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pinnacleiii

Dec 30
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Attract Surgeons

How to Retain & Attract Surgeons to Your ASC

By ASC Management, Leadership No Comments

Do you have a favorite store where you enjoy shopping? It may be convenient to your home or office. They always seem to have what you need.  And, when you can’t find something, friendly staff members are readily available to assist you. It may not be the least expensive place, but the service and atmosphere make the extra dollars spent worthwhile.

Think about your favorite restaurant – perhaps the excellent food was the original draw.  But you keep going back because the service and overall feeling you have while you are there adds to your overall enjoyment.  It wins out often despite the multitude of dining options available to you.

Then there’s that shop you use to service your car or bike.  When you call, they always remember you.  When you walk in the door, the owner and staff greet you as if they genuinely care about your business.  They provide you with service options that may not always be the most profitable for them, but may make the most financial sense to you.

When we consider how to retain and attract surgeons to our surgery centers, it is helpful to keep these types of experiences in mind.  I purposely mentioned retain first.   It is much easier and less expensive to keep current business than it is to attract new business.  This is especially true for surgeons in an ASC. Emulate the owners and staff members at your favorite businesses who provide you with the quality customer service you appreciate.  Ensure the actions and attitudes of everyone at your center convey to your physicians their business is valued.

Surgeons use ASCs for a variety of reasons.  Here are six ways you may be able to attract them to your center:

  1. Consistently provide outstanding customer service. One size doesn’t fit all.  Surgeons value different aspects of their customer experience.  They may be drawn to measurable factors – low infection and transfer rates or high patient and physician satisfaction, for example.  Or, it may be as simple as the reliable availability of competent staff, the proper equipment, and necessary supplies.
  2. Save them time. When you save surgeons time, you improve their quality of life.  This can be as simple as your center being near their home or office which reduces time in the car.   On time starts and rapid room turnover times strongly impact surgeon time.  And, if the scheduling process is convenient for physicians and their staff, they are more inclined to use your ASC.
  3. Ensure quality. In today’s healthcare environment, quality should be a given.  When we are asked to revitalize struggling centers, we rarely encounter ASCs providing poor quality of care. Surgeons look for measurable factors when assessing quality – make this information available to them.   They also want to see the high nurse to patient ratios they have come to expect in an ASC.  Lastly, quality usually comes down to perception – is your staff knowledgeable, skilled, and experienced?
  4. Offer extensive managed care participation. Provided you are not an out-of-network center, physicians and their offices do not want to have to choose their site of service based on remembering which center participates with which third party payor. Being able to offer surgeons the full spectrum of managed care plans in your market makes your center a more desirable place to work.
  5. Provide return on investment. Most investors subscribe to a simple formula.  If they are receiving distributions – tangible ROI – they are much more likely to participate.  If distributions are far and few between, investor participation decreases and your ASC has minimal opportunities to recruit new surgeons.  Managing your center in a fiscally responsible way with financial stewardship in mind affords you opportunities to both retain and attract new physicians. 
  6. Add value. Be able to answer the question, “What have you done for me lately?”  Constantly look for ways to add value to the lives and practices of the surgeons who use your ASC.  Focus on the items I’ve outlined above and never rest on your laurels.

Rob Carrera – President and CEO

Dec 22
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Billing Solutions

Billing Solutions: Forensic Collections – Lost Revenue Found

By Revenue Cycle Management No Comments

If you suspect your existing billing solutions service or internal business office isn’t managing your accounts receivable well, you are likely concerned about uncollected revenue.  Perhaps you recognize that acting quickly may allow your facility to recover lost income.

To obtain the objective data you need to make an informed decision about next steps, enter forensic collections mode.  Your goal?  Leave no stone unturned.

During your search for this potential uncollected revenue, include these activities:

  • Analyze the A/R and payor mix. Look for sizable changes or significant swings in outstanding balances.  Ensure you thoroughly examine patient balances.
  • Investigate write-offs including bad debt adjustments. Are the write-offs consistent with the reimbursement terms outlined in your payor contracts?
  • Examine billed charges. Review payors being billed.  Are your secondary payors being billed after the primary payors have paid?
  • Inspect implant billing and reimbursement. Compare the results to your contracts.  If separate reimbursement is allowed for implants, are you billing them accurately and receiving full payment?
  • Determine when the last fee schedule increase occurred. Are your billed charges keeping pace with your contractual reimbursement?

Here are a few examples of what my team and I have discovered while in forensic collections mode.

