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00:00:01
Mel Gunawardena – What an Experienced RCM Expert Needs to Know
45 Plays7 days ago
Mel Gunawardena is the Co-founder and Managing partner at SYNERGEN Health, and he is here to share with us a few things that every RCM expert needs to know. In this episode, Mel shares essential insights every RCM expert needs to know, including best practices for ASCs, how technology is revolutionizing the process, and the key considerations for keeping RCM in-house versus outsourcing.
In our news recap, we’ll cover a new surgical tech training center, what to watch out for in your payer contracts, a new controversial decision by Anthem, and, of course, end the news segment with a positive story about a new, game changing therapy for people with asthma or COPD.
Articles Mentioned:
Plaza College unveils $1 million surgical tech training center in Forest Hills
Watch Out for Payer Contract Proposal Red Flags
Anthem Blue Cross Blue Shield Won’t Pay for the Complete Duration of Anesthesia for Patients’ Surgical Procedures [Editor’s Note: since this episode was published, Anthem has decided to reverse this policy.]
Doctors hail an asthma ‘breakthrough’
HST’s State of the Industry Report
Brought to you by HST Pathways.
Recommended
Transcript
Episode Introduction
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.
Understanding Revenue Cycle Management with Mel Gunawardina
00:00:28
Speaker
Here's what you can expect on today's episode. Mel Gunawardina is the co-founder and managing partner at Synergy Health, and he is here to share with us a few things that every RCM expert needs to know. Mel sat down with Nick Latz to talk through the best practices every ASC should adopt, how technology can streamline the process, and the pros and cons of keeping RCM services in-house or outsourcing.
00:00:54
Speaker
In our news recap, we'll cover a new surgical tech training center that just opened up, what to watch out for in your payer contracts, a new controversial decision by Anthem, and of course, and the new segment with a positive story about a new game-changing asthma treatment that just came out. Hope everyone enjoys the episode and here's what's going on this week in Surgery Centers.
00:01:19
Speaker
Mel, welcome to the show. Hey, Nick, thank you. Thanks for having me. So Mel, excited to talk to you today about revenue cycle management and some best practices within the revenue cycle management space. Before we jump in to get started, you help us understand from in your view, what's really the high level objective of revenue cycle management? Yeah, I think in healthcare, the healthcare providers are providing services and At the end of the day, they got to get paid for the services they rendered. So that entire process, whether it's a patient coming in and paying cash or whether they have insurance, that entire process of submitting claims to the insurance carrier and collecting those funds, basically following the money for the healthcare provider.
00:02:08
Speaker
is the RCM process in a nutshell. And doing that efficiently and in a compliant manner and to collect the funds that they do is the key component in the RCM operation and process. Right. Got it. So it sounds like getting paid, getting paid in a compliant manner and getting paid on time and in full is the big part of what we're trying to drive here. Exactly. So with that in mind,
00:02:37
Speaker
I want to talk to you about some of the specific best practices chuck yeah from from your perspective and what you said and what was in the market, what are a handful of best practices you think that are important for ASC specifically as they think about their revenue cycle management processes?
00:02:55
Speaker
Yeah, I think there are multiple best practices, but I think it starts from the very beginning where from the time a patient is scheduled, I think getting the right information. So I would say the first thing is getting the accurate information from the referring provider. So one is, you know, making sure that you understand and document procedure or the procedures they plan to do, getting the right and accurate demographic information is very important of the patient or the responsibility party. Getting the right accurate insurance information is important. And then other one is getting the medical records from the referring provider. And people ask us, why do you need that? it's Sometimes ah when the insurance carrier is denying a claim and asking for additional information, ah it's important for you to have those medical records in hand at the time that yeah you are scheduling that patient. So that's very important.
00:03:48
Speaker
Number two, I would say is eligibility. It's important to get your eligibility done. I was watching one of the HSC state of the industry reports and it states that only 78% of the time insurance um is verified. So it is very important to make sure that you're checking for coverage and then also checking for what are the balances, what is the co-pays, co-insurance deductible. So it's important to do that verification of benefits.
