Becker's Spine Review

18 PRACTICE MANAGEMENT 6 Biggest Revenue Cycle Challenges in 2017 for Spine, Orthopedic Surgeons By Emily Rappleye T his year brings new revenue cycle challenges for spine and orthopedic surgeons, according to Lisa Rock, president of National Medical Billing Services. Luckily, with a little foresight, providers can correct course and avoid losing revenue. At the Becker's 15th Annual Spine, Orthopedic and Pain-Management-Driven ASC Confer- ence in Chicago, Ms. Rock outlined the top pit- falls providers currently face in revenue capture. Here are six things to watch out for this year. 1. Insurance verification. Providers need to understand who is paying their claims at the time of patient registration, according to Ms. Rock. She advises pulling the automated eligibility sheet to identify whether the patient is fully insured or self-funded — direct-em- ployer contracts are considered part of the self-funded group. "If it is a self-funded pa- tient, we need to understand who the employ- er is because they are paying the claim, and they can change the way they pay the claim frequently," she said. Other items to watch out for during the insurance verification process are tiered or narrow network plans — among both self-funded and fully insured patients. 2. Coding. When working with vendors, Ms. Rock advises getting a second opinion on re- imbursement codes to ensure the products are actually reimbursable. is is an issue particu- larly for implants. Ms. Rock said she sees reim- bursements for some implants are coming in at 50 percent of the bill charges. "e contracts I'm seeing today are scary," she said. "You can't sign a contract like that. You are going to lose 50 per- cent of cost on your claim." She also advised pro- viders to stay up-to-date on payer policies and staff education to reduce the number of denials. 3. Narrow networks. While narrow net- works may be nothing new — there is a new breed to watch out for, according to Ms. Rock. ese are the employer-direct contracts, which she is seeing crop up all around the country. And as quality and cost information becomes increasingly public, employers have the deci- sion-making power. Employers looking to cut costs are striking deals directly with narrow networks of providers who can offer the best quality care at the lowest price. "You should re- ally have your ear to the ground in your neck of the woods so you know what's going on," Ms. Rock said. "You don't want to be in situa- tion where your competitor just did a deal with a major employer group and you are out." 4. Narrow network language in con- tracts. Providers who want to set out and strike contracts with employers on their own would be wise to take a closer look at their con- tracts with major health insurance carriers, ac- cording to Ms. Rock. Noncompete language is oen baked into the text of contracts with these carriers, she cautions. One such contract forbids providers from engaging in "activities that cause loss of potential members," she said, and in- cludes a 12-month wait clause aer termination of the contract. However, this doesn't mean pro- viders can't strike employer contracts; they just may not be as direct. Ms. Rock suggests work- ing with an outside company to manage those employer contracts, so you are not a "direct competitor" to your payers. "ere is always a workaround to these things," she said. 5. Bundled payments. Bundled payments are the fastest growing value-based payment model, Ms. Rock said. And while bundles aren't new, they are newer to the ASC industry. She advises ASC providers to again look carefully at the language in their major health insurance carrier contracts, where they may find they have agreed to work with a bundled payment com- pany. In these cases, spine and orthopedic sur- geons are given a list of cases they must contract separately for with the bundled payment com- pany. ese contracts are oen unsophisticated and disorganized — in some cases they have gone back to faxing claims or asking ASCs to write checks to other providers who participat- ed in the bundle, according to Ms. Rock. 6. Patients as payers. e growth of high-deductible health plans, employer con- tracting and greater out-of-pocket costs for consumers means providers must look at pa- tients as true payers. "It's something we can't ignore anymore," Ms. Rock said. To start, pro- viders should begin developing sound internal collections policies for patient payers. ey also should be sure to stay up-to-date on laws that affect patient billing, such as surprise bill- ing laws. ese laws offer patient protections regarding in- and out-of-network billing. ey protect a patient who undergoes surgery at an in-network hospital, for example, from getting saddled with an out-of-network bill because their anesthesiologist wasn't in-network. For providers, these laws dictate their payment rates. In California for example, health plans pay out-of-network physicians 125 percent of Medicare rates, Ms. Rock noted. n Rothman Institute Merges with Trenton Orthopaedic Group: 4 Key Points By Mackenzie Garrity P hiladelphia-based Rothman Institute merged with Trenton Orthopaedic Group in Mercerville, N.J. The new group will be called Trenton Ortho- paedic Group at Rothman Institute. Here are four key points: 1. The merger took effect September 2017 and adds four offices and 14 phy- sicians to Rothman Institute. 2. The new centers provide services across various subspecialties, including joint replacement, spine, back and neck, sports medicine and orthopedic trauma. 3. In 2017, Rothman Institute signed a strategic affiliation in April with New Hyde Park, N.Y.-based Northwell Health; partnered with Bryn Mawr (Pa.) Hos- pital to open an orthopedic ASC in June; and partnered with Capital Health in May to develop orthopedic centers of excellence. 4. Rothman Institute CEO Mike West said, "[Trenton Orthopaedic Group has] an exceptional standing in the Central New Jersey market and surrounding areas. We look forward to building on the high quality care the group already offers, and for continued growth in the future." n

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