Decoding Managed Care Contracting

welcome everyone to today’s program I am Kari power T with Becker’s healthcare the program will begin with the presentation and we will have a question and answer session the silent completion of the presentation you can submit any questions you have throughout the presentation by typing them into your control panel and the space labeled enter a question for SAS and clicking sent our presenters will attempt to answer as many questions as they can during the time we have and will follow up on questions they do not have the opportunity to address you’ll receive an email within about a week selling the webinar that will include instructions for how you can download a copy of the presentation you’ll also receive a follow-up email shortly after completion of the program you can submit your feedback or any additional questions at that time this email will not receive the presentation it is now my pleasure to introduce today’s presenters since 2003 Lisa rock has served as president of national medical billing services one of the largest ASC billing companies in the country Lisa is a seasoned healthcare management veteran with over 25 years of experience in the industry her wide-ranging background consists of positions such as director of training and education for the largest regional payer in the mid-atlantic area for seven years and vice president of business office operations for an ASE development and management company for two years she has also managed private practices in the specialties of orthopedics retina surgery cardiology and anesthesia early in her career Lisa worked in the O R and PACU in Northern Virginia her unique knowledge of healthcare management provides national medicals clients with the tools and information they need to most effectively run their facilities admits a highly fluctuating business of medical billing and complaints Scott Allen join national medical billing services in 2008 and is the vice president of managed care contracting he manages all aspects of ASC managed care contracts which include analysis of language and rates contract audits and developing best practices from dementing standard operating procedures for the managed care contracts throughout the revenue cycle Scott is heavily involved in ASC industry through a variety of advocacy roles he serves on the peer relations committee of the Health Care billing Management Association and has lobbied on Capitol Hill for the ambulatory surgery center Association Scot is also a frequent contributor to industry publications writing about managed care contracting and other ASC topics Scot earned a BS in political science to a st. Louis University it is now my pleasure to turn the floor over to Lisa Rock to begin today’s presentation Thank You Kari let’s go ahead and start on slide two chargemaster review we’re going to discuss the multiple ways that charge masters are being created and managed we’re going to discuss how payers define certain items in a contract with respect to surgery center coding zone we’re going to discuss how this impacts the revenue cycle in terms of claims mission and reimbursement and we’re going to give you sort of some detailed inside information in managed care contracts as it relates to the revenue cycle on slide 3 let’s talk about setting a charge master first in order to properly set a charge and after we want to understand how our current charges are being reimbursed so we’re going to not do the typical thing and lay out the spreadsheet by cpt code and you’re allowed amount by payer but instead we’re going to group the cpt codes by case and look at your taste rate allowed now and so you’re going to take a group of CPT codes for example E&T might have five or six codes and then you’re going to layer the contract on top of that do your top ten cases first start there and find where your reimbursement falls or you’re allowed amount full with the case rate and not a buy CPT code rate it’s the biggest mistake that we see in analyzing current charges so now we’re ready to set our charge master we know that perhaps some of our charges fall below a lot amount in terms of the case so we’re going to want to increase our charge master and there are limitations on increasing your charge manager which I’ll talk about in a second but let’s talk about how how we’re going to set a charge master so there are multiple ways right now you can use a multiple of Medicare which is sort of been the case for majority of surgery centers in this market for the

last twenty years using a multiple of Medicare works most of the time where you don’t have a Medicare crosswalk then you would come up with a different methodology for that particular case or code you can also use Fair Health Fair health.org has some good information for surgery centers and you can get an idea of your particular area by going onto their website and and understanding that most of the data there is H OPD but still if you’re working in the you know 50s 60s 70s percentile you’ll probably be for the majority of cases in line with where you should be setting your charges the other option is to use state collected data to come up with your charge master and it’s very common to use a combination of these three so from a coding and billing perspective when you’re appealing it is a little more difficult to appeal to a carrier for additional reimbursement if your out of network for example if you’re using Medicare as a benchmark because they will too when they adjudicate your claim that’s a separate discussion but it’s good to have a solid methodology for calculating your charge master so so now we’re we calculated the charge master and we’re going to apply cases again and we want to make sure that we take cost into consideration too because some of your contracts are not going to cover very expensive