The Profitable Retina Practice: Unlock Strategic Growth ...

American Academy of Ophthalmic Executives®
The Profitable Retina Practice: Unlock Strategic Growth and Profitability SPE 20 - Oct. 11, 2019 South, Room 211 | 1:30 to 4:30 p.m.
Moscone Center | San Francisco, CA
AMERICAN ACADEMY
OF OPHTHALMOLOGY®
Presented by:
Co-instructors Richard J. Connelly, CEO
Sean D. Goodale, CPA, MBA
AAOE Program I Friday, Oct. 11, 2019 I San Francisco, CA
Moscone Convention Center I 1:30 - 4:30 p.m. I South, Room 211
Protecting Sight. Empowering Lives."'
AAOE 2019 | Master Class Presenters Joy Woodke, COE, OCS, OCSR Practice Administrator — Oregon Eye Consultants LLC
Joy's 30+ years of experience in ophthalmology includes all aspects of practice management, accounting, coding and billing. Joy is the author of The Profitable Retina Practice series, a contributing author of the Academy coding product line, and recipient of the Academy's Secretariat and Achievement Awards.
Richard J. Donnelly Chief Operating Officer — The Retina Group of Washington
Rich is a senior healthcare executive with a broad background and proven track record of success in all aspects of financial management, provider network development and management, information technology, human resources and administration, mergers and acquisitions, legal, business development and capital formation. Rich is currently the Chief Executive Officer of The Retina Group of Washington (RGW) and he is in the eighth year of his tenure there. Rich’s career has spanned almost four decades where prior to RGW, he was promoted to a series of increasingly responsible positions over a 10-year period at UnitedHealthcare (UHC). After Rich left Ernst & Young in 1983, he held various executive financial positions with a venture capital firm specializing in telecommunications and technology for over 15 years, then onto the position of Chief Financial Officer at a Dental HMO prior to joining UnitedHealthcare.
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Sean Goodale, CPA, MBA
CEO — Retina Associates, P.A.
Sean is the CEO of Retina Associates in Kansas City and has over 29 years’ experience in health care administration and financial management. He is the chief executive officer of Retina Associates, P.A., the largest retina-only practice in the greater Kansas City area, with eight retina surgeons and 13 locations. He has also worked as the CFO and CIO of a large multi-specialty physician practice management organization. In addition, he serves or has served on national and regional advisory committees in health care and business, including local and national committees of the MGMA and HFMA.
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The Profitable Retina Practice: Unlock Strategic Growth and Profitability Presented by: Joy Woodke, COE, OCS, OCSR Sean D Goodale, CPA, MBA Richard J Donnelly, MS
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Financial Disclosure • Richard Donnelly, MS
• I have no financial interests or relationships to disclose relative to this topic.
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Agenda
Relative Value Units (RVUs)
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Acknowledgement
The Retina Group of Washington Dr. Michael Lai, Board Member John DiNardo, CAO Candice Richardson, Controller
Bob Fleshner, Former CEO of UnitedHealthcare
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Why does a drug float need to be managed?
How to manage a drug float?
The RGW experience?
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What Is a Drug Float Significant portion of a retinal specialist’s
clinical activity involves use of expensive injectable drugs.
Utilization of expensive injectable drugs creates both revenue and expense.
The timing in collection of drug revenue and payment of drug expense can create an imbalance between the two. This imbalance results in a “Drug Float.”
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Payment Cycle of an Injectable Drug
1 vial of drug A is used on a patient with X insurance Drug A was ordered prior to injection at cost of $1,900 Bill for drug A submitted to insurance X for reimbursement of
$2,000
Timing of the drug reimbursement relative to its payment results in one of 3 possible scenarios: If both occur simultaneously, the account balance would be
$100 If the reimbursement occurs before payment for the drug
was made, the account balance would be $2,000 If payment was made prior to receiving reimbursement, the
account balance would be -$1,900
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So What’s the Problem?
