So, I'm Lauren Wessel, I will introduce our esteemed panel in just a moment, but we are going to take you through kind of highlights of revenue cycle management, starting with how the U.S. healthcare system drives how the system has developed. And then we will get into an introduction to kind of the nine key phases of the revenue cycle management with Dr. Rode from Orthosincy. Moving on, Dr. Ratliff, who runs a private practice in New Jersey, is going to talk to us a little bit about the specifics of a couple of the cogs in that process, specifically on the back end, which Cal is going to talk about afterwards, Dr. Shaw, a little bit how that's the most modifiable section, and how we can kind of change our practices in that phase most effectively to become more efficient going forward, and that's a little bit of the future of the revenue cycle management process. And then finally, we'll end with the regulatory and administrative challenges with Dr. Adams from the University of Tennessee, so it should be a great session. I do apologize, I have a COVID reschedule wedding, so I'm going to leave in the middle, but Dr. Adams is going to take over moderation when I leave. So we'll start with the U.S. healthcare market. So the U.S. healthcare market is really driven by this triangular relationship between patients, providers, and payers. So interestingly, in this third-payer model, the consumers of the product are not the customers of the product. And when the customers are not the consumers of the product, you get this triangular relationship. The consumers pay taxes and premiums to the actual customers who pay for the services to providers, who then in turn provide the services back to that third party, or the first party in our sequence. However, in this setting, the kind of supply and demand can't, prices can't be regulated in the same way for supply and demand. So when demand for a service goes up, then, or supply of a service go up, prices go down, and vice versa, but things don't respond the same way in the healthcare market. Additionally, there's lots of regulation from that fourth party in our diagram with the government body, which places pressure on kind of providers, as well as payers, to adapt their systems for reimbursement. And those kind of layers of complexity have increased over the years since the 1950s. In the 1950s, payment to hospitals was mainly through nonprofit organizations and charitable campaigns. With the advent of Medicare, medicine really saw its golden age. There was largely unchecked payments to providers through the Medicare system. There wasn't a standard kind of regulation of what payers could charge for services, and so that was really kind of the golden age in medicine, where doctors were able to make a good amount of money without a lot of, I would say, red tape. And additionally, if a provider charged X amount to a patient, like Jane Doe, if the next payer couldn't pay that amount, or if a collection was incomplete, tracking down the rest of that collection wasn't as necessary, because there were more buffers from these charitable foundations in combination with Medicare. Fast forward to 1983, the prospective payment system created an opportunity for, and this is also when there was more investment from kind of large organizations. The prospective payment system created an opportunity for other types of revenue, but also established the commencement of fixed Medicare payments, so you couldn't charge whatever you wanted for each service. And then furthermore, in 2010, the next big change was the Accountable Care Act, which we're all familiar with, but there's kind of a trend for diminishing healthcare payments, which makes collecting on each of your payments more important. In general, U.S. healthcare spending has continued to outpace the GDP at an alarming rate. Last year, it was at 9.7%, and the total spending is about $4.1 trillion, which, this is from the AMA, is a quite unsustainable rate, if you're thinking about roughly doubling the GDP. And so, there has been a focus on innovation funding for trying to reclaim this lost kind of money, because about 30% to 40% of the revenue in the healthcare industry is lost to third parties. And I don't mean third parties as in insurance payers, but clearinghouses, medical claims facilities, and billers. And so, if that could be reclaimed to providers, that would significantly shift the health of any individual provider's financial security. So, and that's a kind of big overview of kind of the landscape that we live in, but how does it apply to revenue cycle management? And not everyone might be super familiar with the steps, and we'll get into those in our next discussion, but really, revenue cycle management is all the administrative clinical and clinical functions that contribute to capture and management and collection of patient service revenue. So, this starts with patient access. The moment that your patients call your facility, private practice, hospital, whatever it may be, they provide their insurance information, they get approved. Patient capture is really at the front end of the revenue cycle. When they come in to see you, typically, we think of that as the middle of the revenue cycle, and that's when you really have provider interaction, coding, and then claims remittance, all of these things that come on the end of account, you're getting the payment for your service to your accounts receivable fund is the back end, and that has to do with quite a bit of data transfer, which makes it a little bit more automatable. Historically, data in healthcare has been siloed, which has precluded a lot of synergy between provider information, so EMR, and getting to billers, and so it actually had to go through a biller process where they would look at and interpret your charts, but with new kind of emergence of open source data, and specifically blockchain, this has kind of opened up some opportunities in revenue cycle management, and so this decentralized open source data would kind of increase the amount of liquidity, and has the potential to change how data's reported to billers, which we will also get into. It's estimated