00:04:14
Speaker
And although the surgery center might not be doing the prior authorization, usually it's done at the faci the physician level. Got to also make sure that you understand which procedures require prior authorization and you know that, right? Again, this HST data, the industry data report showed that only 24% of the required prior authorizations are being done. So that's a huge gap in the RCM process. So that's something that you as a facility needs to know that as well.
00:04:42
Speaker
yeah And
Best Practices and Denial Management in RCM
00:04:43
Speaker
just to double click on that one, Mel, because 24% is low. right I think we think yeah eligibility is low at 78%, but 24% really stands out. From your knowledge of the process and the gaps that sometimes exist within the process, why do you think prior auth is so low? I don't think the the referring providers know what procedures for which pair do you require prior auth. That's one of the things that's happening.
00:05:11
Speaker
So I think educating that physician as well is important. And you as a facility, at the end of the day, you're carrying the bag, right? And they may be doing the prioritization for the physician side, but that's the same thing that you're using at the for the billing for the surgery. So you need to have your own template. It's best practice is to have your own template ready so that if you don't get a prioritization, you call and and request that before you schedule that surgery.
00:05:38
Speaker
There's definitely an dependency on the provider if there's not a good check and balance because your point that the ASCs aren't doing it, but they've got to have a check within their process to get it. Right. That's right. That's right. and And a couple other items that I would say as a best practice is collecting patient balances upfront with these high deductible health plans.
00:05:59
Speaker
It could be be the difference between profitable cases or not, right? Making sure that you do the estimation. So it goes in hand in hand with the eligibility check, making sure that you're checking ah what the patient balances are and doing the estimates and then collecting those funds up front is very important. And even at least having a card on file that's important. So patient collection up front is very much a key best practice that we state.
00:06:24
Speaker
And then if you go to the next two steps, I would say is getting the claims out. Basically coding is an obvious component, but a lot of people miss components in submitting a claim. For example, putting the prioritization in there could be an issue. And then also if you're doing in implants and if you have excess supplies, making sure those invoices are part of the billing and included is very important. It could be a case of whether you're running profitably or having a case that you're losing money. So it's important to have the right information going every time in your bill. And then finally, I think you've got to have a robust denial management process. And in this case, I would say making sure that you have a denial management playbook. So especially if you have a denial management or or billing team,
00:07:12
Speaker
to ensure that there is consistency in what you're doing and how people are fixing those claims, we recommend that you have and document for each pair and procedure and denial code and remark code, you have a fix that's documented, right? And that you can share with your team so that there's consistency in the way they fix yeah the the claims, that it's accurate and timely. And then you can continue to work through it if it's not working right to improve it or tweak it.
00:07:42
Speaker
So I think those are the main items I would consider best practices. And on top of it, of course, you got to have your reporting and analytics. You got to be able to track everything that you're doing. So I would say those are the key items that I would consider as best practices. Yeah. I love that documentation from a denial management best thus practice. And it seems specificity is important there in terms of the type of denial and and the the next steps that need to happen from that.
00:08:10
Speaker
I got to imagine that processing a lot of volume helps to have that many reps in that many types of cases in terms of the documentation of some of those edge cases. That's exactly right. and I think one of the other key things is that people the method is you know assigning pairs to a certain group of people. so You say, hey, you work the Medicare claims and you work the commercial UnitedHealthcare claims.
00:08:36
Speaker
And the reason they used to do that is that if you're continuously doing working the same type of pair, hopefully you're getting used to it, right? And we are saying, no, let's codify it. So what we've done is we've codified it, meaning we've taken the pair ID, procedure code, dinner code, remark code, and sometimes we even add the diagnosis code and say those combinations There is a fix. There is a definite fix how to do that, right? And if you can document, me it takes time for you to do it. That can be thousands of combinations, but the fixes are maybe only six or seven fixes, right? So determining the fix based on the combination and providing that as a document to your team can be very important and helpful. Yeah.
00:09:17
Speaker
And have you found with your own team, Mel, that once, if you get the fix right across those thousands of permutations and combinations, it eliminates a lot of the back and forth around those denials. Absolutely. Because you could have
Role of Technology in RCM Efficiency
00:09:31
Speaker
multiple secondary denials coming in, right? So you may have to touch the claim multiple times, and especially as an in a client that when you're working with clients that their key thing is they want cashflow, right? And every time a claim gets denied and you work a claim again, it's not the 45 days added to your ref cycle process. So you're denying the, you're denying the cashflow coming into that facility. Yep. Yeah. Okay. Um, the other thing I wanted to circle back with you on, he talked about the claim submission and getting the claim right. And you mentioned.