Due to the expense and volume of injectable drugs, a drug float can grow very large very quickly
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3 account balance scenarios from use of 1 drug vial
If both occur simultaneously, the account balance would be $100 (No Drug Float)
If the reimbursement occurs before payment for the drug was made, the account balance would be $2,000 (Positive Drug Float)
If payment was made prior to receiving reimbursement, the account balance would be -$1,900 (Negative Drug Float)
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Creation of Drug Float (1 Day) 3 account balance scenarios from use of 10 drug vial:
If both occur simultaneously, the account balance would be $1,000 (No Drug Float)
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3 account balance scenarios from use of 50 drug vial
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3 account balance scenarios from use of 200 drug vials
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Creation of Drug Float (1 Month) 3 account balance scenarios from use of 200 drug
vials If both occur simultaneously, the account balance would be
$20,000 (No Drug Float = True profit)
If the reimbursement occurs before payment for the drug was made, the account balance would be $400,000 (Positive Drug Float = False profit)
If payment was made prior to receiving reimbursement, the account balance would be -$380,000 (Negative Drug Float = False loss)
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Impacts of false loss: Artificially deflate practice financial performance Artificially decrease physician compensation Affect calculations for physician buy-in & buy-out Negatively affect cash flow
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Drug float can distort practice financial performance
Drug float can alter physician compensation
Drug float can impact physician buy-in & buy- out
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Set pre-defined dollar target
Match drug accounts receivable (A/R) with accounts payable (A/P)
Match drug A/R plus value of drug inventory with drug A/P
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Methodologies for Managing Drug Float
Set Pre-Defined Dollar Target This is set by the individual practice How much in Drug Expense is outstanding at any point in time Example: At the end of December 2018, the practice had $600,000 owed to the Pharma company or
distributor The practice decided that they would only have $400,000 owed to the Pharma company or
distributor at any point in time Therefore the practice would have paid down their drug expense at the end of December
2018 by $200,000 to leave $400,000 outstanding
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Manage Timing of Drug Pay Off This method manages days outstanding rather than dollars
outstanding at each month end Pharma company or distributor sets payment terms that define
the payment due date in number of days; ie. 30, 60, 90 days Practice paying with credit can further lengthen payment cycle Individual practice can choose to make payments earlier to lower
drug float, or later (with credit) to increase drug float
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Methodologies for Managing Drug Float Manage Timing of Drug Pay Off Example 1: lower the float The Pharma gives the practice 60 days to pay for drug A The practice wants their Drug Expense to never be more than 30 days outstanding At month end, the practice would pay down their Drug Expense so that there were only
30 days outstanding Example 2: raise the float The Pharma gives the practice 60 days to pay for drug A At month end, the practice would pay their Drug Expense with credit card, extending
payoff by another 30 days Drug Expense is paid 90 days after drug is ordered
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Match Drug Accounts Receivable (A/R) with Accounts Payable (A/P)
A/R = amounts a company has a right to collect; assets A/P = amounts a company owes; liabilities Drug A/R = reimbursements expected from drug usage Drug A/P = drug expense, cost of drug usage
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Match Drug Accounts Receivable (A/R) with Accounts Payable (A/P) The practice reconciles the difference between Drug A/R and Drug A/P to
determine the amount of Drug Expense that needs to be paid Example At the end of December 2018 the practice had Drug A/R of $400,000 At the same time the practice had Drug A/P of $500,000 The practice would then pay down their Drug A/P by $100,000 which would then make
their Drug A/P equal their Drug A/R
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Match drug A/R plus value of drug inventory with drug A/P Balance financial obligations of the drugs with the expected assets (both drug A/R
and drug inventory) The practice compares the amount of Drug A/R plus the Drug Inventory to their
Drug A/P to determine the amount of Drug Expense that needs to be paid Example At the end of December 2018 the practice had Drug A/P of $500,000 At the same time the practice had Drug A/R of $400,000 and Drug Inventory of $50,000 which
totals $450,000 The practice would then pay down their Drug A/P by $50,000 which would then make their Drug
A/P equal to their Drug A/R plus Drug Inventory
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Tips for Improving Your Drug Cost
Be aggressive with the Drug Vendors -- Negotiate upfront discounts or back end volume rebates
Use a credit card to purchase the drugs and negotiate a rebate on the card. Forget about points negotiate cash back. You can’t pay your employees with points.