implants or multiple procedures and and so we need to understand what the cost of doing those procedures would be before we set the price now once you’ve analyzed your contract if you find that you’re falling below a lot amount and you need to adjust you have to read all of your contracts to make sure there are no limitations one contract and limit your ability to increase your chargemaster across the board and so the payer may require notification they may have a certain time period for you to notify of a chargemaster increase and if we go to slide 4 we’re going to talk about something else that we’re seeing in your charge master increases so let’s say you analyzed you have a methodology methodology inline and now you want to increase this is an example of a contract with language that states that you are allowed to increase your charge master no more than 0% in addition if you look further in this little paragraph you’ll see that we can’t fragment and what that means is what we’ve done for many many years in this in this space is if we have limitations on increasing our charge master well we will simply do a revenue-neutral increase will increase our more frequently performed procedures and will decrease others that you really don’t see high volume on and therefore if we have a percent and build in our contract because a lot of you still do then this is an increase automatically well this language states that you can’t do that you can’t wide item increase so any line increase would have penalties if we go to slide five this is an example of language in a contract today’s contract that shows the penalty which is ambiguous interestingly enough we’re going to look at a contract that has a 40% discount off of billed charges and if we adjust our charge master more than the allowed five percent then the carrier is going to take an additional discount in this case it’s a revised discount of 43 percent and the language in this contract states that if the carrier will apply this similar methodology as a penalty and again ambiguous language but if there Scott

did you want to add anything to this I just want to point out it thinks that you know we’re seeing a lot of providers not taking advantage of these charge master increases you may be about 5% annually and you have an increase your charge master for three or four years so make sure you understand the contract may be able to compound that and you know stack up those annual increases and then do one lump sum for say 15 or 20 percent so I think that’s a really good point if you are allowed a five percent increase and the other contracts do not prohibit you from that five percent increase and you haven’t taken advantage of the five percent increase say in four or five years if the contract does not specifically state that you are not allowed to stack then you can you can stack those increases so whether you want to do it or not is up to you but you do have the opportunity any any improvement in your contract right goes straight to the bottom line trout changing anything so we would by taking a look at this contract that’s already in place and if you have a percent of billed reimbursement methodology and again what have you do then again this increase will go straight to the bottom line all right on slide six carriers will put in the contract or in their online provider manual specific language on what they consider to be a clean point and what’s interesting about this is before those pairs that fall under HIPAA we’re using standardized transactions and code sets but for for carriers that are exempt from HIPAA you may be required to build with homegrown codes or something that’s out of the norm and it may not be specifically defined in clean claim language if there is clean clean clean claim language there but you definitely want to read this piece because the carriers will specifically tell you if they consider a 1500 a queen claim or a UV form a clean claim or both and a good story we have there would be a large payer actually per contract stated they could you could fill with either the UV or hexa and what they were doing was the nine coming up on for claim form Tyson and so I think it’s important to make sure that you clarify that within your contract well in addition let’s say your carrier in the contract requires you as a facility zu zu be form and your claim is loaded in the system as 1500 your clean we’ll still get paged probably but most likely be reduced to a professional reimbursement and so starting at the very beginning and reading your clean claim language whether it’s in the contract or in the provider manual which the contract will follow then you need to check and make sure that your software system is properly set up for the correct claim form all right slide 7 and we talked about the 1500 vs. the duv but interestingly we’re seeing this a lot look at once you lose a third sentence down claims may be subject to standard claims editing software to detect bundling and unbundling all right as far as I know there’s only one national edit system and that’s the National correct coding initiative there is a mcKesson’s product claim check which is utilized by the Blues most of the blues most of your major payers are going to use one of those primarily we see the national correct coding initiatives being used but if you allow language like this in your ASC contract you are now subject to whatever bundling edits the carrier deems are appropriate so if they feel