  • Our analysis of workers’ compensation claims revealed payments equaled 100% of billed charges. This rarely happens which lead us to dig deeper.  We compared the state’s work comp fee schedule to the facility’s charge master.  The state’s fee schedule was much higher than the facility’s charge master which hadn’t been updated since 2006.  We promptly notified the payors (per their contract requirements) that an increase to the facility’s fee schedule was scheduled to take place in 30 days.  Consequently, the facility realized an immediate increase in work comp revenue.
  • A review of Medicare claims revealed when a secondary insurance was active but not being billed. We queued up all claims within timely filing and billed them to the secondary payors.  The results were an increase in payments to the facility, a decrease in bad debt, and correction of balances erroneously being transferred to patient responsibility.
  • We reviewed ortho cases where implants were being used. Our analysis revealed the facility never billed for implants.  We discovered facility personnel knew their contracts allowed for implant reimbursement when claims were filed with supporting documentation.  However, they were unable to obtain implant invoices from their hospital partner thwarting their efforts to pursue payments on implants.
  • A review of patient balances revealed patients had not received statements in more than seven months.
  • In our review of claims denials, we discovered claims were never appealed. Payor payments were merely accepted.  The balances between the billed charges and the allowed charges were written off without first confirming their accuracy with the contract terms.
  • When changing patient accounting systems, a facility turned their entire A/R over to a collection agency. If they had opted to work that A/R themselves, hundreds of thousands of dollars could have been easily collected.
  • Facility contracts were not loaded into the patient accounting system. With each passing year, contracts and fee schedules changed but the cash poster’s memory did not.  Explanation of benefits (EOBs) were not compared to contracts.  Amounts received were accepted, correct or not.  Remaining balances were written off.  Credit balances were never refunded.

The examples go on and on.  It doesn’t have to be this way.  Audit early and often.  Be willing to dig a little to uncover potential problems and fix them.  When you do, your reward is a nice increase in your net revenue per case and happier investors!

Carol Ciluffo – Vice President of Revenue Cycle Management

Dec 14
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ASC Reimbursement

Already maximizing ASC reimbursement on your commercial contracts? Now what?

By Payor Contracting No Comments

I am often asked, “What if I’m already maximizing ASC reimbursement on my facility’s commercial contracts?” Three responses quickly come to mind.  First, how do you know you’re receiving optimal reimbursement?  Second, have you capitalized on moving cases from the hospital setting to your facility to create a leverage opportunity on your lower acuity procedures? Finally, if you truly do know you’ve already secured maximum reimbursement, don’t draw fire.

How Do You Know You Are Receiving Optimal Reimbursement?

From my bleacher seat, you don’t know what you’re capable of securing in terms of reimbursement unless you’ve answered at least two questions.

Have you thoroughly analyzed how your major commercial payors reimburse your ASC for the services you routinely provide?

Measuring how your ASC is reimbursed for its top volume procedures is a great place to start. This will allow you to assess your facility’s market parity and identify differences in reimbursement among your key payors. Since differences sometimes create opportunities, this analysis could help you identify ways to increase reimbursement.  It could also assist your facility in establishing practical renegotiation goals. Please see my blog “Payor Contracting Tip: How to Determine Market” for additional details on determining market parity.

Has a payor contracting professional evaluated your opportunities?

This starts with hiring an impartial third party who possesses the knowledge and expertise necessary to analyze your facility’s contracts with, and corresponding reimbursement from, commercial payors. This party should also be able to fully negotiate third-party payor contracts. Having this additional set of eyes on your reimbursement when evaluating trends is priceless.

Moving Cases from Hospitals to ASCs

Your facility is most valuable to its payors when it can help them lower their costs.  Simply asking for reimbursement increases will not work in your favor.  In fact, payors may view this approach negatively and be less likely to grant you the reimbursement increases you are pursuing.   However, if payors can save money by moving high acuity cases from the hospital setting to your facility, they may see value in what your facility offers which could facilitate increased reimbursements.  Only then will they be willing to dig deeper into their pockets to pay you more for lower acuity procedures. Please see my blog “What Opportunities Can You Leverage to Increase ASC Reimbursement?” for additional details on moving cases from hospitals to ASCs.

Don’t Draw Fire

Once you determine a payor is paying your facility exceptionally well, do not request changes on your contract unless forced to do so by the payor.  If, however, a payor is utilizing percent of billed charge as their payment methodology – a rarity among major payors these days – you can offset increasing costs of care by performing modest charge master increases annually.[1]  Doing so allows your facility to maximize reimbursement afforded under percent of charge reimbursement without drawing fire because you tried to renegotiate your contract.

[1] Pinnacle III encourages facilities to thoroughly research whether its commercial contracts have charge master increase limitations prior to implementing changes.  This will allow them to avoid any unintended consequences of any adjustments made.

Dan Connolly – Vice President of Payor Relations and Contracting

Dec 09
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Boulder Surgery Center

When Your ASC Outgrows Your Physical Space

By ASC Development No Comments

Boulder Surgery Center has experienced steady growth since its inception.  The ambulatory surgery center (ASC) opened in 2005 in the heart of the Boulder community with a vision of becoming an orthopaedic-focused surgery center of excellence.  It quickly established a foothold in the community and became a center of choice for many orthopaedic patients.  Eleven years later Boulder Surgery Center is a bustling facility.  Due to robust case volumes, highly aligned physician practices, and attentive management, the center expanded and relocated to a newly built, state-of-the-art facility.  It is the premier location for outpatient orthopaedic care in Boulder County. 