We are in a nickel and dime business. Worry about the nickels and dimes and the dollars will follow.
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What Are RVUs?
Would you say your relationships with your commercial payors (insurance companies) are generally:
Multiple Choice Questions
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Do you know the approximate % of your billables that each Payor represents?
Do you know the average length of time it takes to receive payments from each company?
Do you know the approximate reimbursement rates for each of your major payors?
Do you know the % of claims per payor that is typically disallowed?
How Much Do You Know About Your Insurance Contracts?
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Who handles your insurance company negotiations? Do they have good people skills? Are they empowered to make decisions?
Do you understand your relative position in the market size wise and geographically?
Do you understand the insurance company’s position?
More questions. . . .
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Money— Yes, it’s the root of all evil. Yes, it’s also the most important component in the negotiation----
but not the only one
Relationship You think I’m kidding? Let me tell you a story or two. . .
Ease of use—this goes, in part, to relationship Size and complexity are the issues, not desire to screw the
practice
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Relationship
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Who are they going to negotiate with more, someone they like, someone they don’t know or someone they dislike?
Relationship
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Money
Benchmarks What are the other payors paying. There needs to be parity critical in the network. Payors
compare top four to top four, etc. May ask for “blinded rates”; the Payor can pull COB data and call your bluff Trend (year over year increases) and physician CPI on fee for service rates. ASCs would be a mix between Physician CPI and Hospitals Length of contract
Medicare How important are you to their network?
Negotiating Issues from the Insurance Company Side
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% of overall market you represent-disruption analysis
Ease of Use Problem claims Education of staff on filing claims Provider Service Rep
Ongoing Relationship
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Don’t wait until contract term is over to contact – Be Proactive!
Ongoing dialogue Fewer surprises Desire to treat you professionally - Make them care about you as a person
Who are insurance companies? They are people! Treat them like people Learn about them and their needs in the negotiation Search for common ground
Hints
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This is our report card or scoreboard
It tells us how well, or not so well, we are doing.
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Financial Statements – WHAT ARE THEY? • Financial statements will consist of: Balance Sheet (Assets & Liabilities) Income Statement (Profit & Losses) Statement of Cash Flows (Timing of Cash Inflows and
Outflows)
The financial statements should include a comparison to an annual operating budget. Also include Forecasts throughout the year as well.
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Doctors
over period and to your YTD operating budget.
Trend Analysis – This is a multi-period comparison (Years or Running Quarters)
Metrics – Put together a Dashboard with these metrics. Make it easy to review.
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Financial Statements Metrics--DASHBOARD
Create a Dashboard of important metrics that are the dynamics of the Practice.
Involve the Doctors in what is included in the metrics.
These important ratios should give you the financial pulse of your practice or office.
The result should be a One-Page End-of-Month Financial Report that makes sense and is understandable.
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Types of Fee Income (Clinical/Surgical, Drugs, Clinical Studies, Consulting, Other)
Allowables – Can be RVUs or Dollars based on the CMS GPCI
Patient Encounters & New Patients
Days the Practice is open
Accounts Receivable (Days O/S, Collection %s, Comment on Inv. Doctors & Payors, etc.)
Drug Float
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All of this information should be compared to your Budget and prior periods
Also look at these metrics over multiple periods to see trends
This will help with your variance analysis
Financial Statements – Types of Metrics or Other Information
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Clinical/Surgical Fee Income
Total Fee Income
Drug Fee Income
Total Fee Income
Clinical Studies Income
Total Fee Income
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Allowables – Can be RVUs or Dollars based on the CMS GPCI
Depending on your PM system, you can either Reprice the encounter data at the prominent Medicare GPCI Fee
Schedule and illustrate in dollars. Payor mix is not consistent among the Doctors. Levels the playing field.