00:10:03
Speaker
implant and supplies, the documentation and the invoice and getting that on there. And that's something that we've seen with our clients. It can be a pain point and there can be a mismatch in the invoicing process with those claims. Yeah. I was wondering if you could help drill into that best practice a little bit in terms of where did, when it goes wrong, what goes wrong in terms of the implant and supply invoicing and getting that on the claim.
00:10:29
Speaker
Yeah, again, I think there is a, they there are, you could have a claim go out just having the claim information. That means you're coded the claim and you're submitting the claim without the invoice, but you're still getting paid, right? You can get paid for the, for the facility fees, but what you're missing is that high dollar implant or excess supplies that you've used. So.
00:10:52
Speaker
If you don't have a checks and balances, some kind of a method to track it, right? And here's a high dollar claim that's just about to go out, but you don't know that there's a high dollar cost that you just incurred, right? So I think it's putting that process in place.
00:11:05
Speaker
Having, again, that's what I said, having tracking and trending, track that information to see that reporting is very important. Sometimes you may miss it. That could be, if you're doing, if you're a management company processing thousands of claims, you could have one claim go through, but if you have the the information and and you're tracking it, you're tracking things like profitability of a case and reporting on it, you suddenly quickly see that, hey, you're losing money here, right? So that means you miss something. You can quickly go in and do a corrected claim.
00:11:34
Speaker
But I think it's more about having the checks and balances upfront, having that information upfront before you submit the claim to be able to capture that data. So that's that component that we are talking about. And where it's missed is because people don't have the checks and balances before the claims go out. Sure. Okay. That's helpful framing in terms of kind of the best practices through the life cycle. I think oftentimes.
00:11:59
Speaker
you revenue cycle is thought of as a people-based process, a people-based business, but more and more there's there's automation and technology that are playing an increasing role. Can you talk a little bit about that in terms of what role does technology play in the RCM process today? And how does that evolve? Yeah. So technology can play a huge role, I would say in the RCM process, especially with the costs going up now and the reimbursements are not going, I'm not catching up at the pace the costs have been going up.
00:12:30
Speaker
And we also believe that there are three components in the RCM process to work in SING to make it effective. So it's three things. One is what you just mentioned, people. The other one is process and then technology. And from a people perspective, I would say in the last five to 10 years, people have looked to lower their costs by utilizing some kind of offshore operation or leveraging some of that. and It doesn't mean ah it may have been that the costs have gone down, but it doesn't immediately mean that's better quality or better outcome. So technology is very important and I feel it's imperative for you to leverage the proper technology. And if you do that, right, you could have better outcomes and lower costs. And if you look at the entire RSM process, there are so many components that you may be already, clients may be already using, right? For example, eligibility, eligibility checks can be done.
00:13:19
Speaker
But there is a component for coverage discovery, right? So why why does coverage discovery is needed? Because sometimes you may have the primary pair, but you may not have the secondary or tertiary pair that has been captured at the time of registration. So if you have coverage discovery, you can get that information as well, right? So sometimes, or if they have no coverage, you may run coverage discovery and be able to capture that. So that's one thing that you could use the tools for.
00:13:45
Speaker
If you go down that line patient responsibility component, tools like Clarity, where you can load contracts and do estimations, it's very important because it's you know people have ah done so many surveys and seen that patients don't like getting a bill afterwards. They like to know what is expected up front. So having that patient estimation component and having the right tool there, I think is very important in in our opinion.
00:14:14
Speaker
Some of the other tools like coding, the AI assisted coding is now becoming more and more mainstream and maybe not for all specialties, but it's becoming a big component. One to reduce say the cost and improve the accuracy. So these are some of the highlights that things have been working. People have been utilizing. I will also think that.
