Hello. On behalf of AOSAS, I want to welcome you to the third session of Crack the Codes Practice Management and Coding Course Series. Today's session is Session 3, Revenue Cycle Management, Improve Your Bottom Line. Today's presentation will be given by Karen Zupko, joined by Jennifer Bell and Jennifer Cabrera. You can find their full biographies and disclosures in the program document posted in the chat box and in the On Demand Education Center. The series is funded from the Orthopedics Foot and Ankle Foundation, supported by grants from Paragon 28. I'd like to run through a few housekeeping items before we kick off the presentation. For technical difficulties, please try closing your browser and logging back in the same way you did the first time. Registered physician attendees may earn one hour of AMA, PRA, Category 1 CME credit by completing an evaluation and CME claim form at the end of the full series. Tomorrow, you will receive an email with a link to evaluate this specific session. And then at the end of the sub and broadcast, you will be able to evaluate and claim CME for the full course. This webinar is being recorded and will be available for on-demand viewing in the On Demand Education Center as a module within this course listing in approximately 24 hours. The recording will be available for one year. We encourage you to ask questions during the presentation. To send your question to the faculty, click on the Q&A tab on your navigation bar. If we cannot get to your question during the live broadcast, the faculty will reach out to you following the broadcast to respond. I will now turn the program over to Karen Zupko. Thank you. Hi, everyone. I'm Karen Zupko, and I'm joined by the two gens, Jennifer Bell and Jennifer Cabrera. You can see both of them on page one of your handout, along with contact information. There is a very nice bio of me that my mother wrote. You'll enjoy reading that at your leisure later on. We right now need to look if you've downloaded your handout. If you haven't downloaded your handout, you need to think about doing that. On page three, it's going to make note-taking far more easy. On page three, you will see this diagram. This illustrates all of the reasons why your revenue is being nibbled at. Very often, when people call us in a crisis situation, and there's been a major revenue shortfall, it's not one or two of these things. It's typically four or five, and then six and seven are taking a little nibble. Okie doke. Take a look here. We're going to probably come back to this, but I want to put up some key questions. These are the questions that consultants have when they come to your office. We're going to say, does this practice, working on the revenue cycle, have the right people doing the right jobs at the right time with the right tools and training? I want to give you an example. In the previous diagram, one of the little circles was understaffed turnover, understaffed turnover and training. Here's what we're finding. Post-COVID, there's been a major staff exchange. When we see that the biller and coders are spending their time correcting patient demographics, that means I have the wrong people doing the wrong job at the wrong time. Patient demographics should be handled by those folks at the front desk or in the call center. Now I've got the people who have a unique skill performing at less than their highest and best use. Okie doke. Let's look at this. Guys, there's been much weeping and gnashing of teeth over the 2% Medicare cut, and I feel your pain. I agree that isn't good. However, the money that is left on the table due to leaks, due to inattention on the massive diagram with all of the bubbles, the 2% is puny in comparison to the money that you leave on the table for things that you control. All right. We're going to more than make up for it. Well, I'm going to ask you how you compare. 70%, this is according to instrument, 70% of providers take more than 30 days to collect after a patient encounter. More than 30 days. Come on. That's all the good in-office stuff. 74% require more than one statement to collect. Next to that 74%, I want you to write $8.75. $8.75, because that's what the MGMA tells us it costs to collect, to send a statement. Now I want you to think, if I've got to send three statements at $8.75, that comes to $26.25, if you didn't do that math in your head, I will have spent $26.25 to collect a $25 co-pay. Thus, I'm in the hole if and when the patient pays. You guys, we've really got to get with it. And here's one way you can do that. 75% of providers use paper for collections. They're sending paper medical bills. Only 70% of consumers get their medical bills. 9% don't want to pay with a paper check. Only 9% want to pay that bill with a paper check. So let's look at some of the things that you can do. Your website needs to be a part of the revenue cycle. Your website needs to be part of the revenue cycle. You need to have You need to have accurate financial policies posted, written in a friendly tone. You need a payment portal, and you need an application for financing. And I want to show you a splendid example. A splendid example. Ortho Alabama Spine and Sports really has done a good job. And I want you to notice the font size. We're going to look at some other orthopedic sites, and it's going to be a problem. The fonts are miniature. So if this is the home page, we can online bill pay, right? Click here. They also offer care credit. And we're going to talk about instituting a financing option so that your patients with large deductibles that haven't been met during this first quarter, that those can be paid in full, those surgical patients, if we offer care credit. You can also see that they have a custom link. And I'm going to talk more about that. Now, if we look at Lakeshore Bone and Joint, I think if you look across the top, that type is way, way, way