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Angela Mattioda - Ensuring Profitability by Verifying Eligibility
156 Plays2 years ago
Angela Mattioda is the Senior Vice President of RCM Solutions at Surgical Notes, and we caught up with her to talk about the role of eligibility verification in ensuring profitability. During our discussion with Angela, we dive into common challenges, technology's role, authorizations, avoiding revenue loss, and more.
In our news recap, we'll cover Uber's same-day prescription delivery, OpenAI and EHRs, four reasons surgery centers are struggling to meet margins right now, and of course, end the news segment with a positive story about Virginia's plans to tackle the nursing shortage.
Before we get into the episode, I wanted to personally invite any of our listeners going to the ASCA Conference in Louisville on May 17-20th to stop by HST Pathways' booth. During exhibit hall hours, we'll interview attendees to be on an upcoming episode that will air in late May. So if you want to share your expertise with our listeners, come find HST Pathways at Booth 519 at ASCA!
Articles Mentioned:
Uber Health launches same-day prescription delivery
Epic, Microsoft bring GPT-4 to EHRs
5 reasons ASCs are struggling to meet margins
Shenandoah University and Valley Health Partner to Tackle Nursing Shortage
Brought to you by HST Pathways.
Recommended
Transcript
Introduction and Podcast Overview
00:00:01
Speaker
Welcome to This Week in Surgery Centers. If you're in the ASC industry, then you're in the right place. Every week, we'll start the episode off by sharing an interesting conversation we had with our featured guests, and then we'll close the episode by recapping the latest news impacting surgery centers. We're excited to share with you what we have, so let's get started and see what the industry's been up to.
00:00:27
Speaker
Hi, everyone. Here's what you can expect on today's episode.
Role of Eligibility Verification in Profitability
00:00:32
Speaker
Angela Matiota is the Senior Vice President of RCM Solutions at Surgical Notes, and we caught up with her to talk all about the role eligibility verification plays in ensuring profitability. During our discussion with Angela, we dive into common challenges, the role technology plays, authorizations, avoiding revenue loss, and more.
00:00:53
Speaker
In our news recap, we'll cover Uber's same day prescription delivery, open AI and EHRs, four reason surgery centers are struggling to meet margins right now, and of course, end the new segment with a positive story about Virginia's plans to tackle the nursing shortage.
00:01:11
Speaker
Now, before we get into the episode, I wanted to personally invite any of our listeners who are going to the Ask a Conference in Louisville from May 17th to the 20th to stop by HST Pathways booth. During exhibit hall hours, I'll actually be chatting with people right in the booth.
00:01:29
Speaker
to be on an upcoming podcast episode that will air in late May. So if you want to share your expertise with our listeners, it will only take a few minutes of your time. So come find me and HSC Pathways at booth 519. We have a big booth right in the middle of the floor. You can't miss it. So I hope everyone enjoys the episode and here's what's going on this week in Surgery Centers.
Angela Matiota's Experience and Role
00:01:57
Speaker
Angela, welcome to the show.
00:01:59
Speaker
Thank you, nice to be here. Thank you for inviting me. Excited for it. Can you give our listeners a quick overview of your background in the ASC industry? Sure, so I have been in the ASC industry for going on 25 years. My entire RCM career has been specific to surgery centers. I've been with surgical notes for about six years now and
00:02:28
Speaker
currently working in a lot of different facets for the company, including onboarding, operations, business analytics, client experience. And that kind of goes hand in hand with my background too, for the 25 years I've kind of had my hand in all the facets of RCM related to ASCs. Fantastic. So deep, deep background on revenue cycle and RCM. And so,
00:02:55
Speaker
I thought that would be a great topic to hit on here today.
Importance and Methods of Eligibility Verification
00:02:59
Speaker
And when we think about the overall RCM process and life cycle, one of the upfront pieces is obviously eligibility verification for the patient. And that seems pretty important because if that's wrong or not captured, it can lead to downstream impacts on the ability to collect. And so I wanted to ask you about that in terms of how do you think about
00:03:23
Speaker
eligibility verification, and why is it so important to the overall arsenic process?
00:03:32
Speaker
Well, the eligibility verification really is the first step after scheduling the case. It determines the viability, whether or not the patient is eligible with current effective dates of insurance. It also allows you the ability to determine the estimated payment based off the scheduled codes and going into case costing.