Use RVUs to measure the level of work.
Financial Statements – Allowables
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Doctor Days = # of Days that the Doctor saw patients measured as AM and PM
Number of days (per month) a doctor is in the office or surgery
This helps account for the effects of vacation, adding a new doctor, or partial retirement. Patient Encounters / Doctor Days New Patients / Doctor Days
Financial Statements – Patient Encounters & New Patients
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Clinical Staff Ratios (Encounters, Doctors & Fee Income)
Encounters / # of FTEs Encounters / Doctors Fee Income (Non-Drug) / # of FTEs Fee Income (Non-Drug) / # Doctors Fee Income (Non-Drug) / Encounters
Financial Statements - Clinical Staff Ratios
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Days the Practice is open is looking at how you are utilizing your capacity and resources. Do this by Office and in total.
Total Encounters / Days Open Fee Income / Days Open
Financial Statements – Days the Practice is Open
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A/R Days Outstanding – Your PM system will calculate this for you or use the traditional accounting formula. This can be done by Doctor, Office and Payor.
Collection %s -- How much of what was collected this month relates to days outstanding. 0-30 days = 70.2% 31-60 days = 17.1% 61 - 90 days = 5.2% 91 - 120 days = 2.9% 121-150 days = 2.8% 151 – 180 days = 0.4% 181+ days = 1.4%
Highlight the problem Payors and comment on the >90 days by Doctor.
Track your Denied Claims and know what is causing them; this adds to you’re A/R Days.
Financial Statements – Accounts Receivable Metrics
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What is Drug Float -- Defined as the amount of money that we owe to the injectable drug vendors at any point in time for Lucentis, Eylea, Avastin, Ozurdex, etc.
As we contacted peer practices, each one had their own respective spin on this definition. Some defined this as the amount they owe the drug vendors less the amount of receivables outstanding for drug claims less the amount of inventory that they have on hand.
Others defined this as the amount that they owe to the drug vendors period. This is what we consider the range.
Financial Statements – Drug Float
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If you are on a Cash Basis accounting method, you are not required to recognize expenses in the same period that services are rendered and therefore have taken into income. This means that at year end the Shareholders/Partners realize a “false profit” in the amount of the outstanding Drug Debt. So effectively this is a loan paid out to the Practice that needs to be paid back to the pharma vendors.
Conceptually this is money that the Shareholders have received over the years that needs to be returned so that it can be paid back to the pharma vendors.
If a disruptive technology, for example, a long term implant that is purchased by hospitals and placed by us surgically, came along today, future receivables would not be collected and you would still need to pay the expense within the Drug Float period.
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Operating Expenses
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Collections (Non Drug)
Average is 65.7% (Range 43% to 96%)
Result is dependent on how often you adjust your Billed Charges and at what multiple of Payor Reimbursement
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Collections (Non Drug)
Number of RVUs Worked
Typically $38 for Medicare $48 to $55 is typical for commercial insurance
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Conclusion
Know what works for you.
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QUESTIONS
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A. New to our practice
B. An option we have been considering
C. A subject we need more resources for retina practices
D. Not interested at this time
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• The changing landscape o How is this impacting retina practices?
• Why PE and the long-term outlook
• How would a PE buy-out impact our practice? o Our physicians? o Our staff?