too tiny. But they have a good request, request an appointment, and I compliment them on having a workers' compensation referral line that is promptly answered, and nobody had to listen about it. This is an emergency, you know, go to the hospital ER. They have an online bill pay and a patient portal. I am disappointed to tell you that there are so many practices that did not take advantage of going paperless and contactless during the COVID period. Well, there is a standard management axiom, and it's that you cannot manage what you do not measure and what you don't measure right. So I want to go over some of the things that quickly you should be looking for in your AR. You might want to make some notes on this on page six, if you have your handout downloaded. We always want to separate patient owed money from insurance owed money. Those are two very different, I'm going to demonstrate that, two very different sums. We want to know if the report is clean. Well, what does clean mean? Clean means that we need to adjust off balances. One of my clients wanted to only go to $10 over a year old. I myself would have upped that amount to $20 or $25 over a year old if patients weren't making payments on that balance. And then the other thing that we find all the time are credit balances. Well, what explains that? You may have some people at the front desk who are collecting co-pays, they're collecting prior balances, and then they're interrupted. And so they're not applying the payment to the balance. There's a whole lot of other reasons for credit balances, but one does occur at the front desk or the checkout desk. So we want to apply all of the credit balances and where it's appropriate, we'll give patient refunds. Okay. A couple other points. What is in the AR? So as foot and ankle surgeons, yes, you've got office visits. All right. Those often lead to surgery and these are not necessarily, by the way, in equal amounts. So is it more on, I will show you in some practices that we have visited, the amount of money that is in the AR from office visits, which is absurd, or is it surgery? Is it a number of cases or is it just, or is it big dollars in surgery? So we'll look at that. Imaging, many of you, all of you have certainly x-ray and maybe other imaging in your office. PT could be a part of your practice. And because I currently am a foot and ankle patient sporting a very large boot, I know that DME can be a significant revenue leak. Not because of me. I paid my bills. I swear. All right. Here you go. Let's look at this patient AR report. First of all, the golden benchmark is the amount of dollars over 90 days. So you want to pay attention to what's over 90. In many practices, they stop at 120. So they're going to stop here. We disagree with that. I want to take that out to 151. If you are listening to this presentation and you are a new manager or a new revenue cycle director, I'm going to encourage you to take it out to 180 days. Those things over 180 days, chances are very, very slim if patients have not made an arrangement that they're going to pay. And that brings up a whole other series of questions. My point here is 34% of the patient AR is over 90 days. Okay? Then we look at the insurance, and that is 17.8%. 115.30. Okay? The point is that this 115, let's go to the next slide. This is a very important slide. The patient receivables in this practice, this is the illustration that's in the middle of the page, is 354,000. Okay? Patient receivables. The total insurance receivables is 676. 676. But then you say, Karen, why is that arrow down there with 281,000? It's down there because the 676, that 676,000 represents an inflated number by the fee schedule. Okay? This practice used 2.4 as a multiplier for their fee schedule. 2.4 times the then Medicare allowable. They will not, if they collect every dollar, it will not equal 676,000. It will equal 281. And I want you to notice that is $72,653 less than the patient AR. Failing to pay attention to patient accounts receivable is a big and very, very expensive mistake. Okay? So 354. So we're going to talk some more about patient AR. Now, typically at this point, there is a doctor, if I'm giving this presentation live, in the room and I can see his or her thought bubble. Why do I need to know this? Isn't this my staff's job? Yeah, it's your staff's job, but you should care because it's your money. If you are the physician, it's your money. And nobody cares as much about your money as you do or as you should. All right. Well, what are some other things? Very few doctors, orthopedic surgeons, foot and ankle surgeons that we talk to and work with receive an accurate accounts receivable report aged by payer. Some people say, Karen, I didn't even know that it could be aged by payer. If you are in a group, listen to me, please. You're in an orthopedic group with multiple subspecialties. You want to see your individual AR aged by payer. There's only one category for Medicare here. You want to put a note, you want two categories for Medicare. Two, two, two, two. Why? Because there's Medicare Part B and then there is the Medicare Advantage Plan. And we'll be talking more about those Medicare Disadvantage Plans in a minute. But I always want to see two categories because they are not the same in so many important ways. Okay. All right. Then we only have one category for patient. Boo. Boo. Folks, people who are uninsured, who may have come through the emergency room and now are in your office, they are uninsured. Their balance bears no equivalency to a balance owed by Jennifer Bell, Jennifer Cabrera, or Karen Zupko. We have insurance and we have a means to pay. We are employed. So we always want to take the uninsured and put them in their own category. Your staff can put holy water, say prayers of every denomination over the uninsured patients. The chance of collecting is very slim. The