00:04:00
Speaker
Is it a high cost case and will they recover those costs as far as the estimation goes? And taking it even further, of course, is going into the patient collections up front. The importance of providing the patient with those options and collecting that so that you're not chasing it on the back end. Got it. And how are ASCs
00:04:27
Speaker
doing this today? Are there some different ways that ASCs conduct eligibility verification? There's so many different ways in it and it does have an impact whether or not the center is out of network or in network. When a center is out of network, it's really important to pick up the phone and call the insurance.
00:04:50
Speaker
Even if you look at their eligibility online, you can determine that they do have current insurance benefits, but it doesn't tell you the type of patient policy. For example, an MNRP policy, which is through UnitedHealthcare that indicates that it's going to pay Medicare rates.
00:05:12
Speaker
or a percentage of Medicare rates. But when you're in network, then you have a whole array of software out there available to the ASCs. You can do it through Waystar, which is a very common, prominent clearinghouse. They do the eligibility and benefit verification as well. And then there's also specialized software that not only does real-time benefit verification
00:05:41
Speaker
and patient estimates of responsibility, but has the ability to also reach out automatically via text or email to patients and track the percentage of patients that are looking at that communication and receive a professional estimate through that text link. Got it. So you mentioned, you know, I think, I think a couple of different ways to do it, right? You said, Hey, in
00:06:09
Speaker
the out-of-network scenario, you really got a call and there's not a lot of automation or software that you can use. For the in-network, I assume you can still call, right? And we see some customers that are doing that, but more automation becomes available via clearinghouse or via patient estimation and insurance verification kind of software tools, right?
00:06:36
Speaker
Right. And even the practice management software nowadays available to ASCs can interface with the clearinghouse and do those estimations as well and verify the benefits real time. Yep. I'm curious, with your guys' customer base, you know, looking at the end network side,
00:06:59
Speaker
What's kind of the mix in terms of people are using software for insurance verification versus folks that are calling? I would say it's probably about 50 to 60% that is utilizing some type of software and others will utilize picking up the phone or they will go directly to the payer portals themselves. Okay.
Timing and Frequency of Insurance Checks
00:07:31
Speaker
Got it. And so we talked a little bit about eligibility verification. In terms of the coverage, one of the things that I see centers talk about is how often they check or ping the insurance regarding the coverage and is it still current before the procedure? What's your kind of guidance or best practice there?
00:07:54
Speaker
It really depends on the size of the center, but the most industry standard is to stay one to two weeks out from date of service. And that gives you a little bit of room also so that you're handling any add-ons within a 24-hour period because there's always going to be add-ons.
00:08:15
Speaker
When you do it one to two weeks ahead of time and you're using a software and it's kind of one of the benefits of the software is the real time benefit verification check so that when the patient comes in on date of service or even one to two days before, you can recheck those benefits. And not only you're looking at is the patient still eligible,
00:08:41
Speaker
But you're rechecking their deductibles and what has and has not been met because likely when a patient's coming in, they have other claims, their doctor visits, for example, that are going through the insurance and so their deductible decreases. It helps to avoid over-collecting and doing more
00:09:02
Speaker
I do prefer over collecting, estimating on the high side and being in a position of refunding on the back end. But if you can prevent that where you can, then it's good practice to do that as well. So it sounds like checking with insurance more often through the benefit of software really is allowing providers to get more tight, more accurate on their patient estimates.
00:09:28
Speaker
That's correct. If they're doing phone calls, they don't tend to recheck benefits. If they are utilizing software that makes it easy at a click of a button, then we see an uptick in where those estimates and upfront deposits are more on track to what is real time. Got it.
Challenges in Software for Eligibility Verification
00:09:51
Speaker
So curious, Angela, you mentioned, hey, 60% of
00:09:55
Speaker
The industry or centers are kind of using software to help automate this process, 40% or not. Sounds like there's a lot of benefit to using a tool. Maybe what are some common reasons that you see why centers may still do it manually? Why do folks still like to call? Or maybe what pitfalls do folks encounter when they think about adopting a software solution?