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Profitable Retina Practice – Efficiency and Clinic flow Sean Goodale, CPA, MBA CEO of Retina Associates, Kansas City
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• Revenue Cycle Management Considerations
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Maximizing Efficiency and Physician Productivity • Patient Workflow and Planning o Physical Layout of space Minimize patient movement/steps
Pods vs. Pattern vs. Single site
Dual utilization Physician/Staff workspaces Challenge existing utilization (i.e. chart room, procedure room, dual use)
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Maximizing Physician Productivity • Patient Workflow and Planning (continued) o Workflow and time/task analysis EMR and PM systems task tracking Check-in/ preliminary information Patient in take/ Work-up Testing
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Maximizing Physician Productivity • Patient Workflow and Planning (continued)
o Workflow and time/task analysis EMR and PM systems task tracking (continued)
Exam Lane
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Maximizing Physician Productivity • Staffing Analysis
o Supporting Physician schedules and patient load Doctor specific clinical staff vs a rotating pool
Dedicated Lead Scribes/Technicians-Volume/demand dictates #
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Maximizing Physician Productivity • Staffing Analysis
o Supporting Physician schedules and patient load Excess? staffing to improve patient and doctor experience Cost Benefit Analysis of additional staff and additional encounters
Increasing staff leading to increasing access and higher patient satisfaction
Improved quality of life for physician and staff=more patient access
Providing staff a bigger role benefits both the patients and the staff
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Maximizing Physician Productivity o Decisions, Decisions, Decisions….. Cost Benefit Analysis (continued) Staffing vs Volume
- # of Encounters to cover staff costs - Quality vs Cost - Increase in efficiency - Improve patient experience - Sometimes less is more
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Maximizing Physician Productivity • Patient Workflow and Planning
o Workflow and time/task analysis EMR and PM systems task tracking
Training opportunities
Maximizing Physician Productivity • Location office analysis
o Strategic geographic access Zip Code Analysis for new and existing patient base Patient zip code and Referring Doctor zip code
- Where do existing patients come from - What areas are lacking zip code presence - What presence does a referring base have in the area
Cost Benefit Analysis of the cost of a new location o Ease of access for patient directions and transportation o Physician and Staff travel considerations
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Revenue Cycle Staffing Efficiency o Encounter documentation and physician (part of process) billing
Same day or next day billing Physician requirement to complete chart
Real time tracking of unfiled encounters/claims
Goal Setting for billing staff
Denial rates
Revenue Cycle Staffing Efficiency o Staffing strategies for Accounts Receivable Management Productivity goals for Charge Entry/ Review Charge entry
- Lines per hour - Total Charges
Utilization Management - Prior Authorization, Drug lists, Step Therapy, etc.
Claims resolution/ follow up
Revenue Cycle Staffing Efficiency o Staffing strategies for Accounts Receivable Management (continued) Productivity goals for Charge Entry/ Review
Dedicated staff for drug assistance programs
- Skilled experts in the various copay/assistance programs
- Dedicated resources for clinical staff to interface with regarding treatment options • Insurance Coverage concerns/ requirements • Benefits investigation/ utilization management
- Investment in staffing that has had a solid return
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o Staffing strategies for Accounts Receivable Management (continued)
Charge Entry Process Certified Coders vs In House trained vs Outsourced
Remote access Challenges Regulatory Concerns-OSHA, HIPAA, etc Productivity tracking Company culture
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Revenue Cycle Management Efficiency
o Patient Education on Medicare Advantage and Commercial Products Helping patients understand their options Informing patients of plans that you may not be participating
o Collection rates Compared to Medicare/Medicaid Compared to other commercial Payors
o Payor contract review and negotiation
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1. Information is the efficient use of data