the carrier feels that procedure B is inclusive to procedure a but it is not considered bundled by CCI or McKesson you’re kind of stuck you have no recourse because you allowed very vague language to dictate what’s payable and what’s not and believe me when I tell you that little line in there is used often to deny claims yeah we’re actually seeing a lot of this with the pricing companies large pricing companies initials you know MP they actually have language within the contract now that allows them to edit and bundle per Medicare so if your current contract pays percentage of billed charges that they 80% of billed charges and you’ve been receiving those payments their education system has just recently allowed them to start taking the MSR discounts so check your contracts section 5.2 B it may be a different section but it’s definitely in there so that’s interesting and across the board something note if your contract is a percent of bill and you’re used to getting a percent of bill know that now payers are beginning to enforce or add language to contracts and allows for multiple procedure discounts in a percentage of build environment so if you’re negotiating a contract and you’re still able to get percent of building in some areas you are depending on the competition market then I would recommend that you address the multiple procedure watch and percent bill also something else that we want to mention on this slide is that carriers will dictate to which revenue code your youth which modifier you were to use and and again some homegrown codes those that are exempt from the standardized transactions and code sets and you might think you’re supposed to be using a modifier because that’s what the rest of the world uses or particular revenue code for implants and that one little change if you read this contract will make all the difference in the world yeah I think one more thing here to point out this last line lisa touched on this earlier would be you know contracts do state you’ll be paid lesser of the to the bill charge are the rate per contract so it’s so important make sure you have complete copy dude I’m trying to understand them very thoroughly well that takes us to flight so having complete contracts is critical for you to do good and you have to read every part of it you’re going to have to understand product participation so what am i signing am i signing the HMO PPO the Medicaid replacement plan the Medicare replacement plan workers comp or even seeing motor vehicle insurance is coming a contractor coming along and so you have to understand what those different products are because the carrier is receiving a higher premium dollar for the richer plans and so you want to make sure that if the carrier is receiving a higher premium dollar but that’s passed down to you as as an ASC so for example I would have a fee schedule for my PPO I would have another one for my Medicare replacement plan and I would have another one for workers comp whatever and so understand what each product is and if you’re getting one lump sum for all the products I would say the carrier probably has a really good deal yeah and in the work type area is when we see a lot is the payer taking advantage of providers and will happen to give you contract and well you know what let’s do I go two months like nine and yeah I’ll hit with your so goal will send you no contract over it’ll it’ll have multiple products and it will be a large commercial payer but love a work comp prize in there and they’ll say for this slide they’ll say you know we’ll pay you 90% of the state allowed fee schedule and you know the problem of that is you’re not receiving any direction of care the payer is only taking that and selling it as a discount so those are pretty easy to get take it out but like I said you have to understand it and you know okay so we see this not just in workers comp not

just in that product but we see this counts in Medicare Medicare bands product so where you might say well you know what I’m getting makes your rape so it’s a given cake well if your contract is 150 25 you’re no longer at Medicare rates you’re below Medicare so you have to do all of that math prior to signing a contract so you understand that whatever rates you have for Medicare or Medicaid replacement plan actually mirror what you would get straight from those pairs oh by the way this is a 10% discount this example that we we have ramps like nine but we’ve seen as high as a 30 percent discount off the state fee schedule and something that you have to be in some states don’t have work comp II schedules in place actually the pair will try to use the Medicare methodology or group of methodologies to reduce your rate even further so the states like Wisconsin don’t have a set rate or what I’m now on slide 10 this is important for out-of-network surgery centers in the professional contract the surgeons contract surgeons may be required to notify um through prior authorization the payer when he or she will be taking a case to an out-of-network facility and if your operation is one that the professional side obtains the pre authorizations for the professionals and the facility the carrier may not tell you that the facility is out of network and therefore requires an authorization because that procedure in network doesn’t and so with carriers now getting very tight on retroactive authorization it is critical that your staff understands out-of-network procedures many times require us where in network do not so if you have that situation with a pro referring to an out of network and the pro is doing the due diligence for both offs then you’re going to have a problem Jenna group make sure people yeah they just delay in hoarding the other you know front end right now and so huge to make sure we get everything in place and make sure you’re accurately taking you know down the insurance type you identify what plans are going to exchange plans and you arm your front desk with these contracts so they know you know what things are going to pay before in climbing that’s a really good point the exchange products are identified usually by some kind of a metal gold silver front and then the other way the carrier’s identify the