00:10:19
Speaker
They may not be familiar, some with smaller case volume centers that do maybe 100 cases or less per month, may not have as much of a need for this type of software. So that's one because the
00:10:39
Speaker
The higher the volume, the more impact it is, the more time consuming it takes your front office to do all those different facets, not only manage the intake when the patient is checking in, but they have that responsibility to also stay on top of the cases that are scheduled one to two weeks out and the add-ons.
00:11:00
Speaker
So I think, you know, it's more of knowledge of knowing that there is good software out there. You know, some of these centers that aren't going to the conferences, when you go to the conferences, you see this, you know, these booths, left and right. I mean, they're, they're pretty prominent. And there's some
00:11:18
Speaker
really great, great products out there. So I think that that's more of it because I do talk to our clients, I know, and promote these types of softwares, especially if they're a higher volume center. Sure.
Complexities in Authorization Process
00:11:36
Speaker
And what about authorizations? Because this seems to be a thorn in the side. Some of our customers that I talked to because it can be a time intensive
00:11:46
Speaker
process. You know, what are your best practices or tips and tricks around prior authorizations? How authorizations, like you said, I mean, there's, there are a lot of potential issues that can come up with authorizations. I consider the authorizations to be one of the more recent games that the insurance is playing over the last year. And
00:12:14
Speaker
What they are doing is they're putting in these time statutes that you have to update authorizations within four days, seven days, 14 days from data service.
00:12:27
Speaker
or you can be penalized 50% or the case will be denied. And if it's denied because of that, some of these payers, it's really difficult to overturn those denials. So with the authorization, one thing with the software that's used for eligibility and patient estimation, that is the one area that is still lacking is the authorizations.
00:12:57
Speaker
There's improvements over time, but it's still lacking. So this is an area that in general, the technology still hasn't fully automated this authorization side. And so it sounds like centers are still having to call for prior authorizations. And so given it's a manual step, what can centers do to make it more efficient?
00:13:22
Speaker
or make sure that they're not calling for authorizations that they don't need to collect, for example. How are people managing this? So first is working with the provider's office. I would say it's most common for the provider's office to call for the authorizations initially.
00:13:47
Speaker
because they're authorizing the surgeon's case. And if they're going to authorize the surgeon's case, they should be authorizing the case being performed at the center they're referred to.
00:13:58
Speaker
So if they're already on the phone, then knock it out at the same time. And really when it comes to the surgery center, ideally they're just verifying that yes, here's the authorization. We have the authorization number. It's for the correct procedure. Make sure that it's for the correct surgery center because that happens. Some providers work in multiple centers. So that's something that they need to make sure to check too. So this is one of these areas
00:14:29
Speaker
Yeah, sorry. I was just going to say, this sounds like one of those areas that does require kind of coordination or communication between the practice and the ASC facility. Yes, absolutely. One benefit now with the authorizations is the ability more and more to do it on the payer portals. And so that does help. And there's even some that require you. They won't do it over the phone. And I think
00:14:58
Speaker
For me, I think it's even better. You do it over the pair portals. It's quicker. You have a tracking number. You can follow up on the status of it versus picking up the phone. You can get through a lot more quicker when you're doing it through the portal. So I would always recommend checking and
00:15:20
Speaker
If you are in charge of doing the insurance verification and authorization, then keep, keep a matrix with the payers and whether or not they do have that portal. And so you can always just look over on your matrix and say, yep, this one I'm going on the portal and reduce the number of calls and hold time. Got it. So that's a good kind of medium step, not, not fully automated, but, but at least not calling. So, okay, great. And, um,
00:15:49
Speaker
One thing that sometimes happens in surgeries, I believe, is the procedure might change a little bit from the initial play in, right? What happens when after the procedure, the team's looking at the charges and codes and they're different than what you got authorization for? Another good thing to put on a matrix for the insurance verification team
00:16:16
Speaker
When the code changes from scheduled to final coding, there are some payers that won't allow you to add on a code or do a retro authorization. They just require you to handle it on the back end through an appeal. And that's okay, just because it denies initially for authorization.
00:16:37
Speaker
it's unless they have a time statute, then you're fine. You should not lose revenue because of those types of denials. And then for payers like Cigna is an example, you have 14 days from date of service to update that authorization. And so with that,
00:16:59
Speaker
it's really important to have that communication with your revenue cycle team. Whether or not it's in-house or you have a partner doing your revenue cycle, that communication that the person that's entering the charges, they see what's scheduled and they also have the coding sheet. They see the final coding and they also have the ability to see that it was authorized. They should be the ones to communicate when there is a change of codes and
00:17:29
Speaker
if it's a payer that requires you to update it immediately. Yep. Great.