00:14:38
Speaker
There is a lot of opportunity in the denial management speed. This is where the heavy lifting that's happening. Today, a lot of companies and center billing officers use workflow management systems, but most of those just are used to manage queues, assign claims, and track productivity. But I mentioned earlier that there is denial management playbook. So if you can incorporate it into a technology that's something that we utilize and have the system drive based on those components I mentioned, for example, pair ID, dinner code, procedure code, remark code, and those combinations and have the fix. And based on that, if it's recommending fixes, you can now really drive the efficiency and accuracy. And then if you can also integrate with, for example, a billing platform and do bulk fixes, right? For example, if there's a combination and there are multiple claims that have the same combination, and if you can fix it in bulk,
00:15:38
Speaker
Now you can really drive efficiency. So there is a lot of technology that there that's continuing to evolve. And if you utilize it right with the
In-house vs Outsourced RCM: Pros and Cons
00:15:47
Speaker
RCM in the operations, I think you can really drive that efficiency and the outcomes that you need and also lower the cost overall. I hope lot appreciate that walkthrough and you mentioned AI and and I think it's something that all healthcare technology providers or adding in their product marketing materials and talking about AI enabled. and You mentioned the specific use case around coding. Can you double click on how AI can help with the coding process and what information those AI models can get trained from? Yeah. So for AI, for example, machine learning to work, right? So what you got to do is you you got to help train it. You got to train the system by one is you got to first look at
00:16:33
Speaker
when you do a manual coding, what is what are you really looking at? So from a documentation perspective, what's been documented and how has it been coded manually, inaccurately. So that's one thing that you got to look at. And then once you keep training the data and tweaking it, then as you get this, the for example, a transcription that's there, the that is documented of an op report,
00:16:59
Speaker
The manual way of doing it is reading the up report and then determining how to code it, right? So by using AI, what it's doing is it's reading it. So you're digitally reading it. The system's digitally reading it. It's using machine learning to train the model. And then based on that and based on the historical data, it will now start recommending here are the codes, right? And you can get 95 plus percent accuracy. And if it kicks it off, you can have it go to a manual queue to somebody to review, even the automated ones, you can quickly manually review and submit it. What is needed is, one, is you got to have enough of a large enough data set to be able to train it, right? By utilizing, reading, somebody has read it manually, coded it manually, and then you can use it, the machine learning to learn it. Just like a human learning it, you're using the machine learning to learn it.
00:17:49
Speaker
And then as it runs more and more data, the accuracy level becomes better and better. So AIS is that coding can really drive the cost down and increase the efficiency. And I think there are other areas that even in our dinner management system, we are utilizing AI to look at how the fix is working or not. And it's looking at the data from the back end and coming up and saying, hey, the fix that you made before is not the fix that is paying. So here are some of the fixes that we are recommending using from the AI is coming and saying, hey, here's a fix and I think you got to change the playbook to make the change to have the outcome that you want. So
00:18:31
Speaker
AI can be used in many ways. One is one is in the yeah the coding part that you were mentioning that we were talking about. We're also seeing in the patient side propensity to do pay. You can use looking at things like propensity to pay. Today, the patient collection component is important, but you can think look at multiple data points. That's why you're using, people are using AI here and looking at multiple data points, not your ah credit scores, right? You can have external ah data points and saying, Hey,
00:19:01
Speaker
This patient has the propensity to pay, the patient has the capability to pay immediately. This patient doesn't have the capability. So you can change the model and the method you're utilizing and how you approach that patient when they come in upfront or as well as at the back end, if you're sending a stake. Interesting. So that, or with that knowledge, that might help you set the strategy of when and how to collect payment. Absolutely. ye Yeah. Yeah.
00:19:27
Speaker
Thanks for sharing those use cases. I want to talk about, so specific to the ASC industry, right? A lot of ASCs choose to do revenue cycle in-house. Others choose to outsource RCM to a specialist. And then there's groups out there that are doing kind of a hybrid, right? Using in-person resources or either their own resources for some of the process, outsource resources from some other pieces of the process.
00:19:52
Speaker
is you work with different clients in the ASC industry that are thinking through in-source versus out-source. What do you think are some of the important evaluation criteria and considerations for that decision?