chance of collecting from us, on the other hand, is very great. So patient balance after insurance, we should be in a different category. So I've added two additional payer categories. A recent practice we visited had workers comp mixed up with autos and assorted others. This is unacceptable. Whoever did this, I hope is no longer in your employ. But autos and comp are very different. This practice is a small amount and they're lucky because they seem to be getting, they seem to be paid. But Jennifer Cabrera and I know that quite often workers comp claims can stretch on, can stretch on for a year or more. Same with some of the autos. So let's have those, when I look at the total accounts receivable, I'm always going to be able to back those out. Okay. Now, while I'm speaking about workers comp, I, very important to me that you know about this dirty trickster business. These comp plans are paying you with a credit card instead of paying you versus an automated clearing house electronic funds transfer. They are not allowed to do this. They are not allowed to charge you this 5% fee. This is what I'm saying. Everybody's upset about the Medicare 2%, yet workshop after workshop last year, I had practices who were unaware of this and had been taking these 5% deductions. So on a $5,000 payment, you're down 250. This was banned specifically in the health insurance reform. They were not to be doing this. Here you have, since this went into effect in 2014, the AMA has advocated that CMS issue guidance spelling out physician rights regarding insurance company electronic payments. And this was done in HIPAA. So all you do is you write them and say, no, I want, I only accept payments via ACH EFT. Please promise me you're going to pay attention to this. That is a totally painful and needless haircut. All righty. So that material, if you want to read more, if you're a staff person, you want to show the doctor, you'll find that information on pages eight and nine of your handout. Okay. Now we're going to go to page 10 of your handout. And I've got a little summary off there to the right. We're going to run charges, payments, and adjustments, a report by provider. So if you were in a foot and ankle group, I want to see each of you profiled for charges, payments, and adjustments by provider. By payer, I want to notice if there was any significant difference in the payer mix between doctor number one and doctor number three. We would remember, I'm going to compare foot and ankle surgeons with foot and ankle surgeons. Very difficult to compare foot and ankle with hand and spine. I'm going to look at that CPT category that I showed you earlier. And of course, by location. Very often, orthopedic groups hire Dr. New, Dr. Young, and they send him or her out to the hinterlands. So we want to see if that office, that extra office has the same payer mix as the home base. Okay. Other reports you will want to run that I cannot do, cannot discuss in depth, but I am going to highlight a CPT frequency report. And I'm going to encourage you to run your CPT frequency report for 2022. And I'm going to ask them, you'll ask the staff, or the staff, if they're listening, should do it this way. You run all the visit codes together. Okay. The new patient, the established patient, and of course, the hospital visit codes, if you are rounding and doing that. Because you want to look at your CPT frequency report and look for any anomalies. Like somebody fell in love with only 99204 as a new patient code. Okay. For RVUs, I'd be making a mistake if I didn't highlight. If the listener is an employed foot and ankle surgeon by a hospital or an academic institution and you're compensated by RVUs, you will want to go to our website, www.KarenZupko.com. There is a free, free, free webinar that was just done in December by our colleague, Sarah Wiskursion, and it is all about how RVUs translate to pay. Okie doke. So let's be sure we do that. Ah, the highlighting came on good. We want to always age the AR by the service date. This is one way that if I'm a staff person, I can sort of misrepresent the data to the doctors. And I complimented an academic institution because on their big dashboard reports to the surgeons, they said, we are 45 days behind in charge entry. In other words, in other words, they are giving the plans a 45-day interest-free loan. Okay. so everybody's concerned about the Medicare 2%, meanwhile, I am giving plans and almost six weeks free loan, and you all know that money market funds are now paying between three and 4% depending on how good you are. Okey doke. So, let's look together at that your practice bubble again. I want to take a deeper look at the subject of denials. And again, we have some interesting information to share there. We think the best way to avoid being denied is to document it right. The first time. If a surgeon has never seen what the medical necessity criteria are for a bunionectomy for Blue Cross Blue Shield versus Aetna versus Cigna versus United. I'm going to suggest that that's a missing link. So if you please stick with me, I am acting in your best interest, I want to see you paid painlessly the first time, and not going through the denial runaround. So, if you take your top three surgeries. Top three surgeries, and you look at the medical necessity criteria, I would print these out for my physician, I would laminate them. And if it's a Blue Cross Blue Shield patient coming in for one of those top three conditions. I'm going to have him or her look at the criteria specified by the plan. So, failed conservative therapy is an example of a phrase that gets you nowhere. You are going to have to articulate what that failed conservative therapy is. Alright, so let's look at. I'm now running your group. All right, I'm the new manager. I am going to look at the denials by surgeon. Again, I, if there are more than one foot and ankle