exchange products before you is on their member ID card there are specific prefixes typically to go on the cards again understanding what those prefixes are by payer you know would really help to you can go on the state website and get a list of the pair’s participating in the exchange products and and then you can educate your front desk on how this works with exchange products because you may have a different rate for exchange products in your contract and the large commercial payers actually let you go online on the website and extract the information or email your prior to rep so there was a little sidebar if we go to slide 11 we have a number of issues that can affect contract coordination of benefits one you have to check with state laws on this particular issue so for example if a guy who drives a dry-cleaning truck is delivering a product and someone hits him but we find out he was driving drunk well we have an issue who’s responsible for paying the claim and your state all will have specific subrogation information for you on who’s responsible for paying whether you have to wait or typically what we see as a pay and chase so if you’re under contract then the private payer would pay and then wait to see who’s responsible and then notify you and then that’s when the recoupment or offset would begin but typically the private payer would have to notify who that is and then you will have a certain period of time to refund that which is

not a lot that’s a good point I think is some payers will allow you any recourse you know we have contracted States you know they can just start recouping money right away without any type of formal letter or anything so it’s important to know that section in your contract read it understand it because it’s going to apply to adjustments recoupment offsets going forward right most of the time I’m going to be asking most of the time I see recruitment of any kind other than coordination benefits there they’re getting a fight this isn’t why you have to earn your pay posters with with the contracts they got a post per contract because you know what’s happening is we’ll just put this on the EOB so retracting money and you don’t know it if you’re espousing pro-v interesting that timely filing should be at a minimum six months we continue to see contracts with timely filing with 30 days now with motor vehicle accidents there are several states that have states that have timely filing for motor vehicle insurance so your GEICO’s and naturally listed primary in your billing system you letter exhaustion they extended to the to the private after that which should be listed second in your billing system but many states have a three-day timely filing limit on those benefits so so that’s not anything you can override Channel two state law but I think with forcible contracts obtains tele filing and also transmission it’s pretty easy you guys moved up or down wherever you need to do so on slide 12 we were talking about timely filing and what you want to be careful of is that if your state allows a certain period of time you want to make sure that your contract doesn’t extend our partner short in that time yeah and pendrives will also state how they want to just mythical name do they want to do a percentage like electronic they wanted to do all Ektron ik male we have some instances where trailer billing so just there’s all kinds of different okay trailer trailer billing for those of you two dogs you know what that is it is when the carrier requires you to submit the facility fee by itself pay and then you take that you be submit another claim form with the implant if applicable and that goes in separately it’s bizarre I know but some contracts have trailer billing so if you have denials on your implant unlikely this is the problem but it could be it’s very it’s not typical for my reasons you have to feel free to send any questions over you know that usually it happens on the East Coast okay we’re going to skip to slide 14 and if you look at the first paragraph and I think it’s the third sentence payer may change its payment policies from time to time and in the event that the payer changes a payment policy the payer will make available the information describing the change that doesn’t necessarily mean then tell you it means that it’s probably going to be loaded in the provider manual and none of us have time to comb through changes in provider manuals on a regular basis but understand that the carrier’s do have the power to change your payment policies and that can mean anything but it typically means medical necessity and changing a required diagnosis in order to support medical necessity for a reimbursement and you have to really watch this one because if you notice a change and again the person that’s going to notice this changes your payment poster they’re going to see it firsthand on the EOB so they have to understand the contract and we’re not suggesting that you are am your entire billing staff with contracts but someone has to go through and read this word for work who understands revenue cycle and contracts and come up with a matrix matrices to or cheat sheets for the entire billing staff to follow so that they can discover changes like these which are really hard to discover by the way I’m challenged to with it and I’ve been doing this