00:20:05
Speaker
Yeah, I would say that's a good question and really depends on the needs and the goals of the organization and the availability of resources and whatever type capability they have in-house, right? Let's say it's a management company, right? And they have a successful central billing operations. They have centralized most of the components. and They have a strong RCM team. And in those cases, then you'd continue to support and utilize your internal team. So you'll have an in-source team. Now, however,
00:20:33
Speaker
that assumes that you have experience management team managing the RSM operations, you have documented standard operating procedures, ah you have established training programs, onboarding staff, ah you have systems to automate and assist, and your costs are low, your attrition is low, and you have a successful scale operation that you can scale, right? So in that case, there's no need to go as outside. But If any of those items are lacking, right so we have seen certain ah management companies who've come to us as well said, hey, you know what? We can't scale, or we don't have the technology, or costs are too high, or attrition is getting too high. In those cases, where you already have some sort of a management team that is doing some part of our same operations, we would recommend a hybrid model. Because
00:21:24
Speaker
They do have some capability within the organization in in, I would say corporate. And you may keep some of those functions internally, for example, contracting or maybe even patient collections component. They may do that. ah Some do their own eligibility checking part of it. So that's some part that they may keep in house. But then the scaling part.
00:21:47
Speaker
Uh, the heavy lifting side is coding submission of the claims did our management posting can be done from an external team. So in that operations, you could use a hybrid model. So that's when we see the hybrid model working pretty well. But if you're a
Tracking KPIs for RCM Improvement
00:22:04
Speaker
standalone center, right? So if a physician groups that come in and said, Hey, you know what, I want to kick off a facility or a few, they have a few facilities, they're adding a new facility.
00:22:14
Speaker
They don't have the resources and they don't have the technology. I would recommend that they utilize an external company, the right company to work with because they have the technology, they have the team, they can scale up. Also in those cases, as you're scaling up, right? the If you have your internal team, your cost is fixed or quite, you're you're carrying a heavy cost, right? And in the outsource model,
00:22:43
Speaker
Usually it happens on a contingency fee basis, that being meaning it's charge you're charging on a percentage basis. So as you're ramping up your revenue, your fees are also ramping up slowly. right It's not a high cost at the beginning. So in those cases, I would say the outsource model works, whether it's a single facility or a few facilities, they're adding a new facility, I would say outsource model works. Now, if a management company determines that, Hey, we don't have a centralized operations. We have a distributed model where it's independent centers running their own billing teams yeah and they don't have that model. Then an outside operation could be an option, but we, so we feel for the right management company, a hybrid model works best. Gotcha. That's helpful to think through the different decision factors there. What what about independent centers that have
00:23:42
Speaker
in-house people doing it today, right? And are evaluating, Hey, can I get better results from outsourcing? Both from a revenue perspective and or potentially a cost perspective. How do you, and that can be a sensitive discussion, obviously, because there's people in place, but from a, just from a business, let's just think about the business side of it. What's the best way to evaluate, Hey, what's my revenue performance?
00:24:08
Speaker
What are those metrics to look at to help determine if you might be able to do it better a different way? Yeah, I think one of the key things is you got to do an assessment, right? I, I, we recommend, uh, doing an assessment of on a client or group that is looking to see how are they doing just being in the healthcare industry. Right. So we doing a health check is normal, right? It's the obvious things. So for the physicians, we may feel great, but we don't know whether we we are doing well or not. That's why we do all this the test.
00:24:38
Speaker
I would say to do a RevCycle assessment. there's An assessment can be done that will look at things like your days outstanding, your total AR, things like paid claim percentage, your bad debt, then your collections percentage of net revenue. There are a bunch of KPIs that you can look at, net revenue per case based on your specialty.
00:24:59
Speaker
denial trending, where you're at. So you can benchmark. There are companies that we can, we recommend our clients before we even engage a client. We always do a benchmarking and that I think is important. So if it's a facility that doesn't know how well they're doing or not, i we we recommend them for them to do, we recommend that they do an assessment at least once a year to see whether they're leaving money on the table.
