Optimize Your Practice
Philip Clark, MBA, CMPE Business Manager, Duke Metabolic and Weight Loss Surgery
Billing and Coding, the Role of Fellows and Physician
Extenders, Band Adjustments and Diversifying
Strategies to Increase Revenue
Billing and Coding: Revenue Cycle
New
Patient
Visit
Evaluation
Surgery
Payment
Accounts
Receivable
Referral
Pre-Authorization
Pre-Determination
Pre-Verification
Op. Notes
Coding
Appeals
Patient Balance
Physician Involvement
=
=
+
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]
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
Negotiating Self Pay Package
Negotiate with Hospital Negotiate with Ancillary ProvidersCreate 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)
ASMBS Sleeve Gastrectomy Coverage Map
ASMBS Sleeve Gastrectomy Coverage Map
Why E&M Coding Matters
Recovery Audit Program [RAC]
CMS: Medicare Fee-for-Service Recovery Audit Program Myths – December 17, 2012
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
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
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
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 80
M.D., D.O., D.M.D, D.D.S., D.P.M. 16% 81 Minimal Assistant Surgeon
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
M.D., D.O., D.M.D, D.D.S., D.P.M
13%
82 Assistant Surgeon [No Qualified Resident]
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
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%
Deploying Fellows and Physician
Extenders
Physician Extenders and Fellows
Strategies for Deployment
Pros Cons
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
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 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
Hard to find well trained surgical PA
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
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
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
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)
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
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
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.
NP Financial Modeling
Diversifying Strategies to
Increase Revenue
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 20-45 minutes time
Can be billed in the pre-operative phase if diagnosis
supports (commonly GERD)
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
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
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.
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.
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
Financial Outlook for Bariatric
Surgery
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