unfortunately 125 years 35 years of units and it’s still very difficult to stay on top of all of these changes nevertheless if you are seeing a reimbursement change either a reduction or a denial you don’t typically see that you have to figure out why and that is to go and you need to go on the payer website and and find out what it is but again it’s usually a medical necessity change could be a nos change too as Carrie mentioned earlier at the beginning I work for a carrier or a large one for a long time and we would come up with a list of items that require pre-authorization a separate list for notification and notification is very different than relation and and typically you see those offs on on frequently performed procedures so we would run a frequency report and top ten you know we would start putting off son so 20 years ago that would have been hysterectomy 15 years ago or so it would have been carpal tunnels and so on and so forth and so you have those odds requirements and then once you watch the data come in you make a decision whether you want to continue requiring that to be us or not so that that list changes every month can’t a can change every month so just because something requires an off today doesn’t mean it’s going to require one next month conversely right if it doesn’t require one day it may require one next month so you really have to call all the time and find out what these changes are you have to know where it’s going to be listed in your contract it has complete contracts on file and I’ll be honest with you we do a number of audits all over the country and I would say you know 70% of the time providers don’t have complete copies of contracts fee schedules they don’t know that the provider reps are or you know will receive just a cheat sheet on the rate like I said at the very beginning that first life you cannot look at ASC reimbursement by CPT code you just can’t now if you’re an eye surgery center okay but if you’re an eye surgery center and you want to add another specialty you’re going to have to look at the case and you’re going to have to look at and again it’s looking at your contracts in a very different way so you may think that you have two hundred percent of Medicare you take that contract and how it is due to case claim whether it’s two procedures or five procedures and your implants and you take that performed case and lay it on top of every single contract you have I think will be I openin for you many many times we are very surprised to see rates as low as twenty five to thirty percent of Medicare you can’t survive on that and carriers want to work with you they want to move business from H OPD to a surgery center it is more cost effective it really is but if you don’t know your own numbers they’re not going to hand it to you on a silver platter item so you have to understand the political environment as well is the local hospital a local hospital or is it one of 135 hospitals that changes your negotiating power just a little bit so just understanding all of those pieces while you’re negotiating your contracts is critical all right I’m page 15 same thing alright we’ll go to page 16 and jump right to page 17 interestingly you do have accreditation and licensure language in your contract typically do and in this case the example shows that second paragraph Joint Commission on Accreditation Valkyrie with Jayco and or pretty much anything that falls under Title 18 of the security actives nice to meet you so we’re okay with whatever accreditation we have here we have to have one or we don’t get paid I’ve seen contracts with specific accrediting agencies listen here so just be careful because we have seen that not too often but we have seen a triple-a and they wanted Jayco or Jayco and they went triple-a and and it’s old language and you can usually fight it and when nevertheless I would make sure that I had something that

tailors whatever Surgery Center whatever your compliance credentials are alright 18 you want to talk about your terms yeah a term structure I mean this base is pretty basic stuff just knowing you know how long the initial term is of your contract and if it will auto renew going forward I think one of the most common questions I get would be you know can I renegotiate during the term can I get carve out that is my contract I designed this last month you know and that’s that’s a tough question it’s going to depend on a lot of different variables I think if you have good leverage and you maybe a new provider you can even get that worked in but a lot of times these terms are set in place for reasons they want to lock you in for a two-year term and right and that’s that initial terms also possible to get out of though now if if I have added a new specialty all right I can call the carrier and work with them and and if they’re if they’re good and they understand that you have a new cell assay or an eye surgery center you’re bringing on a retina that’s a different specialty and my current contract doesn’t accommodate that they have to work for me or work with me here because I want to bring these cases from hospital to the services oh you make that argument you should be okay but if the carrier gets you to sign a four year initial term they’re probably pretty happy with the deal just so you know the other phase look I see would be you know having some sort of escalator built into that contract so it does renew either you get you know 5% 10% annually increase all right we’re going to go to slide 19 because this is the reason why ASC billing and contracting is so difficult it’s different than in hospital and it’s different than pro or ancillary services going and this is why because our reimbursement methodologies are all over the place we have groupers 2004-2007 a lot of folks to come from the professional side or U star V RBS and there’s a reason for that and there’s a reason why it was developed back by the doctor Chow Harvard study all those many years ago back in the 1980s I remember when it happened and ASCS were reimbursed on like eight groupers back then and something like a tonsillectomy was ungrouped because the elderly simply didn’t have a tonsillectomy so there was no reason for Medicare to grouping so what carriers started to do is move those ungroup o–‘s into their own groups and they and they thought you know what we can do this too