The new facility is equipped with five operating rooms, one procedure room, and 20 pre-op and recovery bays, including four recovery rooms available for overnight-stays in the facility’s 23-hour care model.  The surgery center’s largest affiliated physician practice, BoulderCentre for Orthopedics, is located directly upstairs, occupying the entire second floor of the new building.

Robust Case Volumes

When the new building project began in 2015, Boulder Surgery Center performed an average of 307 cases per month – an increase of 15 cases per month from 2014 and an increase of 25 cases per month from 2013.  Increased case volume led to increased prosperity.  The exemplary care provided by Boulder Surgery Center physicians and staff was steadily gaining recognition in the Boulder healthcare community.  This became part of the equation which led to the plan to expand into a larger physical space.

Highly Aligned Physician Practices

Boulder Surgery Center hosts specialists in orthopaedics, including hand, pain management, podiatry, and sports medicine.  In April 2016, Boulder Surgery Center’s two largest orthopaedic practices, Boulder Orthopedics and Mapleton Hill Orthopaedics, merged to form BoulderCentre for Orthopedics.  Four additional physician practices – Boulder County Foot & Ankle Care, Foot & Ankle Care of Boulder County, University of Colorado Sports Medicine Clinic, and RISE – are also served by the surgery center.

The BoulderCentre merger was a significant step in strengthening physician alignment with Boulder Surgery Center.  The merger placed 13 out of 20 of Boulder Surgery Center’s utilizing physicians in a single practice.  The newly formed BoulderCentre for Orthopedics and expansion of Boulder Surgery Center led to their move into the same newly constructed building.  Boulder Surgery Center occupies the first floor of that building while BoulderCentre for Orthopedics, including the group’s physical therapy office and MRI imaging, occupies the second floor.

Boulder Surgery Center is held in high esteem by its physicians.  The ASC’s physicians think of the facility as an extension of their own practice.  All 20 of the facility’s utilizing physicians are investors in the surgery center.  The ASC’s physicians collectively hold a 50% ownership stake in the joint ventured center, with the local hospital, Boulder Community Health (BCH), holding the other 50%.  Boulder Surgery Center benefits from having the perspectives of their hospital partner, BCH, and management firm, Pinnacle III, in the board room.  The ultimate drivers and decision makers, however, are the physicians.  In this way, Boulder Surgery Center maintains its vision of an orthopaedic-focused ASC of excellence.  The physicians at Boulder Surgery Center enjoy being involved in the process.  As a result, Boulder Surgery Center has become the preferred surgical facility for the invested physicians, contributing to a case volume on which the center can rely. 

Attentive Management

The increased case volumes and the enhanced alignment of the physician practices signaled a market primed for ASC growth.  The pressure to respond shifted to the ASC management firm to position Boulder Surgery Center for continued prosperity.  The physicians were eager to know:  How do we capitalize on the current increases in case volume and take advantage of this opportunity to seize a larger market share?

In the case of Boulder Surgery Center, both the expanding market and an expiring, non-renewable lease agreement compelled the ASC to consider alternative space options for their facility.  Fortunately, the prosperity of the ASC allowed its investors to consider the option of moving into a newly built facility that would allow for customization in the building development process. 

Due to the physician investors’ confidence in the longstanding relationship with Pinnacle III, the center’s ASC management firm, the board chose Pinnacle III’s facility development team to oversee the development of its new surgery center.  The process began with an analysis of the projected volumes, including the addition of higher acuity cases.   After determining the existing center would not allow for the projected volume, Pinnacle III developed a project proforma.  Detailed input from all involved parties was incorporated into the proforma.  After significant review and discussion, the facility’s board of managers concluded moving to a larger location was necessary for future business growth.  While an expiring lease agreement with no option to renew was the reason the ASC had to relocate, the proforma helped investors determine a new, larger facility would need to be built. 

While Boulder Surgery Center was considering the move into a newly constructed facility, BoulderCentre for Orthopedics had already made the decision to move into a new space under construction.  There was available space in this new building that could accommodate the new surgery center.  Thus, the ASC’s board made the decision to relocate here as well, foreseeing synergy and efficiencies between the orthopaedic practice, ASC, and support services which may not have been found elsewhere.  Pinnacle III acted on behalf of the owners, providing oversight of the design-build process.  The management firm’s hands-on guidance of the architects, construction team, and engineers, ensured a licensable and certifiable surgery center.  Keeping the contractors accountable to the agreed-upon budget saved the facility an estimated $100,000.

Pinnacle III also focused on helping physicians sustain case volumes during and after the move.  The physicians were surprised decreased case volume did not occur during the process.