2. Key elements of usable information: o Easy to obtain Quick and accessible
o Effective for decisions Accurate, reliable and clear
o Critical vs. Non critical
3. What is “Big Data”, IRIS registry, CMS, etc.
4. The link between Information and Value-Bad Data costs $$$
Information vs. Data
• In-house or external support (Cost benefit analysis)
• Hardware/User Interface considerations
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To Cloud or Not to Cloud • Definition of Cloud vs. in-house (server- based)
o Physical Location
• Cloud-based systems o Pros Hardware Simplification and management Software updates Near world wide accessibility
o Disadvantages Internet Based (Access) Cost
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To Cloud or Not to Cloud (continued)
• Office (server) based systems o Pros On site access Physical presence Potentially lower cost
o Disadvantages Security and Backup responsibility Hardware/Software configuration and maintenance Remote office access challenges
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To Cloud or Not to Cloud (continued)
• Hybrid Part Cloud Part Office based systems o Pros On site access and positive redundancy Potential best of breed solutions for certain elements Potentially lower cost
o Disadvantages Potential lack of clarity on security and backup responsibility Multiple vendors for configuration and maintenance Upkeep of interfaces and interoperability components
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• Expertise and training- superusers
o Leveraging technology-Extended life
• Immediate hardware redundancy for support
• “Guest” network management
• Laptops, Desktops and Phones…Oh my!
• Network Security Audit
• Malware, Ransomware and Intrusion protection-potential costs
• Other portable media considerations
Examples • Hybrid systems:
o Cloud EMR/ Local PM o Inventory systems integrated with PM and EMR o Accounting systems linked to PM systems
• Laptops and Portable Devices o Tablets, convertibles, Hotspots
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Audience Poll - KPIs • Do you use KPIs in your practice to track profitability or efficiency?
• YES!
• NO!
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Audience & Panel Discussion • What do you feel are the most useful KPIs for a retina practice?
• If you could only track on KPI, what would it be?
• How do you present KPIs to your physicians?
• When should you include or exclude drug income or expense from KPIs?
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BREAK
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Audience Poll - Hot Topics • What is the biggest challenge your practice is currently facing:
A. Tech shortage
B. Clinic flow
D. Medication management
Panel & Audience Discussion • Best Practice tips related to hot topics?
• What are the best resources for practice administrators?
• What resources do we need?
• What other challenges are impacting retina practices?
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Avoiding Common Errors Impacting Drug Profitability Presented by: Joy Woodke, COE, OCS, OCSR
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Financial Disclosure • Joy Woodke, COE, OCS, OCSR
• I have no financial interests or relationships to disclose relative to this topic.
• Academy Codequest instructor, private consultant and contributing author to Academy products
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Drug Profitability • Key players -
o Drug Reimbursement o Drug Cost o Drug Margin o Overhead
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• Based on CMS Average Sales Pricing (ASP) o Updated quarterly o Price per unit o Calculate 2% sequestration o Commercial and Medicare
Advantage plans may based reimbursement on a percentage of ASP pricing
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• Negotiated cost per vendor or pharmaceutical company
• Consider all rebates
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$ Reimbursement
Practice cost - 1750
Drug margin $ 140
• Allocating expenses o Practice overhead o Direct expense related to
management of drugs o Supplies
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• Tracking profitability
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Correct Coding • Potential errors
o Incorrect units billed o Wrong medication coded Billing Avastin, when Lucentis was injected
o Bill sample, regular dose used o Diagnosis link error Dry AMD
o Diagnosis not medical necessary per payer policy o Missing –LT or –RT modifiers o NDC missing or incorrect o Neglecting to bill for wastage
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Are we proactively auditing?