surgeons in that big 30 doctor ortho group. I'm going to look at those foot and ankle guys together, individually, and then as a group. I'm going to look at what the line item CPT codes that are most often being denied what are they. Are they, I'd make a note of this guys. Are they visits with a modifier 25. Understand that the payers were on that in 2022 and then they backed off, but our listening posts across the country tell us they are back again. I'm going to look at the denials by payer. What are the denials that are coming from Medicare versus Blue Cross Blue Shield versus that Aetna or Cigna plant. Okay, so we want to look at that by payer. And see what the pattern is. So, when I see the Blue Cross Blue Shield is very often jerking us around on some sort of fracture care. I'm going to go to that medical necessity, I'm going to do a little research and see what we're sending in. denials by amount. And by the percentage of claims submitted to that payer. You will see that this is relevant when I get to the subject of talking about the Medicare advantage plans. So if you are looking there. That's where I am I'm sorry I was little detained there. Okay. This is an example of surgeons orthopedic surgeons in one sub specialty. The variation between $1,000,000 in denials and 282,000 in denials was explained by the fact that Dr. Number two was an egregious on bundler. So, of course, he had outsized and outsize number of denials, but I would never assume that all surgeons are created equal when it comes to denials that that would not be true. This is a report that I like very much. And I want you to notice this report is for one quarter of Aetna. So this only represents and obviously this is a big group. Okay. So, as I recall, this could be an academic group that I did some work for always we expect contractual obligation 45 to be among, if not the largest because that is the write off that explains the difference between your fee schedule and they're allowable. All right, remember the fee schedules are built on helium. What would get my blood pressure up. If I were foot and ankle surgeon is to see that my care was being denied my care was being denied, because it was sent in past the filing deadline. Okay, it expired. Right now, I can tell there's some staff people that say, don't blame it on us, Karen, we have asked him or her to dictate that report to turn in their charges. So if you have been Dr slow, and you have been ignoring your staff, shame on you, you are picking your own pocket. You can see the reasons, but you can see for this carrier, the amount of money and I had meant to add up that total because it's astounding but this is one pair. Imagine what it would look like. If I had the others will denial by percentage of charges denials by percentage of charges on guys, take a careful look at this. 34% not 34% of the total denials, it's by the charge amount is because documentation is being requested. And many of you are going to say, yep, it's the paper chase. I want to know, you should want to know how often we are successful in overriding that denial because we have sent pitch perfect documentation. How successful. Have we been. All right, I'd be making a note on that I'm on page 12 coding denials. I want to know what the nature of the coding denials are. I want you to write down, please. It's not just CPT. It could be that one or more of your surgeons needs a refresher course in ICD 10. And I will tell you, it was an eye popping experience to be at a practice where one of the ortho surgeons would not say whether it was the right or the left foot. That's a problem. You can't send in and expect to get paid on surgery for an unspecified foot that that is going to be a no go every day of the week. 21% no authorization. Now that is a completely preventable denial. It has been legitimately applied. I'll give you an example of an illegitimate. I was working with an academic department of orthopedic orthopedic surgery, and the shock trauma team right the helicopters landing the doctors are there everybody's deployed. They were denied because they did not call for prior authorization. That just about put all of us into orbit and we decided that 60 minutes needs to focus in on that. Alright, so then you've got 6% registration, come on, you can clean that up. 4% on credentialing, whose job is it to do credentialing, and to keep the quarterly credentialing up to date, guys. And then 3% duplicate claim. All right, that doesn't get me going so much. We want to look. Jennifer, Jennifer Bell Jennifer Cabrera do we have any comments or questions so far. So far we do not. Okay. All right, then I'm going to decide I'm doing a pretty good job of being clear and specific. The cost of detail, the cost of detailed denial codes is outlined for you in this next report. And then, nope, no payment, because it was part of another procedure co 97 is another way of saying that you are on bundling co 151 said the documentation didn't support the number of services. Everybody who does PT, please make a note in the margin. All good software has a PT countdown feature. So we would know, guys, we would know that Karen has two more PT visits left for that torn ACL, and that fractured ankle. I cannot tell you how many practices. Again, in this turnover. People are not entering that data. So then we're going ahead, doing PT, and we're not being paid. Okay, so the document, it's not just the documentation it was the approval for the number of services. Okay. All right, moving on. We have non contractual with that contractual write offs and non contractual. And again, this is a dramatic example in a group. And this group. Sorry to say, no foot and ankle surgeon had joined. No, we had to write off 295,000 from the spine doctor for no authorization medical necessity. Again, these are not contractual write offs. These are all things that we can control. You