Strategies for Patient Collections and Policies
00:17:37
Speaker
Well, final question for you here, Angela, and this is something we ask all of our guests every week. What is one thing our listeners can do this week to improve their surgery centers?
00:17:48
Speaker
Well, I would say keeping it related to this specific topic, I would say to have strong policies around collecting upfront. Having the ability to give the patients options, whether or not it be funding or payment plans, financial hardship, whatever those policies may be, but do
00:18:18
Speaker
your patient's a favor, give them a professional and as close as accurate estimation upfront, collect that estimation. And that just helps the patient. I know if I'm going in to have surgery, I want to know how much I'm going to be out of it. And I expect to pay that upfront.
00:18:41
Speaker
should be the same across the board for other centers. Just focus on patient satisfaction and providing them what they need so that they can pay up front and then that will help reduce revenue leakage on the backend. Yeah, makes total sense. So give them an accurate estimate up front and then collect it by, what's the best practice? Should centers be asking their patients to pay by data service?
00:19:09
Speaker
pay by or at data service, you know, at the time of service is okay. If they don't pay, then at least have that pre-service financial call to tell the patient what they owe and what is the expectation, you know, provide them with a link to pay online through credit card.
00:19:32
Speaker
Is the patient saying they'll bring a check with them on the date of service? Did you set up a payment plan? And if you do set up a payment plan, set up an auto payment plan. Don't just make a note to say for the RCM team on the back end to set up a payment plan, depending on whatever the balance is on the back ends. Get those payment plans set up upfront.
00:19:59
Speaker
Yep. And that seems like good practice and common sense, but there's still a lot of centers that don't do that. They don't require their patients to even pay at data service. Do you have a sense of why? What are the common objections? The most common reason for centers that I have experience with, it's their demographics.
00:20:23
Speaker
It always comes down to demographics. It's the types of patients. It could be Medicaid patients or an older demographic, more strained financially demographic that they tend to be a little bit more forgiving. The other reason would be not having those policies, not reviewing it, not KPIs,
00:20:52
Speaker
key performance metrics aren't just for on the back end, our collections and volume and charges and AR. It also should include your upfront collections. You know, those types of KPIs are really critical too, so they should include those. So sometimes it's just kind of a lack of visibility.
00:21:15
Speaker
You know, kind of focus on other things within the surgery center. You know, not getting feedback from the team doing the RCM could be also a reason that they don't realize that there is more urgency to improving those processes up front. Sure. Well, Angela, thanks so much for joining us today. I really enjoyed the conversation.
00:21:42
Speaker
Yeah, thank you. I appreciate it. Thank you for having me.
Innovations in Healthcare Delivery: Uber and AI
00:21:49
Speaker
As always, it has been a busy week in healthcare, so let's jump right in. Uber Health, which is self-described as the non-emergency medical transportation arm of the company, announced a new partnership with Nimble RX and ScriptDrop
00:22:05
Speaker
to provide same-day prescription delivery to patients across the US, and even including those in rural areas. Patients can request prescription delivery through their healthcare provider or pharmacy, and Uber Health will connect them
00:22:19
Speaker
to NimbleRx's network of pharmacies. Patients will receive updates on the status of their delivery and can track their meds in real time through the Uber app, just like you would if you were waiting for a ride or if you were stocking your food as it's being delivered from the restaurant to your front door.
00:22:38
Speaker
As healthcare providers and patients have increasingly turned to telemedicine and other virtual healthcare solutions, the option for same-day prescription delivery is not only extremely convenient, but also eliminates the need for patients to leave their home if they are sick and pose no risk of exposing their community to whatever they may have going on. This is not Uber's first venture to the healthcare space, as they already provide
00:23:05
Speaker
transportation services to healthcare providers and patients. And they also partner with prescription discount card company, GoodRx, to offer discounted rides to patients. So the service is available immediately and both companies expect the partnership to expand in the future. And if you have tried Uber Health,
00:23:26
Speaker
please leave a comment on HST Pathways LinkedIn post. I would love to hear your experience. I don't know anybody who has tried it yet, but would love to hear what it was like if it worked and all that good stuff.