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o Focus on medication claims
• Troubleshoot and manage o Prompt claim submission o Clearinghouse denial or scrub edits o Insurance claim not received o Resolve denials, promptly o Prior authorization or step therapy barriers
• Design targeted A/R reports
Source: The Profitable Retina Practice: Medication Inventory Management
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Total Drug Reimbursement • Assumed goal – prompt, full reimbursement
• First step, what is the total expected allowable? How do I find? o CMS ASP Pricing – Medicare o Commercial, Medicare Advantage, Medicaid, Secondary Start with your contract
• Contracts o Section: Injectables, pharmaceuticals Reference Medicare Part B ASP Reimburse a percentage of Medicare, U & C, or a carve-out assigned allowable Clause drug not listed on ASP, percentage of Wholesale Acquisition Cost (WAC)
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Total Drug Reimbursement • What to monitor
o Underpayment from insurance carrier based on contract – appeal Run targeted reports
o Delayed payment from PAP, or not requested o Patient unable to pay deductible, coinsurance o Coding error impacting total reimbursement o Skilled Nursing Facility (SNF) – delayed payment, not billed, or recoup from Medicare o Denials not appealed
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o Poor inventory system Best practice: comprehensive spreadsheet or computerized system
o Inventory counts - too high or too low o Expired or damaged drug – not managing o Not rotating expiration dates Bill due for a vial before using/billing
o Lack of routine inventory counts o Lost vials o Inventory used and not logged Missed billing injection
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Accounts Payable • Pitfalls to avoid
o Not monitoring A/P invoice totals o Cash flow challenges o Late payments, losing discounts o Lack of negotiation with vendor – cost, terms and rebates o Mismanagement of credit cards, rewards
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o Medication Inventory Management o Strategically Grow Your Retina Practice
• Coding Audit Success Toolkit
• Audits – aao.org/audits
Rapid Fire Retina Panel Discussion – Prior Authorization (PA) & Step Therapy
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Audience Poll • In the last year, have your denials related to PAs or Step Therapy:
A. Increased
B. Decreased
A. Technicians
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Prior Authorization & Step Therapy • What are some of the challenges we are facing related to PAs and Step
Therapy?
• What resources have been most helpful?
• Have any of the new policies impacted clinic flow or patient care?
• What type of internal tracking system do you use for PAs?
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Audience Poll • In the last year our practice has experienced a
A. TPE audit
B. RA audit
• aao.org/audits
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• How can a practice prepare for the inevitable audit?
• What is your internal process when receiving an audit request?
• What other best practice tips can you share?
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We love RETINA!
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Ever ask “is our physician productivity on par with similar practices”?
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Good news: It’s FREE to members! .
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ANTHONY P. JOHNSON, MD, FACS Jervey Eye Group PA AAOE Board Member and Benchmarking Pro
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Handouts & Resources Friday, October 11, 2019 | SPE20 1:00 to 4:30 p.m.
The Profitable Practice: Unlock Strategic Growth and Profitability Senior Instructor: Joy Woodke, COE, OCS, OCSR Co-Instructors: Richard J. Donnelly, CEO; Sean D. Goodale, CPA, MBA
Access your handouts to this course at: https://www.aao.org/practice-management/annual-meeting- courses/master-classes
1:30 to 4:30 p.m.
Growth and Profitability
Senior Instructor: Joy Woodke, COE, OCS, OCSR
Co-Instructors: Richard J. Donnelly, CEO and Sean D. Goodale, CPA, MBA
Protecting Sight. Empowering Lives."' 137
8/5/2019
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Visit reconciliation/ outstanding visit reports-Confirms all visits captured
Drug reconciliation
Days in Accounts Receivable
Breakout by Doctor
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% of Accounts receivable under 30 days;70—75% or better
% of Drug Accounts receivable under 30 days 85-90%
Beware of Drug Accounts Receivable masking other categories
Accounts Receivable by CPT
Accounts Receivable by Payor
Accounts Receivable by Location
o Other Accounts Receivable Indicators to watch
Payor mix and trends from year to year, quarter to quarter
Growth of commercial plans