that administrative and medical employees lose about half of their time to revenue-oriented issues, such as billing, collections, reimbursement, and accounting, so facilitating this could save any given practice quite a bit of manpower and time, and potentially reduce your overhead quite a bit. So just for this primer and orientation to our kind of session today, the U.S. healthcare system is a complex system of payers, providers, and consumers. Sequential changes in the system have layered additional complexity related to massive policy changes, which have each added costs to essentially the providers in having to adjust to those new policies, and layered our kind of overhead and administrative costs, and the future changes are likely related to changing technologies and data exchange processes in order to try to navigate those increased complexities. So I will give it over to Dr. Rode. If anyone has any questions, if I leave before I get to them, then I can provide my email, but it's lwesselmd at gmail.com. I didn't upload the edited slide, but happy to answer any before I leave, so I'll check the questions after this one. Good morning. Let's see. So, I'm Robert Rode. I'm in Cincinnati, Ohio with OrthoSensee. And thanks, Lauren, for kicking us off. It's kind of a dizzying start thinking about revenue cycle. What I'll try to do is think about where are we in the, let's see, hold on a second, where are we in the process as physicians fitting in. And so, we'll go through each of the steps. And I do think that the key here, the take home is going to be how do we get involved, you know, as physicians, every one of us are in a different practice. They all look different. We may be in a large academic center, a small private practice. You may be employed. But what is common here is that everyone is seeing patients, collecting information, and submitting codes and charges. And what do we do? So, getting involved, I think, is one of the take homes. Again, as Lauren really shared with us, it's the process of identifying, collecting, managing revenue based on services that you provide. The key steps, we'll go through real briefly and then I'll expand on them. Appointment scheduling, patient registration, the coding, charge entry, time of service collection, claim submission, patient payment posting, sorry, this is kind of going ahead of me, billing statements, prompt payment adjustment, and then patient collection. It's a lot, but I think it all makes sense once we think about our own processes. So, as we think about appointment scheduling, it's really the first interaction. It's the collection of billing information that happens initially. And right there is where you want to make sure that you're set up to collect as much info as possible when somebody is making an appointment. And the key there is accuracy. If you collect the information accurately, it really helps to build clean claims and we'll come back to that. So, at every point, accuracy is so important. At registration, approximately 25% of denied claims are probably secondary to errors at the registration process, verification, or data input errors. So, that is important to make sure that that's identified as the clean data entry point. When the patient comes in, we know that coding is important for the physician to be able to appropriately document and then assign the level of service. And every physician or team member should be very adequately trained in the coding process and ensure that the physicians understand the importance of the proper documentation with that. It's really nobody else that knows better than you what you've done and how to document that. So, it's accurate. It's probably wise that in any situation you're in that annual audits at a minimum occur for surgical and EOM office coding. And, of course, a practice should employ well-qualified coders and well-trained. Annual audits at a minimum of the coders is also important. At the time of charge entry then, if possible, the automation is critical to get the data entry into the practice management system or electronic medical record. And, of course, that limits cost from data entry errors with automation. Charges are entered and then processed within 48 to 72 hours from the date of service where possible. And, in fact, we do know that failure to file in a timely manner could create a denial situation with the payer. So, that also means that you emphasize timely documentation from the people giving the service. And that can be a difficult point in your practice. So, time of service collection, if possible, it's a goal to collect all the co-pays, co-insurances, deductibles at that time of service. And the cost of collection will continue to increase that moment the patient leaves the office. So, when it's set up nicely and helpful for all involved, collecting up front is a helpful point. Any expected out-of-pocket expenses for elective surgery can be handled prior to the surgery date. And, of course, if it's an urgent surgery, perhaps the main role is to at least educate the patient, communicate options, and help them with arrangements. And in our practice, I will say I've seen the benefit of utilizing trained, wise patient advocates and counselors. And these individuals can help educate not only the patient, but also yourself. Review the accounts prior to any appointment and then review them and get involved when the patient comes. And I think I'm reminded of that frequently. It's true. Sometimes the patient is unaware that they have some issue. And so catching those up front is helpful for everyone involved. Submitting claims, best to have some type of a system that can run the claims automatically on a daily basis. If you have a clearinghouse that has programmed rules in place, you can often catch errors up front. And, of course, you'd have a dedicated staff that works through the edits or the errors. And I think that we all see this. There are certain payers, insurance companies that will just have strategies of routine denials, rejections. And so having some structure in your practice to anticipate and then handle those denials is going to be important. And I think we're going