without the high volume procedures so I’m going to take this Medicare Group four and I’m going to move it to a tree and so you have to if you sell group of contracts you must cross watch your groupers to Medicare so you can see where they fall we have a percentage of build still in existence especially with implants and depending on the part of the country that you’re in we still have ambulatory while we still have because groupers switched over to ambulatory payment categories I want to say – no no maybe five or ten years ago I can’t remember but there was a switch over oh it’s 2008 yeah that’s right that’s a good point we have clients on contracts that you know we’re boards that are five six years old you know I think so they’re there on all about the dollar in water in technology such as Medicare is older what we’re seeing a lot now is a case rate and just to give an example in a hospital environment what we used to do is a payer when I work there is say kardia cardiovascular surgery you have a cabbage which is a coronary artery bypass great expensive procedure and we would pay one case rate and all associated cost with that particular diagnosis group would be cave into that case rate including the professional fees and anesthesia so um we are seeing that now start in the surgery center environment carve out this isn’t one we hear lie I think everything’s is a great thing you know who doesn’t love a carve-out right but I think it’s very unassuming because they can actually be bad just understand you know what type of carve out you’re giving it and how you build the implant cost let’s say there’s new technology that comes out and you just science agreements for a certain range for a carve-out and now this new implant costs way more or understand how that carve out codes going to adjudicate with it a claim that has you know codes that are not carved out so we’re going to see contracts that will have a carve-out code but then to perform other species associated with that case you’re only going to be paid for that carve out right and that’s it so just be very mindful of what you’re saying you would come to the carve out date and they do some gray

eight one more thing I wanted to point out on here too would be any updates to Medicare 2015 so let’s say you’re doing pain management and your current contracts based off 2012 Medicare they want to go 2015 Medicare that’s not always a good thing because a lot of the codes are going to bundle so you really want to make sure you understand methodology you’re currently on and what you’re specially over to what that’s going to mean to not just the rate for each cope that how it’s going to actually adjudicated pay that claim we talked about the multiple procedure logic mirror and Medicare or how it doesn’t actually and how to utilize combination codes when you’re evaluating your charge master having escalators in your contract to accommodate cost of living but don’t start demanding an escalator get your rates and then and then discuss your escalators and we discussed a level of reimbursement and that’s really by product and getting next that that additional reimbursement passed down you go to slide 20 I’m going to quickly go through the last couple of slides here we talked about case rate we’re seeing this more and more the service center environment which would include the professional and the anesthesia fee we are really seeing this and again it’s something this is not new for payers they do with Austell that goes what’s next next slide here I think you know what it patients are payers coming to us saying hey you know we want to let you do this total joint but if you do we want to try to give you this global rate like Lisa said to include an appreciation proceeds well there’s being a look after that on slide 22 this is an example of a percent of build contract on your implants so my threshold is $2,000 setting your charge mattress is a soft charge you’re not going to hard-code this in your system so you’re your coat or your charge poster has to calculate this every single time you post an implant charge if my threshold mm and I need that with my expense depending on how your contracts worded but this is typically expensive if I do what most surgery centers do and double that $4,000 in my reimbursement is 37 percent I’ve just lost money on I implant and the contract will also tell me how much I’m allowed to build now ya read the fine print below they will often stay that they want you to fill out an invoice cost they can come back an audit those invoices make sure the give you live will start the vacuum but it dates but if they have three for 35 or 37 percent of bills they know exactly what they’re doing and they know that you guys typically typically double your invoice and they know they’re going to lose money on I have one recently that actually paid at that percentage of bill and they want you to go at invoice cost so they knowingly were giving you a pretty hefty discount and when you hear wow I’m not getting anything 37 percent sounds great and I can only build in voice cause that sounds like no that’s not – its record all right and then slide 23 is an example of a case rate um that is for the surgery center only and what’s interesting about this go ahead yeah it’s based off how the codes are grouped per the payer so now your google codes and groupable codes are going to be paid differently so jump down to the last paragraph here basically if the non groupable code is billed with a code this falls in a group it’s going to trump to that case rate of $1,300 so this is just so important to know how that plan is going to adjudicate so it doesn’t matter if you have five procedure codes if the primary procedure is ungrouped it would pay if this $1,300 right right that is an expensive section of your contract yeah and then if your if you decide