

33 Non Surgical Physician Providers Endocrinology Base Sal. $180,000 [Partner] PROS: Congruence with surgical practice for diabetic patients, can attract more diabetics, and generate more patients CONS: Thrive of inpatient hospital setting, may not be ideal in ASc, low income specialty, income primarily derived from long term treatment remission of diabetes could be a conflict Psychiatry Base Sal. $200,000 [Buy Hospital] PROS: Absolute requirement for clearance of patients, may be option to employ CONs: Can cause throughput issues if they become overwhelmed with patients, visits take much longer. Not all insurers reimburse the evaluation (Medicaid) Bariatrician Base Sal. $150,000 [Buy Practice] PROs: Can provide higher level of post op care than a non-physician provider (NP/PA). Can develop an ancillary medical weight loss business for low BMI patients, and assist recruiting higher BMI patients CONs: Bariatrician could compete for same obese patient population

34 Financial Outlook for Bariatric Surgery

35 Tiered-Hospital Networks Movement by the insurance companies to sensitize employees to the real cost of health use tiered networks to drive down cost and increase quality Tiered Networks for Hospital and Physician Health Care EBRI Issue Brief #260 Blue Select is a new tiered benefit health plan that can save employers as much as 10 percent* compared to traditional PPO plans. BCBSNC used its provider relationships, claims data and expertise to organize in-network hospitals and selected specialists (general surgery, OB/GYN, cardiology, orthopedics and gastroenterology) into two tiers based on quality, cost efficiency and accessibility. This product includes the following benefit levels: Tier 1 represents the hospitals and selected specialists that receive BCBSNC s top rating for clinical quality outcomes, cost efficiency or accessibility. Consumers pay less out-of-pocket costs when visiting a tier 1 provider compared to a tier 2 provider. Tier 2 represents the remaining network hospitals and specialists that reach BCBSNC s high standards for clinical quality outcomes and/or cost efficiency. Customers pay more to visit these providers New BCBSNC Products Offer Cost Savings for Individuals and Employers

36 Narrow Networks Limited coverage products that will likely match the EHB and offer limited benefits to employees and employer groups. Insurance Industry is preparing to enter the Health Insurance Exchange in 2014, and they bring 150 million Americans with them 2010 Narrow, Tiered Products accounted for 16% Market 2011 Narrow, Tiered Products accounted for 20% Market

37 Affordable Care Act Population

38 Health Care Reform: EHB Each State is required to have a Essential Health Benefits (EHB) Plan that will form the basis of insurance plans in the Health Insurance Exchanges (HIE) The EHB is a federal or state-mandated minimum scope of coverage that all health insurers in that market must include in their plans. States can choose Federal EHB or to opt for a state EHB, which must be based on the coverage offered plan s currently offered by the 3 largest small group plan s in the state. Uninsured patients will receive tax credits to buy affordable insurance from the exchange

39

40 Outlook Summary The outlook depends on whether Bariatric Surgery is included in State EHB Plans as this will set the bench mark for commercial insurance narrow tiered plans. Yes = 50 million more Americans will qualify for surgery No = more insurance products on the private market with narrow tiers, which will exclude bariatric surgery and therefore there will be less patients