to hear more about some of these processes as well. But this requires prompt action and identification of it. Then when reimbursements and payments occur, the posting in your system is set up, ideally, through electronic funds transfer or electronic remittent advice for as many of the payers as possible. Of course, that's streamlined. It minimizes other outside need for handling. Minimizes the data entry on a manual basis. Just better efficiency overall. And any old-fashioned check payments should be handled and then routed to a lockbox quickly. Deposit those promptly. And in general, I think most of us would ideally like to limit the old-fashioned paper checks to less than 10 percent of payments. In terms of preparing and sending billing statements, those are usually sent and billed immediately following adjudication of claims. Follow-up statements would then be sent at least every 30 days to your patients and establish criteria for what is a past-due account and when do you send to collections. And in many practices, although it's not hard and fast, but often that's three monthly statements and then one final notice. But in general, having multiple alternative options to pay the bills is good for everyone and it's good service to the patients. Some patients would prefer to mail it in. Many patients would like to just pay over the phone. And of course, a good user-friendly website patient portal. Another factor that's become a bit more embraced is a prompt payment adjustment. And if you're going to be in a practice that says we offer an advantage to a patient who says, I'll pay up front, I'll do a prompt payment, prepare your billing staff so everyone's on the same page. You have to be able to handle those questions and answer them consistently. And how are you handling an adjustment for that prompt payment? And be aware, that might be something that your affiliated hospital also uses. So some consistency may be a benefit. And a lot of office settings may utilize something in the ballpark of a 10% prompt payment adjustment when people inquire. However, after three monthly statements and if somebody receives a final notice, most practices would consider having the account reviewed and in placement with some form of a collection agency. And in our practice, and I imagine many of us out here, there's an opportunity for a collection specialist position. Review that. Make sure that nothing's been missed. Make a phone call in a friendly way to the patient and see if there's an opportunity to collect on that past due. Maybe that's where you offer some type of adjustment for payment in full. So in general, establish a dashboard as part of the revenue cycle management. Sorry about that. Physicians need to be looking for trends. What is changing in the dashboard or what is changing in the numbers? And own your own coding. Hold the physicians responsible in your group for prompt documentation, for making sure that they are inputting their work and documenting and coding. And then the communication is key. Physicians, coders, billing managers. And so that's where you insert yourself. Make sure that you're part of engendering that open communication. Somebody has a question that should be asked, not assumed. And so I think that would be the take home as physicians, no matter what system, make yourself involved. Make sure that you're a part of the whole system. So thanks. Thanks. Thanks, Dr. Rhoades. That was really great. That was a wonderful discussion about things we can do to optimize our practices. Our next speaker is Dr. Shaw. He's going to talk about what are the tools that hand surgeons can use to facilitate the cycle. Good morning, everyone. Thanks for making the early talk. I'm Cal Shaw. I'm out of San Diego. This is a talk that Lauren had put together. And you could have used your slides, but it's still an interesting talk. We're going to talk about revenue cycle management and what we as hand surgeons need to know. According to 2021 McKinsey's market report, healthcare services and technology is one of the most profitable segments of the healthcare industry. It's driven a lot of growth over the past decade in this arena. Artificial intelligence, machine learning, digitization have driven associated value creation in this arena. As Lauren talked about, this is a slide that I borrowed from her original presentation. The complexity of the third-party payer model in the U.S. has driven cost containment. The complexity of the many facets of the third-party payer model has also driven complexities in revenue cycle management, which we touched on by the previous talk by Dr. Rohde. This slide is a busy slide, but it serves to illustrate the many steps that occur at each of the three phases of the revenue cycle. And traditionally, it requires a lot of manpower in order to drive the workflow from the pre-encounter, the front end, the middle part of the slide here, which is essentially you talking to the patient, you entering the charges, and submitting them. And then the magic that happens on the back end, the post-encounter, where the claims get submitted to the insurance companies and get paid. The complexity of the—in efforts to decrease the manpower required for these processes, technologies have been utilized to automate some of these jobs. Over the past five years, health service technology companies have grown their earnings by about 7 percent annually, and there is an estimated $500 billion of available headroom for continued growth in this field, which is clearly attractive for many venture capitalists and private equity firms. Without considering the impact of inflation, venture capitalists and private equity groups have invested at least $60 billion between 2012 and 2017. And this figure does not include a lot of the internal and industry investments that have been made, so the true amount is likely much greater than the $60 billion. The increased market investment creates opportunities, it creates risks, and structural questions for many of us, the healthcare providers. Integration of the new IT into the market presents a constant need to increase our commitment to technology, which is healthcare