00:25:22
Speaker
And based on that, you'll see where the opportunity is, right? Is it a question of, is it a coding issue or is it, there's people are not working that in our management properly, or is it a contracting issue? They've not, they've not done any contract renegotiation in the last two years. If you have not done something contracting, reintegration for the last two years, there's definitely an opportunity there. So it's a question of where it is. And then determining whether you outsource or not, I think again, it depends whether the team internally has the capability to do that, right? And it is very sensitive, but at the end of the day, if you're not running profit profitably, then you and will not have operations. You and may not have a center at all. And I think in those cases, depending on the company that is working, you could have a company come in and say, Hey, you know what? We'll provide part of the services and you provide the other part of the services, right?
00:26:19
Speaker
It's depending on how much you can leverage of your internal team and how much can you can leverage of the external organization. sure So your assessment is very important. Got it. Love that. Okay. Now, final question for you here. and This is one we do each week with our guests. What's one thing our listeners can do this week to improve their surgery centers? Yeah. So if there's one thing that to be done, I would make sure that they're tracking and trending and reporting the most important KPIs for the RSM operations. and ah We believe in the statement that you cannot manage what you don't measure. so It's really important that you're tracking your data. so As I mentioned earlier, ah some of the KPIs are sales outstanding, the DSO, total they are, and over 90 days. it's It's a good benchmark to look at. Paid claim percentage, bad debt percentages, collection percentage of net revenue, and then denial trending. right As a percentage as well as trending, you've got to be able to trend it to understand what the root causes are.
00:27:18
Speaker
And then finally, profitability per case. It's really important that you are tracking and trending that information. And I would say by measuring, you can really determine the root causes and focus on the areas that you may be having challenges. And then based on that, you can really transform your same operations. Fantastic. Thanks so much for joining us, Mel. Thank you for having me. Thanks, Nick.
00:27:42
Speaker
As always, it has been a busy week in healthcare, so let's jump right in.
News Recap: Surgical Tech Training and Policy Updates
00:27:47
Speaker
Plaza College and Forest Hills celebrated the opening of its state-of-the-art certified surgical technologist simulation operating room on November 15th.
00:27:58
Speaker
This million dollar facility is the first of its kind in Queens, and it's designed to replicate the working environment of New York City's top hospital operating rooms. The new Learning Center aims to address a critical shortage of surgical techs in New York City, a problem that affects hospitals and surgery centers' ability to meet the rising demands due to high turnover and just low awareness of the profession in general.
00:28:22
Speaker
The program's inaugural class of 20 students will receive hands-on training in healthcare sciences, surgical techniques, and clinical practice. Graduates will earn an Associate of Applied Science degree and a national CST certification.
00:28:38
Speaker
The ribbon-cutting event drew leaders from 11 major hospitals, underscoring the program's importance to the healthcare industry. Students praised the immersive training environment, calling it essential for mastering the precision and teamwork required in surgery. Plaza College Provost Charles Callahan IV emphasized the program's commitment to addressing the personnel shortage, while also providing career opportunities for Queen's diverse community.
00:29:05
Speaker
Now with staffing shortages impacting surgery centers, this program will expand the pool of trained surgical techs, which will hopefully have a downstream positive impact. And hopefully this facility is a success so that others around the country can follow in their footsteps and we can start to tackle or continue to tackle the staffing shortage problem.
00:29:25
Speaker
Alright, next story. In the November-December issue of ASC Focus, Rob Kurtz wrote a great article sharing some red flags to look for in your payer contracts. The article really stresses the importance of scrutinizing contract language and pushing for favorable terms.
00:29:41
Speaker
So one key area to review is payment updates. So Brandon Fazio, who is the Senior Director of Financial Analysis for ASCs for Community Health Systems, advises ensuring contracts linked to Medicare percentages include provisions for annual rate adjustments. Without this, reimbursement may lag behind Medicare's updates.
00:30:03
Speaker
Susan Mayuski, who is the chief operating officer at Bedford Ambulatory Surgical Center, warns against multi-year agreements which can delay coverage for new procedure and specialties. Contracts should also clearly define the mapping of procedure codes into payment groupers as missing details could obscure ah reimbursement rates.
00:30:24
Speaker
They also shared two other gotchas with rising supply costs and stagnant reimbursements. Mayuski emphasizes the need for implant carve-outs to cover expenses, and then Fazio highlighted trends where payers assign low default rates for non-Medicare covered procedures, potentially making them unprofitable for surgery centers.