Boulder Surgery Center moved into their new home in August 2016.  Preparing for the move required considerable planning and organization.  Pinnacle III and the ASC’s staff coordinated equipment purchase needs, relocation intricacies, and staffing processes to ensure a successful move.  Jean Day, Administrator for Boulder Surgery Center, remarked, “Under the direction of Pinnacle III’s planning and organization, we experienced a smooth move.”

The Grand Re-Opening

The facility’s physicians and staff were exultant.  This was evident as Boulder Surgery Center & BoulderCentre for Orthopedics teamed up for their Grand Re-Opening Open House Celebration, organized by Pinnacle III’s marketing team, on the evening of October 6, 2016.  Both the ASC and the physician practice excitedly welcomed the Boulder community to their new facility.

At the open house, Boulder Surgery Center hosted many influential members of Boulder’s healthcare provider community.  Attendees included surgery center physicians & staff, physician practice staff members, referring providers in the Boulder Community Health & the Boulder Medical Society networks, hospital administrators, local legislators, third-party payor representatives, medical device representatives, and many others.  The event not only served as a celebration for the physician investors, ASC, and practice staff members, but it also provided a positive boost for business.  Referring providers toured the facility with Boulder Surgery Center specialists, had an opportunity to meet new specialists, and gained confidence in the practice(s) to which they will be sending patients.  A few prospective physician specialists toured the facility and inquired about obtaining credentialing privileges.  A representative from U.S. Senator Michael Bennet’s Office attended and learned about some of the legislative issues facing ASCs in Colorado.

The evening culminated in a toast given by Dr. Drigan Wieder, Medical Director for Boulder Surgery Center, and Dr. James Rector, President of BoulderCentre for Orthopedics.  Both physicians outlined the history of Boulder Surgery Center and BoulderCentre for Orthopedics as well as the vision for the future. 

Several days after the Grand Re-Opening Open House Celebration, Jean Day stated:

“The open house was a powerhouse marketing extravaganza!  Attendance far exceeded my expectations.  The feedback was so positive I expect Boulder Surgery Center will receive inquiries from professionals hopeful of working here.   Two podiatrists each inquired about the feasibility of performing cases.  They presently conduct all cases at the hospital.  Staff members’ level of pride has been elevated to near euphoria, or perhaps they remain intoxicated by the swell of happiness in their hearts from witnessing such a receptive crowd!”

Conclusion

Boulder Surgery Center experienced steady growth and prosperity over the course of their first decade in business affording physician investors an opportunity to consider:  Is now the right time for expansion?  The board, after pragmatically assessing its options, agreed it made sense to take advantage of space available in one of the community’s new building projects.  Ultimately, Boulder Surgery Center’s board members made a confident decision to expand based on robust and sustained case volumes, highly aligned physician practices, and attentive ASC management.

If your ASC is experiencing sustained growth that is outpacing its physical capacity, a project pro forma is essential to visualize the new business model in an expanded space.  Consider contracting with an ASC solutions company like Pinnacle III to guide you through the process.

Jack Mast – Physician Liaison

Dec 01
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Busy Professionals

Time Savers for Busy Professionals

By ASC Governance No Comments

For busy professionals, there is no doubt we live in a world where time savers feel like life savers.  Work-life balance is essential but it’s increasingly difficult to achieve.  During my tenure managing numerous surgery centers, I sought ways to make my days feel less daunting and leave feeling more accomplished at days’ end.  Here are a few tips I’ve gathered over the years to organize and save time in my daily routine:

1. Take time to start your day with a short exercise period and/or meditation.  Both activities can help you organize your day. If your mind is scattered, your day is likely to follow suit.

2. Ensure your day’s agenda and goals are realistic. Prioritize your task list to ensure you complete the most important items first.  Create a flow to your routine that allows you to smoothly transition from one item to the next.  Nothing gets accomplished if you are trying to tackle multiple projects simultaneously. 

3. As you accomplish your agenda and goals, check them off your list. Take a moment to relish your success.  You got something done – acknowledge it and let that propel you toward tackling the next item.  Crossing items off your list can be a small but significant reward for staying motivated.

4. Minimize disruptions and personal interactions by using this technique: If someone enters your office space unscheduled to chat and there is no extra time in your schedule, stand up.  This non-verbal cue signals you are involved in something or have somewhere to be.

5. Stay on task when in meetings and on conference calls. Tangents and side conversations waste valuable time.  Focus on the purpose of your meetings.  If you discover an unrelated item that warrants discussion, schedule another time to talk about it.

6. Do not procrastinate. If it’s on your daily list, do your best to complete it.  Procrastinating drains the energy you sparked from accomplishing your previous task.  Avoid losing the momentum you built.  If you continuously dive into mindless to-do items, you’ll find yourself having to complete all the important tasks you avoided at the last minute and under greater stress and anxiety.

7. Keep phone calls concise and on point. Long conversations not only create fatigue, they cost you time.  Suddenly your day got a lot shorter while your list stayed the same length.  Don’t let long phone calls throw a wrench in your routine and create unnecessary chaos.