providers must continue—you know, we must familiarize ourselves to maximize the efficiency. Within the IT market, revenue cycle management captures a category often called payment services, and earnings in this small sector of the whole pie was roughly $35 billion in 2016, and it continues to grow. Some recent reports at the conclusion of 2021, especially from McKinsey, have estimated the growth to be about $50 billion, and they projected a growth of 5 to 10 percent over the next few years, and it outpaces similar business services. Most notably, categories of data and analytics and information services, as well as software platform and technologies, are expected to outpace specific business service categories and remain the main driver of the growth. The presence of these functionalities will further the importance of us physicians familiarizing ourselves with the AI, the automation, the machine learning, and other technologies which our healthcare systems or our groups will be using to get the payments from insurance payers or the patients. Many of the changes in the payment services platform has been driven by the rise of high deductible health plans, which puts a lot of burden on the provider offices to focus on accounts receivable, as well as the rise in challenge of the value-based care. The complexities in dealing with the evolving payment landscape has contributed to the consolidation of smaller practices in order to achieve the scale required to manage some of these administrative complexities. Much of the highly manual work involved in the revenue cycle management processes, such as patient registration, benefits, insurance, eligibility verification, and referral authorization occur on the front end of the cycle on the left side of the screen, and that requires manpower. There's not much automation that can be done over here, but in the middle and the back end, which is the middle of the slide on the right side of the slide, much of the processes can be automated, but there are still specific pain points that our offices should be attentive to, including charge capture through mapping the clinical procedures we perform or the patient visits we perform to the chargeable codes, as well as denial management, which Dr. Rhodes touched upon briefly. As such, a lot of the revenue cycle management technology vendors have focused their efforts towards automated components of the revenue cycle. With increasing technologies available, these functionalities are growing with the use of AI and machine learning algorithms as technologies are helping to automate the abstraction of billing data from the medical record. This slide illustrates the key players at the bottom of the slide in the revenue cycle management space, and it aligns them with specific components of the revenue cycle process which they target. You may recognize some of the names at the bottom of the slide here, like Epic and Cerner and Athena, eClinicalWorks and AllCribs, because these are EMRs that we use. They're all working on internalizing a lot of the processes to provide a more complete package to the health system, which are their clients. With a tight relationship between the EMR and the revenue cycle management, EHR vendors are aiming to capture the rapid growth in this category in order to become the sole end-to-end provider for their clients. And the traditional boundaries between the companies are increasingly getting blurred by one, you know, they buy each other and merge. The main drivers of bundling are cost savings. About 20 to 50% of providers who bundle EMR, sorry, the savings are about 20 to 50% when the providers bundle the EMR and revenue cycle management products. This along with the increased convenience of front-end workflow with the patient registration and eligibility verification, given the tight linkage between the authorization and documentation for the clinical visit and the claim, has driven EMR providers to work towards internalizing the RCM process. One thing to keep in mind, though, is the users of the RCM, the billers, are very distinct than us who are utilizing the EHR. This requires two different interfaces, one for the billers, one for us, and that adds to the complexity that the companies, the EMR companies have to deal with. As such, you know, the balance remains at odds. is Dr. David Ratliff. So I'm sorry I'm late, I was at another ICL. I am a private practice physician in New Jersey, and so trying to really drill down on how we actually get paid, and what the steps are for that is sort of my task here. So initially I had joined, after fellowship, a 12-person group in Buffalo, and I left to join a former co-resident in a small practice in New Jersey. And then in 2019, we started a new practice from the ground up. He and I and a couple admins in a WeWork to start, and then we had to build that from nothing, and it's a challenge every day, and it's going well, but the whole key is we need to get paid to keep funding this practice and keep growing. And understanding this process has really been critical to the practice's success. So really, why do you care? Obviously, getting paid for what we do keeps the process going, but we always tell ourselves that if we don't value what we do, the insurance companies surely won't. They are in it for profit, and you need to fight and value your services. I am in, currently I'm in an out-of-network private practice, and that's a whole separate sort of process, but again, most people aren't. In my research, it seems that about 4% of hand surgeons are out-of-network, but knowing the way that we do things can help inform the process and give you tips and tricks, even for in-network billing, to increase collections. And the appeals and negotiations are still kind of the same idea in or out-of-network. So again, working in New Jersey, some of the forms and processes are somewhat state-specific. So again, the actual numbers and things may not be applicable to you, but I do think that there's very strong universalities that matter to this. So again, boots on the ground, Jane Smith calls our office to make an appointment. She gives her insurance info to our front desk. They