can see that the 140 and the 25,000 likely would have been collected, if this practice had been doing what I suggested earlier, which was to have a download for the top three cases for the five major payers that's grand total of 15. The medical necessity criteria. And you're past the denial filing limit. And again, this is a bad way to lose money. Bad way to lose money. Um, I've got just this idea popped in my head. Would you write down the name of a core EVI co re. You'll want to go to ever course website. Why, because ever core are the people who write the pre authorization criteria and the medical necessity guidelines. And I suggest you spend a little time nosing around on their website would be worth your time. Okey doke. So if you go to page 13. That slide is represented at the top of that page. So we've got the surgeon selecting the CPT and the ICD 10 codes. And if you're not using code x put out by the American Academy of orthopedic surgeons. I do recommend that you look into that because this could really speed things up for most surgeons. Then your patient scheduler uses availability. And availability is a tool that allows you to generate a cost surgical cost estimate for the patient. Okay. You can also generate a surgical cost estimate through the major carriers website so Blue Cross Blue Shield. And the advantage of that is, it is the patient's name, it is their policy number. It says this is what their deductible or unmet deductible is, and this is what they will owe you post up. Okay. We are big advocates for, and this is way before no surprises we were into no surprises before anybody in Congress thought about it. We want to give the patient the surgical cost estimate form. And we want to initiate a collection of a surgery scheduling deposit. Depending on where they are in terms of who the economic base of the patients they serve, depending on the subspecialties, depending on what we found out in receivables about patients not paying are going to define what their minimum payment guidelines are. I urge you to consider offering care credit. We'll talk more about that. And another easy, easy technique that I've got people, oh they argue with me. You want to put a credit card on file. Why? First of all, you've got credit cards on file, all over. Okay, you do. If you have a storage locker, you've got a credit card on file. If you've got a club, you've got a credit card on file. And these bills then just automatically, I buy bouquets from books, you know this online floral service, I've got a credit card on file, it shows up on my visa, they don't send me the flowers, and then hope I'm going to pay them. Your software, make a note. People should be taking some notes. Quality software has a place for you to securely store the credit card on file. It does not belong on a post-it note anywhere. Okay, so we're going to put that credit card on file. And when Blue Cross Blue Shield pays my claim and says Karen hasn't met her deductible so she owes you the $67.50, you don't, listen up folks, we don't now wait to the end of the month to bill Karen. You bill Karen that day or the next day, using the credit card on file feature. You automatically bill that. This does wonders, boys and girls, for your cash flow. We believe that the schedulers should be the people obtaining the prior auths, because without the prior auth, I can't schedule the case, right, at the ASC or the hospital. Documentation training is a must. Again, I'm echoing myself, get it right the first time because your robust appeals will depend on it. When we talk about coding education is a must, the AAOS code X, you're going to want to investigate that product. You should go to our website. Again, for the free. There are two free presentations I want to talk with you about, three, actually. Sarah's presentation on clawbacks, which is all of the reasons orthopedic surgeons across the country have experienced clawbacks from health plans, and in some cases how they were complicit. Sarah's presentation about RV use is free is up there. We have some live workshops. Some of you are in big groups, and frankly the whole coding and billing team should be visiting us at one of these. And Jen Bell, who's smiling faces here, and I don't know why Michael Marks is there, but Jen Cabrera should be, they will be doing four more presentations for you on specific aspects of coding for foot and ankle surgeons. This presentation, if you are involved, is relevant if you are involved in value-based care. We just spoke at the big meeting that Dr. Zev Cain did on value-based care. The HCCs, the hierarchical coding condition categories, are what give you the kicker, what demonstrate that you are taking care of more complex, sicker patients. So if that topic comes up in your office, know that we have a resource to help you. All right. Well, page 14 has this slide, and establish a feedback loop. This slide is a little cockamamie, but it was done for a particular organization. When I talk about a feedback loop, what I am talking about is the fact that at some point, the coder billers meet with the orthopedic surgeon, preferably in person, but if you've got remote billers, you'll do it by Zoom, and you look at what is being denied. You're going to say, you've really got to do a better job at strengthening your diagnosis documentation. You've really got to do a better job about pointing out what failed therapy exactly consisted of. But if the doctors never get any feedback, you know, it's that old Einstein thing, you're not going to get anything different in the absence of coaching. Will all foot and ankle surgeons listen and comply equally well? No, I'm not Pollyanna. But I would say if I had five foot and ankle surgeons, and I had two who did welcome the feedback and correct their dictation and documentation style, they will make more money, and that will surely get the attention