8. Ask for help or delegate when the need arises. The onus doesn’t have to always be on you to handle everything.  If you work with a team, there is a reason you call them teammates.

9. Take time out for yourself. This may be a 10 or 15 minute break to get your mind off the work you are doing and rejuvenate. These little breaks can go a long way to help your mind reset and refocus.

10. Move unaccomplished items to the next day’s agenda. It won’t always be possible to tackle everything on your daily to-do list. Don’t push yourself to the limits for the sole purpose of crossing them off.  Sometimes it’s just not worth it.

11. Create your next day’s agenda and action plan before leaving work. Just like a football team studies before a game, get ready for tomorrow by figuring out your action plan ahead of time. This will allow to enter your office ready to go when you arrive in the morning.

12. Stay hydrated. This is not a time saver, but helps with clear thinking and prevents fatigue. Taking care of your body is crucial to your ability to attend to tasks while not draining yourself in the process. Your health should always come first!

These tips can lead to an easier-to-manage routine that should help you be – and feel – more productive.  Being productive does not equate to constant fatigue.  These adjustments take time but will go a long way toward helping you feel energized.  Busy professionals should feel accomplished at the end of the day.  Hopefully these tips help get you there!

Rick DeHart – Principal Partner

Nov 29
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ASC Revenue Sources

Put the “Revenue” in Revenue Cycle Management from Your Most Important Source: Your Patients

By Revenue Cycle Management No Comments

Patients are quickly becoming the top revenue source in ASCs which presents unique challenges.  The days of “send me a bill” or “let’s bill your insurance and see what they pay” are long gone – at least they should be if you expect a steady flow on your revenue stream.

With the growth in high deductible health plans, your facility needs to develop and maintain a strong up-front collections strategy.   A patient’s out-of-pocket costs for their portion of a health care procedure can easily exceed their monthly mortgage payment.  An unforeseen medical procedure can place a significant burden on them.    

Although the situation can seem dire, all hope is not lost!  There are several things ASC personnel can do to proactively position your facility to collect the allowed reimbursement – from insurance carriers and patients.

Let’s start with insurance reimbursement.  When scheduling a patient for a procedure, ideally ASCs should:

  • Be in-network with the insurance carrier. If operating in an out-of-network situation, confirm out-of-network benefits are available to cover the planned procedure(s).
  • Confirm the scheduled procedure is allowed by the patient’s plan.
  • Verify the patient’s plan eligibility and benefits.
  • Obtain prior authorization, if required, for the procedure and implants.

Tools available to assist you with gathering patient specific information include payor web portals and eligibility information through EDI clearinghouses or patient accounting software. 

Using these invaluable tools enhances efficiency in the authorization process.  Take the information you confidently rely on and create your own tools to summarize your unique insurance contract details to serve as easy references for ASC personnel.

Employ features in your patient accounting system to alert facility personnel to nuances that are likely to be encountered.  For example:

  • Enter your fee schedules or grouper rates. Ensure this information is updated when your contracts change or renew.
  • Create reminder pop-up notes to alert schedulers to the need to secure authorizations for specific CPT procedure codes. If this feature is not a component of your current software system, establish your own list of CPT codes requiring authorization and sort it by payor.

Front desk personnel need to be able to calculate a logical estimate of patient financial responsibility and convey that information in understandable terms to their customers.  Information obtained during verification and authorization is necessary to accurately calculate patient estimates.  Identify the following patient specific details:

  • Their annual deductible and how much is remaining to be paid,
  • Their co-payment and/or co-insurance responsibility,
  • Their out-of-pocket maximums, if those limits have been met, and
  • Their in- and out-of-network benefits.

After you’ve collected patient specific details, determine what coverage is available based on your facility’s contract with the payor.  Begin by determining if the procedure scheduled to be performed is allowed in the ASC setting.  Then document the following:

  • Allowable amounts for each procedure code,
  • Multiple procedure limits and/or reimbursement reduction parameters,
  • Case rate caps,
  • Methodology for pricing and reimbursement of implants,
  • Carve-out rates, and
  • Other pertinent contract details.

Don’t overlook the information contained in payors’ newsletters.  This is where they outline policy and reimbursement changes, pre-certification requirements, packaged coding lists, annual fee schedule and grouper updates, etc. 

You should now have the information required to create a useful financial responsibility estimate for the patient.  Review your estimate in detail with the patient prior to the procedure.  Avoid assuming your patient knows the amount of their outstanding deductible or how much they will owe.  Be sure to reinforce that, although you have provided them with the most accurate estimate possible, they are responsible for any amount their insurance doesn’t cover.  Make sure to answer all their questions to the best of your ability and obtain their signature on your financial responsibility policy.