run it through a clearinghouse. We use Triseto, you can use anybody, and submit an eligibility request. We get the eligibility response, and that tells us, again, what their in-network benefits are, out-of-network benefits, cost shares, and that all gets determined at that point. I see her, treat her, code her for the treatment, and then those codes get submitted. We've gone back and forth between third-party or in-house billers, but the codes get submitted. And then with submission, we're submitting them electronically via clearinghouse. Old school is putting them on paper. And then you get your response from the insurance company, which typically tells you that you're not getting paid. And so with that response and the explanation of benefits comes the denial codes, the claim adjustment reason codes. Those can be simple, or they can be more complex, but we go through the denial codes along with the ERB, or the EOB, and reconcile the EMR, just make sure that if it's getting denied because there was a date wrong, or something as simple as that, and we create a simple appeal based on that. And with that initial denial begins the open negotiation process. And we go back to the summary plan document from the patient, which we get from their employer or benefits provider. And that really outlines the exact benefits on how their plan pays. And that's a major piece, a major document that we use for our negotiations. Because again, the summary plan document will say that this patient is covered for XYZ, or covered in such a way for out-of-network or in-network. And when they deny it, you can point to that summary plan document and show that it was actually supposed to be paid. And so we revise the negotiation during that open negotiation period based on their specific benefits. So in that open negotiation, if that doesn't work, then for us, if it's a fully funded or a state plan, we then go into independent dispute resolution. So IDR, which was outlined from the federal government in New Jersey, then it's that right tier, which for self-funded plans, which I think is around 40% of our plans are self-funded. We do level one member and provider appeals, level two attorney appeals, and arbitration via the attorney. So this goes into that a little bit more. So for the member and provider level appeals, we have each patient sign over to us that we are their authorized representative to negotiate on their behalf. So that's the member appeal. We do a provider appeal and then send it to the lawyers. The lawyers typically take about a third of what they collect, but a third of something is better than 100% of nothing, which we were getting before that. For the IDR process, again, for the fully funded or state plans, it's a negotiation based on previous payments, fair health, and again, we provide all the documentation. So IDR is a baseball style arbitration. We give fair health numbers. of Fair Health. This is what we've been paid in the past for this procedure and then the insurance company does the same and then the arbiter chooses. decides how much you get paid. And if your evidence is good, we have pretty good track record of getting paid in this way. And the fair health is, again, I keep referencing, it's this whole fascinating black box of what doctors are charging. So Optum uses claims from 60 health plans and carriers. It's reported charges for each CPT. And it tells you what the charges are in your GeoZip. So sort of like zip codes, but a little bit different. But basically in your area, the 50th percentile, 80th, 95th, for example, of what the doctors are charging. So the crazy thing that I've always just not understood about it is, we bill based on fair health. So we're billing 80th percentile, 95th percentile of fair health. But those charges of fair health are based on what we're billing. So it's this crazy snake eating its own tail sort of thing where the doctors are charging based on that and it's based on us. And so it's almost like a collusion sort of thing where everybody is just going in one circle. And so how does the No Surprises Act affect us that I had referenced? We do extra paperwork for elective surgeries where the patients are provided with their bill charges for each expected code and their cost share and what's expected of them. And beyond that, it's been pretty straightforward. So with this whole process, you need to be organized and track everything. If you only have 30 days for your appeal, you need to track it and be on top of it. And requesting the summary plan document right away is something that we have found to be extremely helpful for arbitration or the IDR process. And so with the summary plan document, we know how their benefits pay and we can argue that they should be paid as they said they would when they provided the patient with that summary plan document. We have the patients sign the assignment of benefits in the designated authorization representative form, giving us the permission and the right to negotiate on their behalf and some insurance carriers have their own form that you need to use. And so again, tracking, spreadsheets, monitoring and touching claims over and over again. It's not just we didn't get paid oh well, it's you keep checking and working the process. And again, it's how we've been able to be successful in a challenge. Thank you, Dr. Ratliff. That was a really great talk. I think it highlights some of the issues. And I think all of us have been in situations or scenarios where we don't have people who are really going after those claims on our behalf. And so if you're selecting a combined EMR biller and someone who's managing your revenue cycle, make sure you find out how diligent they are about chasing them down. Because I don't think they are, on average, quite as diligent as you are. My task is to talk about regulatory and administrative challenges in revenue cycle management. And I think the real challenges are appropriate bidirectional capture of documentation and capture of charges and making sure that those meet and match. Management of prior authorizations, which, as we've heard, many places and many EMRs are going to automated systems. And