00:30:46
Speaker
And obviously, mastering contract negotiations is vital for surgery centers to maintain profitability and sustainability, addressing problematic clauses and securing favorable terms. will allow you to protect your surgery center's financial health in an increasingly complex payer environment. And lastly, our podcasting for the month of January, 2025 is going to be all about payer contracts. And we're going to cover how to really get in sync with your payers and even stay one step ahead. How to leverage data in your contract negotiations and a lot more nuances that go into managing contracts. So this is a sticking point for you. Make sure you catch those episodes starting January 7th.
00:31:26
Speaker
Okay, third story, Anthem Blue Cross Blue Shield has announced a very controversial new policy affecting patients in Connecticut, New York, and Missouri. It will no longer cover the full duration of anesthesia for surgeries that exceed an arbitrarily determined time limit. This decision, condemned by the American Society of Anesthesiologists, as you can imagine,
00:31:50
Speaker
could leave anesthesiologists uncompensated for critical care if surgeries run longer due to complications or other factors. Anesthesiologists play a pivotal role in patient care, tailoring anesthesia plans based on individual health needs, managing unexpected complications, and ensuring patient safety throughout surgery and recovery.
00:32:11
Speaker
Payment for anesthesia typically considers the total time required from preop assessments to recovery transitions. And under Anthem's policy, bills exceeding this preset time limit will be denied regardless of medical necessity or circumstance, which is frankly unfathomable. I can't imagine being an anesthesiologist knowing ah How do you balance what is in the patient's best interest but also about your time like your time and getting paid for your expertise? So it's super bizarre. um Dr. Donald Arnold, who is an ASA board member, called the move a cynical money grab, accusing Anthem of prioritizing profits over patients.
00:32:53
Speaker
This policy undermines trust between Anthem and its policyholders who expect their insurance to cover all essential care. Critics argue that the policy not only jeopardizes patient safety, but also ah penalizes anesthesiologists for providing comprehensive care.
00:33:09
Speaker
So this policy could significantly impact surgery centers where timely and safe anesthesia is critical. We just reported two weeks ago on the results from ASCA's 60-second survey, where the majority of ASCs finally said that they were in a good place with their anesthesia contracts and felt like they had adequate coverage. But now with this, ASCs may face increased financial pressure if anesthesiologists refuse to contract under these terms, which will lead to delays or complications in patient care. Anthem's decision also adds a new layer of complexity to payer negotiations, emphasizing the need for surgery centers to advocate for fair and patient-focused policies.
00:33:48
Speaker
Again, this only for now impacts Anthem in Connecticut, New York, and Missouri, but I would imagine that we can expect it to expand. and The ASA is urging patients and providers to voice their concerns to state insurance commissioners and legislators, and we can only hope that other payers will see the backlash that Anthem is receiving and do not follow suit. We will definitely keep a close eye on this story and how it evolves and share any updates. but I also want to echo what the ASA is saying.
Innovative Asthma Treatment
00:34:19
Speaker
Let's all voice our concerns for this and how it could truly impact patient safety. Okay, and to end our new segment on a positive note, researchers have developed the first new treatment for asthma in half a century, offering a potentially game-changing therapy for people with asthma.
00:34:38
Speaker
In this study, the drug Benralizumab, now I got that pronunciation from YouTube, so please forgive me if I've totally butchered that. I'll put it in the episode notes and you could see how it's actually pronounced and spelled. But this drug was found to be considerably more effective at easing asthma attacks than the current steroid tablets. So it's administered as an injection, and when it was, it reduced the need for further treatment by 30%.
00:35:04
Speaker
Asthma and COPD cause an estimated 3.8 million deaths per year globally. So treatment for both conditions have unfortunately barely evolved in the last 50 years, but hopefully that will change with this new study. And the study lead, Professor Mona Baffedel.
00:35:21
Speaker
from King's College, London, said, we hope these pivotal studies will change how asthma and COPD exacerbations are treated for the future, ultimately improving the health for over a billion people who currently live with asthma and COPD across the world. And that officially wraps up this week's
Episode Conclusion
00:35:40
Speaker
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'll see you again next week.