Once the financial responsibility estimate has been reviewed with your patient, it’s time to collect their payment.  Patients are more likely to remit payment at the time of service.  Once they’ve left your ASC, the chances of collecting from them are significantly reduced.  Try to avoid asking, “How much can you pay?”  Instead inquire, “How will you pay for your portion today?”  Improve your ability to collect payment by offering a variety of payment options – cash, HSA or FSA debit cards, credit cards, or automatic bank transfers.  If the patient is unable to submit payment at time of service, consider offering them a low interest health care loan or short-term payment plan.  It is in your ASC’s best interest to only do so, however, if upfront collection options have been exhausted.

If you must offer a payment plan option, have a solid policy in place and adhere to the defined parameters.  Your payment plans should be straightforward and manageable.  Remember to obtain the patient’s signature on the payment plan agreement, then follow the outlined terms.

Review your facility’s upfront collections processes, tighten them up, coach your staff, and work with your patients to create clarity regarding their financial obligations.  Doing this will ensure you maximize collections from your ASC’s top revenue source – your patients.

Carol Ciluffo – Vice President of Revenue Cycle Management

Nov 23
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Onboarding New Physicians

ASC Management Tip: Successfully Onboarding New Physicians

By ASC Management No Comments

Bringing new physicians onboard can be one of the most exciting and challenging parts of ASC management.  New physicians create opportunities to enhance your center’s initiatives and fuel growth.  Onboarding, however, can present challenges as you orient new physicians while simultaneously managing daily operations.  Despite busy schedules maintaining focus on first impressions is important.  Starting off on the right foot with new physicians is instrumental to establishing lasting relationships for your ASC and physicians alike.  

What can you do to ensure smooth transitions that successfully engage new physicians?  We sat down with Kelli McMahan, VP of Operations for Pinnacle III, for some advice.  Here are her top five tips for successfully onboarding new physicians.

  1. Schedule an introduction & tour: Meet with new physicians before they begin performing procedures at your facility.  Schedule time for them to tour your space.  Introduce physicians to as many staff members, anesthesiologists, and physician partners as possible.  This will help new physicians feel welcome and provide them with friendly faces to turn to or contact should they encounter any issues when they begin work at your ASC.  New physicians may also wish to review available instrumentation and equipment.  Make sure your clinical nurse manager, instrument technologist, and other staff members who are familiar with the potential needs of your new physicians, are available to answer questions during the tour.  Navigation to the locker room, the Pre-Op/PACU area, or ORs can be challenging for new physicians.  Make sure your new physicians leave the tour feeling comfortable finding their way around your facility.
  1. Provide a physician welcome guide: Provide a welcome packet to new physicians when they initially arrive at your facility.  The packet should contain helpful information to successfully orient physicians to your ASC.  Examples include, but are not limited to, your mission statement and core values, directions to your facility, important contact information, leadership bios, and relevant resources for new medical staff members.  Include medical staff expectations from your medical staff bylaws, as well as information on how to start scheduling cases, access transcription services, obtain pre-op and post-op guidelines, and find resources for their patients.  List your facility’s H&P requirements, block time guidelines, dictation instructions, approved procedures, and managed care relationships.
  1. Collect preference cards: Discuss with new physicians the importance of supplying preference cards that are applicable for all the services they intend to offer at your facility.   Useful preference cards provide detailed information on physician preferences for supplies needed, OR set-up, and block time/clinic time.  Preference cards can typically be obtained from any of the other facilities at which physicians worked prior to your ASC.  Obtaining preference cards early will allow you and your staff ample time to prepare for the new cases and ensure the appropriate supplies are available. 
  1. Arrange a meeting between physician scheduling staff & ASC scheduling staff: Your scheduling staff should plan on meeting with your new physicians’ scheduling teams to review scheduling processes.  Your staff should take contact information, instructions, forms, and patient information packets to these meetings.   They need to engage the new physicians’ staff and ask how they currently process scheduling information to other entities.   Doing so will set the stage for both entities to work together to establish a mutually beneficial process for sharing appropriate information efficiently and securely.
  1. Follow-up with your new recruits: When new physicians arrive for their first day at your surgery center, be available to greet them and answer any questions.  If you are not personally able to meet them on their first day, ensure you appoint a qualified designee to fill in on your behalf.  Speaking with new physicians at the end of their first day will help you address issues that arose and instill confidence in your facility.

By following these tips, you can provide smooth transitions for new physicians joining your ASC.  If physicians are satisfied with their initial interactions with your center, they are more likely to perform cases at your center for many years to come.   Your success with new physicians will create a positive reputation and opportunities for more physicians to join your facility.  Simply put, successfully engaging new physicians helps turn your facility into the center of choice.  Wouldn’t having too many physicians to onboard due to your ASC’s growth be a nice “problem” to have?

Kelli McMahan – Vice President of Operations

Nov 17
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ASC Tax Strategy

Administrators: Consider Cost Segregation as an ASC Tax Strategy

By ASC Governance No Comments

Investigating cost segregation of your depreciable assets may serve your surgery center well.  This ASC tax strategy could allow you to reduce your tax burden and improve your cash flow by shortening your depreciable tax life with acceleration methods. 