then regulatory compliance, which, just wait. There's always changes on the horizon. Compliance risk areas include patient access. Certainly, the high tech law and HIPAA, the Cures Act, and the open charts error are all things that have really hit us on the horizon that we need to comply with. Because there are not only reputational harms, but also fines usually associated with that. Medical documentation, making sure that you meet medical necessity, physician orders, the CPOE, the computerized physician order injury, and coding accuracy. We've talked a bit about patient financial services and proper billing and claim submission, as well as denials, proper payments, and refunds. I've recently had the unfortunate scenario of having to receive health care. And it is much better to give than receive, I will tell you that. But many of the places that I've received health care at have done exactly as has been stated before, in which you submit, here's your credit card, and here's how much it's going to cost. And if you pay early, you get a discount. And who doesn't love a discount? So I think that many of those resonate. So thanks for bringing those out to the earlier speakers. What about HIPAA? We think about this as sort of privacy, but it also gives patients the access to their records. The sort of thing that everyone's talking about is this Cures Act signed in 2016 by Obama and the Open Notes thing that happened sort of in April of 21. This was sort of designed to decrease the regulatory burden and administrative burden. As with most government initiatives, not so sure that that was the end result. But also it's intended to improve patient access and self-determination. As part of this, again, the Open Notes giving patients full access to their health information. Consult notes, discharge summaries, HMPs, imaging reports, lab reports, path reports, procedure notes, progress notes. There are some exceptions. The exemptions tend to be around things like, I'm afraid if my note gets to the patient, it could cause harm. And that's not harm like they'll call my office and bug me. That doesn't count. It's like self-harm kind of thing. There's also exemptions when the patient says, I want you to send my note to my Apple Health. And you're like, well, my MR doesn't do that. So there's some exemptions that allow that. From a sort of stepping away from revenue cycle, a philosophical thing is, okay, fine. It's here, it's here to stay. You can rail out it all you want, but you gotta expect it and sort of live within it and maybe embrace it or at least tolerate it because it's here. I would say that some of the strategies are really being aware about abbreviations, like the abbreviation SOB, you might wanna say that's shortness of breath, that most of the EMRs have sort of dot phrases or other sort of macros that allow you to do these things. Instead of saying the patient is disheveled, say that the shirt is untucked. Means sort of the same thing, but it's less pejorative. Patient chooses not to pursue treatment instead of they refuse treatment or non-compliant. Denies alcohol use, that sort of sounds like you don't believe them and a little pejorative. Patient lost five pounds, they're motivated to continue towards our trend of 20 pounds weight loss rather than patient still needs to lose 15 pounds before I do their total knee. I like dictating in front of the patient, that way there's no surprises and using quotes. Patients really like that and advocate for the patient to read their note, sign them up for the patient portal. There are incentives associated with patient portal uses in many systems. I've used my notes to educate the referral sources, now you can use it to empower. What is the other sort of challenge? And this is sort of an administrative burden to you when the patient sends you a message and says, you were wrong about these 80 things in my 15 minute visit note. And what do you do with that? And oh, by the way, we want you to alter the medical record in ways that really aren't ethical or correct. And so some responses, I'm really sorry you disagree that alcohol intoxication had a role in your fall, that you broke your wrist. I really can't change my medical opinion because you were in the ER and your blood alcohol level was blah, blah, blah. But if you like, I can say that you disagree and who can argue with that? You can agree to disagree. I understand you want me to remove patient has a history of cocaine use, but actually it's really important for your anesthesiologist to know that ahead of your surgery. If it's excessive, I have notated in my clinic note, I am in receipt of the patient's two inch stack of expected changes to my note and I have uploaded them to the EMR. It tells you a lot, right, when you reread that note. Medical documentation and charge capture really making sure that your code matches what you did or what you are requesting reimbursement for, that your orders are matched to a diagnosis and matched to medical necessity. You know, the real challenge and I learned early on in my career, I had a patient who had a proximal scaphoid fracture and she decided not to pursue operative treatment, declined operative treatment and so she agreed to casting and I said, you know, let's throw the kitchen sink in it, let's get you a bone stimulator and some very helpful person, which happens to all of us in our office, patient comes in, they have wrist pain, that's their diagnosis. So we use that diagnosis to get an x-ray, see an x-ray, yes, you have a scaphoid fracture of the proximal 1 3rd, non-displaced and I never went back to the EMR and changed that diagnosis. It was in my note, my note was beautiful, so I asked for a bone stimulator and it was denied, right, because it didn't meet medical necessity because I never went back to change and so I ended up with a peer-to-peer and I'm talking to this guy and I'm like belligerent and angry and the guy's like, well, you know, your diagnosis doesn't support it. I'm like, what are you talking about? I've read your documentation on whatever insurance company it is and yes, this is covered and he's like, well, the only diagnosis I see is wrist