of the other three. That's been my experience. We always want to know if surgeons reply to the queries you send. And just as a question, if your biller and coder teams are using the work queue feature that is established in the software. Okay. And I thought this was a very handy report. If you use Phoenix Ortho, which is software designed specifically for your specialty, they don't do eyeballs, plastic surgeons, general surgeons, nobody else but you. And this was a report that we had asked them to create. And again, you can see each one of the plans, what the insurance companies and then what type of plan it was, and how many denials and the dollars represented. So if you have Phoenix Ortho, and you've not run this report, you want to call up the guys in support and say, hey, Karen showed me this, I'd like to try to run it. There are five ways surgeons can help reduce denials, but I want to come right down here to number five. And my best example of this was a woman, hand surgeon, we were at a big meeting. And she said, the minute I walk out of the operating room. First of all, I go to the operating room with what we prior authed. Every orthopedic surgeon would be ahead. If you took the prior auth, what you were approved for to the OR. Because then when you get in there, and it's like, oh, you know that didn't show up on the imaging. Oh, I better fix this while I'm here. If you did something extra. You don't take that and hope that somebody will call next week. The plans typically have a 24 hour or a 48 hour rule. This woman hand surgeon says I walk out of the OR, I look at the prior auth, I look at my dictation. I call myself. And the male surgeons in the room all, oh, there was this big eye roll. She looked at those guys straight in the face and she said, look, I am a woman who has some very expensive habits. And I intend to be able to keep them up. There is one person who's interested in this extra surgery being called in on a timely basis, and that's me. Small effort, big return. Small effort, big return. Okie doke. So anything different than what was planned needs to be called in promptly. All right. Well, this is when I wish we weren't. We're going over. We're still on that denial page. But this next item are any peer-to-peer reviews. I always wish we were live so that we could have several of you surgeons entertain us with your experience with peer-to-peer reviews. You know, I would always say when I was calling for the peer-to-peer review, I'd like this case reviewed not just by another orthopedic surgeon, but by another foot and ankle surgeon. So, there's no harm in asking. And I'd like you to start tracking the results. Again, if I have four foot and ankle surgeons in my group, or five, are one of you achieving better success than the others? Then perhaps you need to teach a little in-service on the secrets of successful peer-to-peer reviews. This is another point. If I was at a very large practice that offered acupuncture, right, and then there was x-ray and then there was PT, you're short-staffed. If I am short-staffed, I cannot appeal all of these aspects of the practice equally. I am going to follow Willie Sutton's advice. Why do you rob banks? Because that's where the money is. I am going to go to surgery and then look at the office visits next. Okie doke. So, if you're short-staffed, you can't be equal. We have to go for the big bucks first. So, let's look at a plan for reducing patient AR. And I'm going to have a little sip of water here. Some specific things we can do. If you look at page 16, there is $140 billion in medical debt. It's not all owed to you. The hospitals, I'm sure, have more than 50%. But in this environment, a doctor saying, oh, I'll bill you, it just doesn't cut it anymore. You have to be, you have to have a plan. You've got to stick to the plan. Remember this axiom. Employees respect what management inspects. And if you inspect and I'm the employee and I've been doing a great job, I want a pat on the back. I want an attagirl and maybe two free tickets to a movie. How about that? So, we have multiple opportunities for in-person collections. So, if in fact you've got a smooth operation, you do surgery on Monday, that case is billed by Wednesday or Thursday, and it's clean, no crazy unbundling, you are going to get a check within 30 days. Blue Cross Blue Shield here has paid surgical claims for me in 15 days. So, you're paid. That means during the whole global period, you have a face-to-face opportunity, eyeball-to-eyeball, with the patient to collect. Orthopedic practice after orthopedic practice that I go to, it seems like everybody's oblivious to this. You should know, hello, medical management software, back you guys in 1990, would print the appointment schedule, it would have the list of patients, it would have what everybody owed right there on the appointment list. Now, why this good idea has been lost or gone fallow, I don't know. Whatever you have to do, you want to know the balance of the people who are coming into the office. And we are going to alert them via text or phone call that the good news is your insurance is paid, and you only owe X amount of dollars. We want to collect surgery scheduling deposits, and that will reduce some of what I have to collect up here, but if you haven't been doing it, again, you're going to have to put some emphasis on collecting the prior balance. We're going to institute credit card on file. I talked with you about that. We're calling and alerting patients. I want you to develop some scripts and not let people free flow about what they say. In my experience, face to face collections always works best. However, if you've got a reception desk and then there's the whole reception room. That is not a great place to be having financial conversations. I think in modern offices we're building just off of the reception room, a financial counselor. If