How it works

Typically, nonresidential real property assets are given a tax life of 39 years.1 A qualified asset management team can investigate and re-engineer those depreciable assets to three, five, seven or even a fifteen year tax life – all of which are allowable under the IRS tax code.  The good news is that this process is not confined to new property or assets.  As long as the assets have not been fully depreciated, there still may be value to cost segregation.

Basic principle

The basic principle is based on today’s dollar which is assumed to have more value than the future dollar.  Accelerating depreciation increases your tax deduction today – an approach that allows you to take advantage of the better dollar value.

Who does it?

Seek out the services of a cost segregation team and ask them to develop a proposal for your ASC.  According to the IRS, “The preparation of cost segregation studies requires knowledge of both the construction process and the tax law involving property classifications for depreciation purposes.  A preparer’s credentials and level of expertise may have a bearing on the overall accuracy and quality of a study.  In general, a study by a construction engineer is more reliable than one conducted by someone with no engineering or construction background.  However, the possession of specific construction knowledge is not the only criterion.  Experience in cost estimating and allocation, as well as knowledge of the applicable law, are other important criteria.  A quality study identifies the preparer and always references his/her credentials, experience and expertise in the cost segregation area.”2

Many of the larger accounting firms and standalone consulting firms have cost segregation teams that are qualified to complete your re-engineering cost analysis.

Cost

The fees associated with a cost segregation study can be expensive.  Reputable firms will prepare a cost versus return on investment (ROI) analysis for you to review before you commit.  With the political environment subject to change, it may be worth investigating this strategy sooner rather than later.

Conclusion

If your ASC is interested in improving its cash flow through reduction of federal and state income taxes, it may behoove you to investigate cost segregation as a potential strategy.    

Rick DeHart – Principal Partner

1 https://www.irs.gov/publications/p946/ch04.html

2 https://www.irs.gov/businesses/cost-segregation-audit-technique-guide-chapter-4-principal-elements-of-a-quality-cost-segregation-study-and-report

Nov 15
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ASC Reimbursement

What Opportunities Can You Leverage to Increase ASC Reimbursement?

By Payor Contracting No Comments

Multiple leverage opportunities are available to increase ASC reimbursement. Two that quickly come to mind are generally applicable across all outpatient surgery centers.  First, always recognize the payor needs you.  Second, the payor community consistently strives to find lower-cost alternatives to their members being served at hospitals.  

The Payor Needs You

The payor needs to provide a comprehensive provider network to its members. Many payors offer their members a site-of-service differential to steer members to the most cost-effective and appropriate care setting.  For example, a payor may only require a co-payment from the member for services provided at an ASC, but the member will be subject to more costly co-insurance provisions if the same service is obtained at a hospital facility.  Therefore, the payor needs your ASC to help them accomplish their goal of securing high quality and cost-effective care at the lowest out-of-pocket cost for their members.

Moving Cases from Hospitals to ASCs

Payors are increasingly looking for additional opportunities to move higher acuity cases from hospitals to ASCs.  Why?  Because the difference in cost to both the patient and the health plan can be three to four times greater at the hospital.  Therefore, if your ASC can entice payors with the cost savings benefit of performing higher acuity cases on their members at your facility, you may be able to create a “leverage opportunity” that can produce greater ASC reimbursement on some of your lower acuity procedures.

For example, many commercial payors have expressed interest in having total joint replacements and high acuity spine cases performed in ASCs because they recognize the opportunity for cost savings.  In some instances, you can increase the leverage opportunity by offering to perform these cases at a predictable cost.  Some payors (self-insured plans in particular) wish to transfer the risk associated with implant variations by agreeing to an all-inclusive facility price for each high-acuity case type that is negotiated.

If your ASC is interested in, or required to, negotiate all-inclusive rates, be sure your data accounts for all variable costs (e.g., staff, supplies, implants) and associated frequency factors before heading to the negotiation table.  This includes a solid understanding of the size, number, and frequency of use for each implant type, along with any extraordinary supplies associated with each case.  And therein lies the rub – many ASCs who want to perform these cases aren’t equipped to negotiate prosperous at-risk arrangements.  To combat this, consider hiring a seasoned negotiator who has successfully secured at-risk arrangements – someone who will recognize and be better equipped to understand all the moving parts.  Alternatively, your ASC would be wise to refrain from performing at-risk cases initially, focusing instead on cases falling under fee-for-service arrangements.  Doing so allows you to assemble the necessary utilization data before attempting to negotiate all-inclusive case rates.

While adding high acuity orthopaedic and spine cases requires a capital outlay for your ASC, the added investment should not be overly detrimental if you’re already performing orthopaedic cases.  In that case, chances are your center already has a good portion of the instrumentation and equipment necessary to perform the higher acuity procedures.  If you are starting from scratch, however, you will want to complete a comprehensive feasibility analysis to demonstrate the costs and benefits of offering total joint replacement and/or spine cases at your facility.