pain. I'm like, you didn't read my note? I'm like, well, that doesn't really count. So going back in and changing it is something. It also helps avoid clawbacks and facilitates care and timely access. I mean, that's the bottom line is we wanna do what's right for the patient. It also keeps you from having hypertension, maybe, and spending a lot of time on the phone with peer-to-peers to tell the peer-to-peer, oh, by the way, you know what, give me five minutes, I will change that right now. Surgical notes, I think one of the burdens is that we can write these beautiful operative notes that tell someone else how to do the case we just did and every step makes perfect sense to us, but that maps with the CPT code, which has a specific description. So it's often helpful to put in kind of the verbiage from the description so that you can avoid your biller saying, well, I'm not really sure what code to pick and also giving them the codes can be very helpful, but also when it is audited by the insurer, they're like, yeah, this meets exactly the criteria. Clinic notes and orders, be familiar like I was with the denials and document clearly. So most cases, if you want an MRI of something, you usually have to have an x-ray first because somebody has an algorithm and they're going, dit, dit, dit, dit, dit. Also in your notes, if you know, okay, this patient has rotator cuff tear and they have failed six weeks of therapy and injections and et cetera, then putting that in your notes specifically can help you facilitate getting that MRI approved. Every time I have a peer-to-peer, I'll remind you to be very polite to these people because they're just trying to do their job and trying to keep people from ordering things that aren't indicated. But I also, at the end of the conversation, I say, it's been a pleasure talking to you today. Thank you so much, even if it hasn't been. And what can I do to not have to talk to you next time or one of your colleagues? And they'll give you little tricks like, hey, you know, this didn't match with this. And I've found that extraordinarily helpful to sort of educate myself. Be a good citizen. I think one of the issues is that you've seen the slides about the GDP and I think healthcare in general is sort of in trouble, right? Because there's a large percentage of money spent. It's a very complicated system and sometimes when patients are admitted to the hospital, our documentation doesn't even meet criteria for hospitalization and make sure that you are documenting every sort of issue that they have that keeps them in the hospital and requires that level of care. Other areas are patient financial services, proper billing, claim submission, denials, proper payments and refunds. I think that collecting a copay at the time of the visit is a really great practice. I love the here's your discount if you pay ahead of time. You know, personally from a parsimonious, you know, frugal, it appeals to me about how I get a discount. But it's a real win because your staff are no longer having to chase down those patients to get the payment. I will tell you that some practices have the strategy of saying you have a large cost event like a surgery and the patient has whatever deductible as a gesture of sort of like, don't be mad at me, be mad at the hospital. Some practices have this specific strategy of having the hospital collect the deductible from the patient first, like sending the bill off and then a couple days later, the practice will send the bill so that the patient has now met their deductible, they're writing a check to the hospital, the hospital has to chase them down and the practice doesn't. I've heard of that strategy and I've never employed it myself, but some places really do look at that. Some patients with high deductible plans may prefer a cash price and this may be a win for you. I had an acquaintance who was pregnant and her particular insurance, this was decades ago, was out of network with the anesthesiologist and she sort of went to the anesthesia group and kind of cut a deal that, okay, how much is an epidural gonna cost me? Here's how much I know that you're going to get paid by CMS or other payers so I know you accept it. And so many patients who have a high deductible plan may actually prefer cash pay prices and I've seen some plans that are really crazy, like $10,000 deductible, but be aware and counsel them that once they pay that, it doesn't transfer to their deductible. These are a couple of articles that have shown up in the lay press and I think that it highlights that a lot of patients are really pursuing these sort of self-pay plans. I have a friend and colleague who is a direct primary care physician and he's like, his practice is full of patients who sign up for these subscription services because they're paying him $60 a month but they're not touching their deductible and so they reserve that for catastrophic insurance. I think we're gonna see more of that in the future and I think we're gonna see patients sort of shifting some of the burden to them and they may choose to do these kind of things. So thank you very much. I'd like to ask the speakers up for a panel question and answer. Thank you. Yeah, I don't know the answer to that. So that's a great question. I think that this panel is a very good resource. I'll just volunteer them. The question was, as someone either about to start practice or early in practice, what are the resources that are available to you? Well, I know that Julie and I are both on the Business of Hand Surgery Committee and with Hand P that Dr. Greenberg has been pushing as well. Those resources are new, but they're going to keep growing. The content from today is going to be on there, and there's a lot more content being put on there. So I think Hand P is going to be one of your go-tos. I would agree, and I've been involved in that as well, and there is some very good content from very basic to very advanced on Hand P, and any member has access. I would also say, if you've not had the opportunity to do that, we all owe it to ourselves to go to a very good, high-quality coding course. And I think many of us, after a few years, said, darn, I