you don't follow my advice, you're going to experience something that looks very much like this. So this came from an actual report we did for a client, orthopedic client, AR, over 90 days, what was in there. This is shocking. These are office visits. This was face to face. $77,000 in visits that could have been collected, and now it's over 90 days. We've got to get on our game. And, again, if you don't measure the day to day collections. This is what happens. I will tell you that a client of mine. I asked we educated I left, you know, scripts, the whole thing. Finally, here's what happened. They had to send a list. Every single Friday of Monday, Tuesday, Wednesday, Thursday, and that Friday of the amount that was owed by individual patients. And what they collected against that and what they collected for surgery scheduling deposits that had to be in my office on Monday by noon. And my then very capable assistant Mary would call people on Monday morning saying, hey, I still don't have your report. And there is something about reporting to a third party that evidently got people's attention. And so, after, you know, takes about 90 days to create a new habit. We, we stopped asking for those reports to be sent to us, but they should be on the manager's desk. Okay. All right. If you look together on page 16. You'll see this diagram, and I mentioned this before, but it bears highlighting. You have different kinds of patient debt. You have patient balance after or before insurance pays. Right, we talked about that category of patients. The other end of the spectrum. You have uninsured patients. I want them in their own category. These people should not be mixed in matched under a category that says patient responsibility. All right. Many of you know, oh and stands for out of network. It's very easy for me to understand that your whole group, or a couple of doctors may say for this plan, I am out of network, and it's, you know, fine if I don't see any of those folks. But if they do, they're going to pay. So, if that is a sizable population in your practice. Please break it out. Why am I so keen on breaking it out. It's because, because ladies and gentlemen, that that group. If the doctors don't collect up front there then in no man's land, then they were waiting for the insurance to pay them, or the worst yet pay the patient 60 or 70% of the allowed amount. Okay, that is not good. What if it is elective not covered, I can give on this one. It's like, I decide I want more PT than my plan wants to pay for. Very important at the bottom of page 16 is that Medicare Part B and Medicare Advantage plans are not the same. Here is fight a denied Medicare Advantage plan. You want to pay special attention to this number, because this is the Office of the Inspector General. This is not Casey a consultants telling you this, the Office of the Inspector General found that plans overturned 75% of their own denials. Then they found that only 1% of the denials were appealed the Medicare Advantage plans are taking advantage of the fact that you are short staffed or uninformed, or both. So it's the greater pool. And I work for an orthopedic practice like this one year ago. I had a biller signing up on the contracts deciding if they should participate, bullish. If I sound mad, it's because I am. They were participating in 35 Medicare Advantage plans. And when you looked at their receivables, it showed. These plans have no intention of paying you honestly and Advantage plan has 30 days to pay Medicare Part B has 14 days to pay. If you are in Florida, there are people that signed up for a Medicare Advantage plan in North Dakota and you are not in their network. If somebody in your staff sees Medicare and decides oh yeah, it's not the equivalent of Part B. Not so. Okay, then they're off, they're denying needed care, which sounds like a lie potential liability problem. Here is another. Guys, look at the source. This comes from ARP. This is educating patients, but we don't we in healthcare, don't do a good job. You should have this article laminated, and in the reception room. June 2022. You should have a poster that says if you're turning 65 this year, think twice before you sign up for a Medicare Advantage plan. All right. But I'm, it's out of concern for you and your ability to continue to pay quality staff to provide good benefits that I am so exercised. Okay. This is something I want you to totally not do this is label this bad example. This is the third slide on page 17. Okay. We do not want any patients notifying the physician about their financial need, we want them talking to Rhonda in the billing office. We think that this is a great example at the bottom of page 17. This practice took full advantage of COVID and went contactless. What are we going to do for folks like this, my ex husband hasn't sent me a support check in six months. We want to use the FPL, the federal poverty guidelines and I think it's stunning how this has increased. Then, here's what I want you to do so you've got that graph on page 18. This is the federal poverty level calculator. I want you to use this tool because this can be very helpful. If you are doing 2.5 times the federal guideline charity care means the patient balance is forgiven in total. You need to go and look at the websites or call the hospital and the ASCs you do work at to see what guideline they use to do complete charity care. And what guideline, if any, do they use to do discounted care. Back when I was in Macon, Georgia, guess what? Community hospital had some very reasonable 2.5 to 3. That is the typical number I see. The for profit hospital had a much, much higher number that they were trying to collect. Remember, wishful thinking that you're going to pay people, that people are going to pay you who are very poor or uninsured just inflates the AR. Okay, so let's zoom ahead. We're going to do