In any case, enticing payors with the possibility of performing higher acuity cases on their members at your ASC could not only create a leverage opportunity, it may also add to the payor’s dependence on your ASC.  This puts you in a strong position to obtain higher ASC reimbursement, something you were seeking all along.

Dan Connolly – Vice President of Payor Relations and Contracting 

Oct 28
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Audit

To Audit or Not to Audit – That is the Question

By Revenue Cycle Management No Comments

Uncover the black holes in your revenue cycle management processes that impact your ASC’s bottom line.

Do you know what you don’t know?  Many revenue cycle management companies assess their services based on key performance indicators (KPIs).  Accounts receivable (AR) days, collections, bad debt, net revenue per case, days to bill, and days to pay are usually at the top of the KPI list.  While KPIs can provide you with a high level view of what is happening with your business, other seemingly minor items can result in uncollected revenue that may go undetected.  This is why auditing is crucial.

Auditing is a time consuming, daunting task.  Those being audited may feel it is punitive.  However, this necessary evil reveals a lot about the efficiency of your revenue cycle management processes.  Let’s look at the bright side of what you can discover while auditing and how your findings can result in process improvement that typically increases your bottom line.

There are many areas to audit – patient registration, coding, charge entry, denied claims, AR follow-up, and collections to name a few.  Routinely and randomly auditing your internal processes allows you to identify gaps that need to be closed, provide additional employee education when needed, ensure your payors correctly load your contracts in their systems, tighten your patient collections process, and so many more.  Let’s look at some of these in more detail.

Registration Audits

Accurate patient registration is the first step to a clean claim.  Routine auditing of registration errors will shed light on struggles being faced at your front desk.  Medicare Advantage Plans routinely trip up front desk personnel who may register the insurance carrier as Aetna rather than Aetna Medicare.  A key point to share with your front desk team is to consider the age of the patient to determine if he or she is a candidate for Medicare coverage.  Also, spend some time looking at copies of insurance cards with your front desk.  Create a notebook of insurance card samples and review them routinely, highlighting areas on the cards that will lead to proper insurance registration.

Another common registration error is registering a young child as the policy holder.  If the patient is not the policy holder, the date of birth of the policy holder will be required to file a clean claim.

Finally, ensure your front desk is taking advantage of online payor tools to verify eligibility and benefits, file requests for authorization, and determine the remaining deductible on each patient’s plan.

Coding Audits

Internal and external coding audits are an essential undertaking.  External audits supply an additional level of compliance and accountability for your coding services.  The external audit results can support internal audit findings or identify areas needing focus that your internal audits may have overlooked.  An external auditor can provide a non-biased, objective audit for you.  Internal audits provide a benchmark to compare to your external audits.  They also help you recognize when additional coder and/or physician education is needed to maintain compliance or secure proper reimbursement.

In your endeavor to obtain maximum allowed reimbursement, ask yourself the following questions.  Are you capturing all available procedures and billing them properly?  Are special modifiers required by individual payors recorded accurately?  Do your diagnosis codes reflect the greatest level of specificity?

Cash Posting Audits

Cash posting audits serve many purposes.  The accuracy of cash posting determines the need for the following:

  • Appeals on underpaid claims
  • Fee schedule increases
  • Payor contract updates in your patient accounting system
  • Additional education to employees on payor contracts and terms
  • Patient statement accuracy
  • Proper journal coding of adjustments
  • Timely credit balance reconciliation
  • Additional education to employees based on your audit findings

Denial Audits

Auditing your denials can be telling.  Are your employees filing timely appeals?  Timely filing requirements, similar to those applied to claims submission, also come into play with appeals.  Do your employees know what they are appealing and why?  If they don’t, unnecessary time is spent appealing denials that will not be successfully overturned.  Some examples are:

  • Filing an appeal on a code bundled into another procedure
  • Filing an appeal on a code that required a pre-authorization which was not obtained
  • Filing an appeal for medical necessity without reviewing the payor’s coverage policy of the procedure
  • Filing an appeal outside the timely filing limits set on the appeal
  • Filing an appeal of an implant payment when separate payment for implants is not allowed per the payor contract

Final Notes

Getting everyone involved in process improvement fosters buy-in and improves your chances of successfully tackling specific issues; but you can’t stop there.  You have to conduct routine audits to make sure old processes or bad habits don’t resurface.

Your time is valuable – make it count!  Determine where your pain points are and begin auditing there.  Share audit results with your employees.  Resolve the issues.  Celebrate the successes and the failures.  Those “failures” lead to correction of issues and improved processes.  Your efforts will pay off in reduced errors and, ultimately, enhance your bottom line.

By Carol Ciluffo – Vice President of Revenue Cycle Management