00:23:38
Speaker
In our second story, HIMSS2023 took place last week, and there is all sorts of news coming out of the show, announcements being made. Epic and Microsoft announced that they will integrate OpenAI's upcoming GPT-4 language model into Epic's EHR.
00:23:57
Speaker
The integration will allow EHRs to process and analyze unstructured data such as clinical notes, free text fields, and patient feedback with greater accuracy and efficiency. The goal, of course, is to help clinicians make more informed decisions and ultimately improve patient outcomes.
00:24:16
Speaker
Now, the announcement marks a significant step forward for the healthcare industry's use of AI in clinical decision making. I feel like at least every other week, I'm sharing a story about some sort of AI, artificial intelligence, that is being woven into every facet of the healthcare industry. So this really shouldn't come as a surprise.
00:24:39
Speaker
It still always feels shocking. So the ability to process and analyze vast amounts of unstructured data has been a challenge for healthcare providers, and the GPT-4 integration would help overcome that hurdle. Now, Epic and Microsoft emphasized their commitment to patient privacy and security, which is obviously the number one concern here, and they shared that
00:25:05
Speaker
GPT-4 will only have access to data with patient consent and that all data will be de-identified to protect patient privacy. So, GPT-4 is expected to be released in 2024 and then the integration with Epic's EHR system is expected to follow shortly after.
Major Challenges for ASCs
00:25:23
Speaker
In our third story, according to an article from Becker's ASC, there are four major reasons surgery centers are struggling to meet their margins right now.
00:25:33
Speaker
The first is still supply chain issues. So ASCs are having a hard time.
00:25:39
Speaker
securing necessary supplies, and if they can secure what they need, the increased prices make it difficult to do so in a financially responsible way. Michelle Islander is an administrator in Iowa, and she shared that there are many times that we have to order a higher price item due to the back order of the regular used item. And she noted that it's common that they need to order from multiple vendors just to get what they need.
00:26:07
Speaker
The second will come as no surprise, staffing. Surgery centers spend an on average 2.2 million on employee salary and wages, which accounts for about 21.3% of net revenue. The third is an increase in publicly insured patients. So an admin in New Jersey shared that the increasing number of patients with publicly funded insurance plans, whether that's Medicare or Medicaid, can be challenging from an economic standpoint.
00:26:36
Speaker
This often happens with dietary and orthopedic patients with unexpected implants that exceed Medicare reimbursement for that procedure. The fourth is declining private reimbursement. So ASC leaders are having trouble securing reimbursements from commercial payers that are rising at the same price of inflation. And admin in Connecticut shared that even with inflation running at 5% to 8% currently,
00:27:01
Speaker
commercial payers are only willing to increase contract reimbursement rates by 2% to 3%, which obviously results in margin compression and can ultimately lead to negative cash flow situations. So you're probably thinking, that's great. Thanks for sharing our problems with us. But I thought it was helpful because you might be struggling to figure out where the leak is coming from. And maybe you aren't sure what hidden expenses are actually draining you or industry trends that are causing you
00:27:31
Speaker
to be struggling to meet your numbers. So I just wanted to share what others in the ASC have found to be the root cause.
Positive Story: Virginia's Nursing Program
00:27:38
Speaker
And to end our new segment on a positive note, Valley Health, the Virginia Hospital and Healthcare Association and Shenandoah University are working to tackle the region's nursing shortage through a program that will enhance the training of aspiring nurses and create a sustainable pipeline of new healthcare professionals. I know that is always top of mind for everybody right now.
00:28:00
Speaker
The Next Gen Nurses program, it's called, draws upon the expertise of semi-retired and retiring nurses to help train the next generation of nurses before they leave the profession. The program intends to create a reliable source of new nurses in the Shenandoah Valley. So congrats to everyone involved in assuming the program will be a success
00:28:24
Speaker
Perhaps it can be rolled out in other areas of the country as well.
Conclusion and Call to Action
00:28:29
Speaker
And that news story officially wraps up this week's podcast. Thank you as always for spending a few minutes of your week with us. Make sure to subscribe or leave a review on whichever platform you're listening from. I hope you have a great day and we will see you again next week.