wish I had done that a little bit earlier. But that would be another thing, and then volunteer in your group to be on maybe your finance committee or your office. and access our brand new ASSH HandP. And just to add to the recommendation about the coding course, Karen, Zepco, and companies like that, they offer consultations. If you have enough partners who wanna. I Believe at this meeting at least in years past and I think this year there's a pre or post course Yep, yep, and So I think those are really really good resources The other thing that I would suggest is getting to know your coders and having a bi-directional communication I think that My first practice I learned so much from my coders. They were really really good And so if you have a really really good coder there, they can teach you a lot They can say well, you know your operative note may be able to tell another surgeon how to do this But it's not really helpful to tell us how this can be coded and meeting all the check boxes And so having that kind of conversation back and forth. It's really really helpful There's Unfortunately, not that many great great coders A lot of people are not so good and I would argue that hand surgery is one of the most difficult things to code to add to that in a Prior relationship we had a hospital system previously managing some of our Capture of the coding and then reimbursement based on that and a couple years ago I gave a talk here about some of the pitfalls with some of those and one of the quotes that took traction was I went back and we audited that and We found so many errors and it generally benefited us as the surgeon but it was accurate and it was appropriate, but they to their credit we did have sort of a Reconciliation of that and what I like to say is it paid for one of my kids years of college by going back and auditing so It was pretty significant. You do have to stay on top of it and just to add to the coding thing I think you were lucky that you had great quarters, but a lot of times it's the opposite You know in a big organization like scripts these coders come and go we don't have one or two people assigned To the hand surgery division. So you kind of have to be on top of it You know, they email us or messages on the epic all the time Hey I'm gonna change this new patient consultation to an established patient because they saw a joint replacement surgeon a year ago What's like no a hand surgery is a different taxonomy I can still bill for a new patient or a new consult So you have to stay on top of it and keep keep educating them on ways to maximize revenue I think there were a couple other questions Well, yeah, we are currently at a network, and we're always open to negotiating contracts, but again, for example, one of the spine groups near me, because of them just continually doing well, they were able to get, I think, eight times Medicare out of Blue Cross Blue Shield, but sometimes the insurance companies will come back to us with 125% Medicare, which I'd rather just stay at a network. So in terms of negotiating, I think if showing them, again, the volume and what you're doing and what you're billing is really where your power is, but again, I think in some states I've been told that out of network is becoming illegal, and without that, then they just do whatever they want. So I think having that available to at least we can go out of network and we can do that for a while, but you also have to remain sort of malleable and nimble in the process and be open to change. To David's point, I think location is everything, and in New Jersey it may work. I'm in Cincinnati, and it doesn't play well to be fully out of network. Now our surgery center in its infancy with many plans was, and boy, that took a lot of communication and hand-holding with patients. I would say some opportunities that are out there, because if you want to open up the whole process again, you risk that trend of taking a downward trend as well, and I don't mean to sound defeatist, but it's reality in many markets. But one opportunity with us as hand surgeons is bringing a differentiation to that payer who's tired of paying for a carpal tunnel at a big hospital and saying, I'm starting to do things in the office, and what is the benefit in our plan, some carve-out, if I do trigger fingers and carpal tunnels in my office suite? That's one opportunity, a low-hanging fruit, rather than a massive overhaul. Just a thought. Great. Dr. Goldfarb. I think that 10% was if you pay the patient pays their portion of the copay ahead of time as opposed to for us at Scripps it's 40% discount if they pay cash ours is more 10% although we have counselors who will case by case it I think that you know we see everyone in our practice and so everyone has a different situation we do case by case but it's significant usually 40 or 50 percent because again with our whole process of billing and appealing and you save a lot of money by not having to go through that process and pay billers to do that your other question was about the carve-outs we have actually had some success with two pairs in our market and I know again every location is different I think that what many of us have already seen is payers won't pay for a trigger finger a carpal tunnel in an HOPD setting right a lot of us have seen that and so I think that what's on the horizon next is either the carrot or the stick and and certainly right now we are receiving with many and obviously you know that Medicare has already you know baked that in with with in-office procedures but we have found a couple insurance payers have very much incentivized to do that but I don't know in each market I think that even within we're in three states in my practice and even in different states we find different handling so it's it is confusing I think it's worth trying it's good for the patient too all right well I'd like to thank the panel I think we're out of time and appreciate you guys and learned a lot from you

revenue cycle management

healthcare industry

key phases

challenges

strategies

patient information

coding and charge entry

claim submission

regulatory challenges

optimization