some more training on that, by the way. Stay tuned. Anyway, that's a lot for me to pay right now. This guy is not poor. He's not uninsured. He may just have been let loose by Microsoft or Google or Amazon. And he does have resources, but right now that $2,500 deductible looks like a lot. So care credit is the solution. If you look at the numbers, care credit already has almost 12 million subscribers. They already are accepted at 250,000 places. I want you to look in your, go to the website, www.carecredit.com. I want you to look at vets. I want you to look at dentists. I want you to look at dermatologists and plastic surgeons. And you will see that all around you, there are other healthcare providers for both humans and animals that are enrolled in care credit. So chances are some of your patients already have a card. One of the interesting surveys they did showed that 41% of patients would not have carried on with treatment or scheduled or wouldn't have finished that PT that is so important to your optimal surgical result because of financing. Having care credit allowed them to do that. I want to rest assured that it does not impact patients' credit score. I want to show you that there are these terrific calculators. I want to introduce you to a new product, Allegra. If a patient's FICO score does not allow them to qualify for care credit, it will automatically go to a lower level to a new product called Allegra. So one of my clients in New York was astounded to see the low FICO scores of his patients. So some very important information. If you follow the good example of Ortho Alabama that I showed you when we first started, right, and it had a custom link, it allows you to do a purse and wallet biopsy if you use that custom link. When you do, you can go in to your user site, your administrative site, and you can get the cardholder available credit report. Okay. That will show you who applied. And importantly, it will tell you the amount of their available credit. Okay. Somebody says, oh, I can't pay that. Well, this person can't pay that. But surely these folks are pretty good for being able to finance their deductible. So that is all on page 20 and 21. We can't figure out why orthopedic surgeons are slow to get on the bandwagon. The money is better in your pocket. In fact, you are a sophisticated group and you are good at cash management, you know, yes, care credit charges. No kidding. So if I collect, if I've got 100,000 in AR, current AR, that I can get put over on care credit, those patients agree. Stay with me here. So, that was 100,000 and let's suppose the caring charge for the plans that I picked was 9%. That means that I will get $91,000. They pay within two days $91,000. And if I'm fiscally responsible, I'm going to put that in a high yielding money market account. I will make that money back. Carrying that on your AR is only diminishing the value. All right. I have made this point. You have an opportunity to collect pre-service, you have an opportunity to collect at the point of service, and you have an opportunity to collect post-service. You've got to ask yourself, how good are we at all of those? I said you should have scripts. This woman is talking about money with a smile on her face, not a scowl. She's talking, she asked for the full amount, which is what you should always do. And then they say it's too much. She then doesn't counter with an amount. She says, well, what can you afford to pay? And then suggests care credit as a solution. So this takes staff training. Care credit has training. We do training. You want to measure if improvement is being made. So I would suggest that you can look at the average number of statements that are going out per week. We can look at the average daily collections at the point of service. We can look at average weekly pre-surgical deposits, measure that improvement, and we can say staff bonuses and raises are based on improvement in these categories. Okay? Remember, 875 to send a statement. 875. And we've got a well-written protocol, guys, on page 24. Are you just supposed to copy this? No. You may want to tweak it, but at least it gives you a place to start. And then the protocol for collecting surgical surgery deposits is on page 25 of your handout. Okie doke. So that's done. So let me open it up. Are there any questions? Any arguments? All right. The Jennifers are all silent. Can you believe we have three Jennifers? You can tell. They're probably all within a couple years of each other's birthday. We don't have any questions thus far. If you do have a question, please go ahead and put that in the Q&A session, and we can certainly ask Karen. Well, good. Then I'm going to feel like we did a pretty darn good job of being clear and specific. There's another valuable resource, by the way, that the AOFAS provides, which is a coding column, and I encourage you to reference that. And if Jennifer Moore or one of the other Jennifers, what's up next for you guys? Who's talking next? Topic and date. Hi there. I will be presenting next week on PA and NP billing for Medicare. For Medicare. Okay. And Jen, what time is that? That is on Wednesday, February 8, which will be 12 to 1245 Central Time. Okay. Great. That's an important subject. I would agree. In case you didn't see, Jennifer Cabrera is a highly experienced orthopedic PA who's had extensive administrative experience. So I think it's a good idea to check that you're in compliance with all of those rules and requirements for PA billing. All right. Well, I'd like to thank you for listening, and we encourage your further participation, and we welcome questions. So I'm signing off. Thank you very much. Thank you.

revenue cycle management

bottom line

proper documentation

coding and billing

maximizing revenue

denials

patient accounts receivable

CareCredit

credit card on file systems

cash flow

audience participation