to build non-group codes with those group primary codes and they’ll also not pay for those additional codes you use the right group okay Scott so I know that when you’re discussing great with when carries you have to be armed with yeah they want to know what you can do for them exactly yeah this is an example of what you need to do you need to show them the cases that you bring in and how much you would save them you need to do your homework before you even pick up the phone and there is a lot here but before you get here you have to evaluate your charge masters against your a lot amount and looking at your total cases yeah there’s also so many other variables associated with getting better rates but that’s one you have to arm yourself again that’s when we see some miss out on all right so as far as opportunities are concerned I promise you if you about you do proper valuation your charge manager and educate your coding billing staff on how it works that’s step one that’s going to improve your revenue number two taking some of the inside tricks of the trade and going back to your carriers when

you’re armed and prepared you will have success and understanding the depth contract applies to the entire revenue cycle it’s not good enough to get the rates and then put it in a drawer you actually have to look at it read it and monitor it and then if there are any changes to your situation you’re adding specialties you’re losing special you may want to revisit these contracts again and also we recommend professional review of managed care contracts you do not do that as a service for the community so we would recommend you find a company that understands how to do this it is a large task it gave you some pointers so if you are experienced in this and you and you do understand the contracting part and the revenue cycle part then you should be just fine but for those of you that are new to the surgery center industry or you don’t do this and I would recommend having a professional review your contract or you help you with that and we’re going to open it up for questions I believe we finished right on time Carrie thank you Lisa and Scott for a very informative and enjoyable presentation as Lisa mentioned we will now begin the Q&A portion of the program as a reminder you can submit any questions you have by typing them into your control panel and the space labeled enter a question for staff and clicking send our presenters will attempt to answer as many questions as they can during the time we have for Q&A and we’ll follow up on questions they do not have the opportunity to address so our first question here from the audience what type of payers are exempt from HIPAA okay workers comp state Medicaid and the small small little carriers Indian reservations so your major all your major large payers are going to have to follow HIPAA but workers comp is example now why is that important because if you’re exempt from HIPAA you can require a homegrown CPT codes to be used you don’t have to follow icd-10 here we match my life to be nice you can have your own way of requiring facilities to build medical has that’s the state Medicaid on California the Ohio work huh follow homegrown codes and if you build with a regular seeks to code you’re going to be denied the carrier that I used to work for before HIPAA we had our own homegrown codes for a variety of reasons mostly that’s how they were put in the system and we didn’t have time to change it and and it’s expensive to change it so for those smaller organizations they are not required to spend the necessary of money to to get up to speed with the rest of the world but as you’re billing for these you have to understand that that some of these that are exempt could have their own requirements and they’re different from everyone else and it’s okay great thank you next question we have we in Virginia were advised not to have more than one fee schedule for legal reasons are you saying it’s okay to have more than one fee schedule this audience member says that they have one fee schedule for commercial products and one for workers comp I highly recommend one fee schedule across the board now there’s one caveat the if you have contracts that prevent you from getting an increase in your in your charge counter then you can call the carrier and ask this is the one that is limiting from increasing and ask if there is any way you can increase your charge manager across the board and keep those that internal charge master that they have on file and many carriers will work with you and do that but you still have your one charge master it is the carrier adjusting those charges on their end but I would always 100% recommend one fee schedule across the board the only variable would be your implant charges and those would not be hard-coded in your system great thank you next question we have here what are the sites you mentioned to look up charges to use as a guide for your charge master fare health.org which pretty much took the place of Ingenix we have the fall of Ingenix in’ and and then fair health sort of filled that gap and then your state may have specific if your state collects ASC data and most of them do a floor f for example has it really when Texas has a good one you can go and look and see what other surgery