Trend reports of Charges, Payments and Encounters by month
Breakout of Drug vs Non Drug (Charges, receipts, adjustments)
New Patients by Doctor
New Patients by location
Review Eye codes vs E&M codes reimbursements
Payor Reimbursement Review
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Patient interaction tools at check in
Kiosks/Tablets
Paper
- Hospital Coverage-Emergent Care
Accuracy and Integrity
Estimates vs Definitive amounts
Simple Layout
Visits per Day
New patients per day
CPT Analysis
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Average Collection rates
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Reimbursement review
- Specific to each drug
Reimbursement review
- By Location
- By Doctor
MIPS and Quality reporting
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Unrelated evaluation and management service (or eye codes) by the same physician during a postoperative period
25 Significant, separately,
identifiable evaluation and management service (or eye
codes) by the same physician on the same day of the procedure or
other services
related to the original surgery:
-New symptoms
evaluation
mean unrelated
(0 or 10 global period days)
Office visit same day, or within 3 days of a major surgery (90 day global period)
OFFICE VISIT
PLANNED OR
the post-op period
period
70% ALLOWABLE
Billable same
Global
Commercial
Global*
66761 Yag PI 10 days -25 90 days -57
66821 Yag PCO 90 days -57 90 days -57
67105 Laser repair RD 10 days -25 90 days -57
67145 90 days -57 90 days -5767145 Laser repair
retinal tear, prophylaxis RD
67210 Focal laser 90 days -57 90 days -57
67220 Laser for choroid
67228 PRP laser 10 days -25 90 days -57
* Confirm global period per
insurance carrier based on
allowable and/or RVU 160
Check List for Injected Drugs. From Coding Audit Success Toolkit
With the current TPE audits targeting Eylea, focusing now on an internal review on this high-volume service is best practice. After reviewing your MAC LCDs or commercial payer policies, review a sample of chart records for appropriate documentation and the insurance claim for the appropriate billing.
Confirm there has been 28 days since the last injection, same eye. Surgical order including;
Medication name Dosage in mg and volume in ml (ie Avastin 1.25 mg @ 0.05ml) Route of administration (intravitreal injection) Site of injection, eye (s) treated Indication for treatment and confirm is a covered benefit per payer policy Physician signature
Plan including the reason for using the specific medication or continuing treatment. Copy of diagnostic testing and interpretation and report supporting medical necessity for
treatment. Informed consent for first injection and when a change in medication or eye (s) is treated. Consent for off-label use as appropriate. Procedure note that documents;
Dosage of medication injected in mg and volume in ml Amount of drug units wasted. If less than 1 unit, document residual medication less
than one unit was discarded. Lot number Diagnosis
Maintain complete inventory and medication log records. Chart notes are legible and include patient name and date of birth. Physician signature
161
American Academy of Ophthalmology
American Academy of Ophthalmic Executives 655 Beach Street San Francisco, CA 94109
The Profitable Retina Practice: Unlock Strategic Growth and Profitability
AAOE 2019 | Master Class Presenters
AAOE 2019 | Master Class Presenters
PPT Title Page
Talk Objectives
Payment Cycle of an Injectable Drug
So What’s the Problem?
Creation of Drug Float (1 Vial)
Creation of Drug Float (1 Day)
Creation of Drug Float (1 Week)
Creation of Drug Float (1 Month)
Creation of Drug Float (1 Month) (continued)
Impacts of Drug Float
Tips for Improving Your Drug Cost
Relative Value Units (RVUs)
More questions. . . .
Relationship
Negotiating Issues from the Insurance Company Side (continued)
Hints
Financial Statements - FREQUENCY
Financial Statements – ADDITIONAL REPORTING
Financial Statements – Types of Fee Income
Financial Statements – Allowables
Financial Statements - Clinical Staff Ratios
Financial Statements – Days the Practice is Open
Financial Statements – Accounts Receivable Metrics
Financial Statements – Practice Overhead %
Financial Statements – % of Billed Charges
Financial Statements – Collections per RVU
Conclusion
QUESTIONS
Sean Goodale, CPA, MBAFinancial Disclosure
Featured Topics
Revenue Cycle Staffing Efficiency, pps. 80-82
INFORMATION TECHNOLOGY STRATEGY AND DESIGN
Information vs. Data
Efficient Information Flow
In-house vs. External Support
Examples
Financial Disclosure
Final Thoughts
Ever ask “is our physician productivity on par with similar practices”?
Link to Handouts
End of PPT
Revenue Cycle Management
Technology Use Examples
Technology and Reporting
Prior Authorization Resource
Diagnostic Services

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