center they’re charging for particular cases and CPT codes just appointed to Fair Health does have a free website you can go to org they also do some private charge data so there’s two different versions of fair health if the free website is not as clear data as they use is not just certainly from a SCS and even the anti-gay is that we’ve a cell we’ve been finding issues with that not really meeting requirements but it’s a good guy a good guy one I’m here on we only have a whole lot and using Medicare we’ve always done that but I’m not so certain it’s the best across the board great thank you now just as a reminder to our audience members you can submit questions by typing them into your control – and the space labels enter a question for staff and perhaps we have another question coming in here an audience member is asking our presenters to repeat names of sources of charge and payment examples other than Medicare charges payments examples other than Medicare not sure I understand that you understand question charges and tariffs they they probably mean I think it’s similar the last questions fair health.org you can go on and that’s not Medicare it is it’s regionally collected data and you can put your zip code in it drills down right to your zip code fare helpless so that’s probably what they’re talking about fair health.org great thank you for that now next question we have here can I negotiate rates are asked for carve-outs during the initial term of a contract like I said not typically if you’re adding a specialty then you you have an opportunity to go into dialogue if you make a strong case for again carriers are interested they really are interested in quality care for their members at a reduced cost whatever way they can save money they’re going to look for it so if you can present an opportunity for them to reduce their costs and and improve care if you can make that argument and win that argument then then yes you can in the initial term but if you look at your contracts for the first time in five years and call up and say hey you know I have a six year term and this is killing me it’s worth a shot but usually you’re locked in to the point as though the time wearing toothpaste negotiate existing contract as well I think misconception is we can get it done in a week or two but we have many times and these things take up to two years to get a good contact in place to prepare well I think that’s a really good point as you’re negotiating contracts or you’re hiring someone to do it you have to allow enough time to do it right you’re not going to pick up the phone and get a rate increase in a couple of weeks a couple months or even six months these you you have to do all of your homework and you have to work with someone and you have to listen to their feedback and go back to the drawing board I mean that back and forth is scotches head can take a year or two is not over great thank you the next question we have coming in do Medicare and Medicaid plans administered by commercial insurers always pay a hundred percent of the applicable state and federal fee schedule so that is a really good question know if they don’t and I’ll give you an example of how we don’t they’ll say our rate is a hundred or item five percent Medicare let’s say on a percent Medicare okay great I’m not getting any more than I would with Medicare I’m buying a case this relation plan and you’re only getting reimbursed now two or three procedures well you’re already now falling below Medicare or it is a multiple procedure logic of one hundred fifty twenty five and now you’re falling below Medicare two different ways it’s always in that multiple procedure logic and and so you really have to take a hard look at that so no they don’t have to pay Medicare rates to you they don’t and they don’t so wonderful thank you next question here how do I set the charge for CPT codes that don’t have a Medicare allowable right so if you’re if you’ve made the decision to use Medicare to set your

charge mass or a multiple of Medicare that’s fine and let’s say you have a spine procedure that doesn’t have a bag here crosswalk well that’s what you’re gonna want to use fair health if there’s nothing that you can extract from fair health or the state then I recommend costing it out with time materials staffing everything and applying your margin on top of that and coming up with your charge that way wonderful thank you now next question here how long does it take to renegotiate the contract well like I said before once you’ve done your proper homework and you’re ready to talk to the carriers then you start with a dialogue over the phone but your your contract negotiation may involve face-to-face meeting it should involve surgeons especially with complex procedures you’re not talking to a physician when you’re negotiating a contract you may not be able to articulate the complexities of what he or she is doing and and in that particular area and so having the surgeon help you at the end game is is critical and that whole process just one thing building on another until you get to that that point you do by developing a solid relationship by the way you certainly don’t get it by calling a pair up and saying you know you bunch you you know what I’m going to terminate if you don’t work with me well you better check your state laws because if there is not an any willing provider law which means if I as a surgery center meet credentialing criteria I can get in once you go on you may not be able to get back in and we have a whole lot of stuff going on the market right now out of network that could dictate exactly how the future value networks billing or roles will be handled and so we’re all watching it very very carefully right now so you want to be very careful of that kind of attitude where you either threaten termination or you get booted out it has to be a very gentle touch when you’re working a carrier and and they require a lot of data before they’re going to listen to you so don’t even walk in the room without it because just simply going in and saying I want a 20% increase is you’re going to get so that that whole it takes like I said a year to thank you I want to again thank our presenters for their excellent presentation and for all of you for participating today we look forward to have you join us for future webinars this concludes today’s program have a wonderful afternoon