Dr. Sarah Smith [00:00:00]:
Hey, I'm Sarah Smith, family doctor, clinical day advisor and the chatting coach. Welcome back to Sustainable Clinical Medicine podcast where we're going to be interviewing peers or world experts who can help us think about our clinical day in a way that is more sustainable and create time for our lives outside of medicine. Hey listeners, I value you being here. Please I encourage you to leave a review. I'm going to be reading out a review each month and that person can have a one on one call with me to have a chat. And I think that is a great way to reward you as a listener. Also as you like and subscribe to this podcast. It helps get our message out to other physicians and clinicians who are struggling.
Dr. Sarah Smith [00:00:46]:
Thank you so much for your reviews and I look forward to reading them out here on the podcast. Hi everybody and welcome back. Today we have with us Dr. Heather Signorelli. And I know that you're going to be very interested in this because she's going to be talking about billing and optimizing your billings, which very important topic for a lot of us, especially those under earners. But in the meantime, let's let you introduce yourself. Welcome.
Dr. Heather Signorelli [00:01:11]:
Hi. Thank you so much for having me. It's so good to see you. I know it's been a few years since I got to see you in person. I think that was at wpw. Where were we? Grand Cayman.
Dr. Sarah Smith [00:01:20]:
No, Grand Cayman.
Dr. Heather Signorelli [00:01:22]:
Yeah, years ago. I mean literally it was several years ago. But it's great to be on and excited to be here. So I'm a pathologist by background. I've been on the business side of medicine my entire career. It's funny, in residency I was doing consulting. Flying off to small places in Canada actually and doing lab consulting in small hospitals outside in different parts of Canada and then here in the States. I've been doing and running hospital labs for the last 10 plus years.
Dr. Heather Signorelli [00:01:55]:
And then also because I'm a glutton for punishment, I think we started a medical billing company four years ago. We have 25ish practices, gosh, I think 70 employees now and get the joy of running a team and managing humans, which is always fun. So. But it's been good. It's, you know, I enjoy being in different circles and different things. I enjoy the education piece, like sitting with practices and talking about their workflows and their process. It just, it, it is what fills my cup.
Dr. Sarah Smith [00:02:28]:
So. Yeah, yeah. And such a. Interesting space to have gotten into as a pathologist. And you're still working as a pathologist?
Dr. Heather Signorelli [00:02:36]:
Yes. Well, I'm in the administration side. So I haven't actually looked at a slide in over 10 years. I don't know, it's funny, I looked at one slide post fellowship and then haven't and then got thrust into administration, business side of things, like literally day one. And so I think it was just what was meant to be. But yes, I do still work full time in that role, but a lot of that is Excel spreadsheets and revenue and making decisions on what a piece of equipment we're going to purchase for a lab. So it's a very different world for pathologists.
Dr. Sarah Smith [00:03:13]:
Totally. Tell us what got you interested in this side of it, because not many people during their medical career end up not doing their clinical side of things for very long. What made you interested in this?
Dr. Heather Signorelli [00:03:29]:
So I think it was my mom. My mom was a nurse or is a nurse, and she was running hospitals and surgery centers for most of the time I was growing up. And so I think subconsciously I was listening to her conversations and, and hearing how she ran really, you know, businesses. Right. I mean, she was employed, but she was running it on the admin side. And I just, I loved it. I really, I did. And when I was in residency, I tried to actually drop part of my residency because I was like, I know I'm not going to read out slides, I just want to get, get done.
Dr. Heather Signorelli [00:04:04]:
But they wouldn't let me. So I did it and it was a good experience. But I really like the business side. I think when you mix the clinical piece and the business side, that enables us to put healthcare in the right place or push healthcare down the right path. And so I think more and more physicians, like, if you're willing and capable and able and enjoy it, need to be on the business side because I think we need, as a healthcare society, more physicians kind of in that driver's seat.
Dr. Sarah Smith [00:04:35]:
It certainly helps you understand what the front line's dealing with when you are one of the frontline.
Dr. Heather Signorelli [00:04:40]:
Yes. And the further I get, it's like, I want to go back and do more stuff with the frontline docs and just any of the frontline staff, because it's hard being in healthcare these days. It's stressful. And so you're always having to figure out how can we make it easier for our physicians and our frontline staff, but also kind of tying that back to just the decreasing reimbursements and all the stuff on the finance side that you have to mix together. So I, I've, I've enjoyed that mix. It is something I Enjoy from a career perspective.
Dr. Sarah Smith [00:05:15]:
Yeah, yeah. Tell us about some of the things you were doing with Canada and in other pathology environments in terms of workflow optimizations, efficiencies, things that reducing the duplications, the things that you thought of, that you were teaching, that help those on the front line or those providers sending to pathology or what are your kind of ideas there?
Dr. Heather Signorelli [00:05:40]:
A lot of it was stewardship. A lot of it is right test, right time. So for when I was a resident, I was actually asked by some fellow pathologists to go out to these Canadian labs and hospitals and I would assess workflow of, you know, follow the tube, follow the patient and then follow the tube within the laboratory space and really understanding, okay, what are we ordering? Why are we ordering? What are we doing with the results? Who's seeing the results? Are we acting on those results? And so here in the States, it's the Choosing Wisely campaign is a thing that's been going on for probably 10 plus years, but very much right test, right time. And so it's something for us to think through like what are we ordering and then why are we ordering it and what are we going to do with that result and how do we then make healthcare more efficient when it comes to making those right decisions? And sometimes there's going to be things we order and we, you know, work. We're shot in the dark. You know, we're trying to figure out something complex. I, you know, I'm kind of leaving that aside. I'm talking about your run of the mill traditional patients that you're seeing.
Dr. Heather Signorelli [00:06:47]:
You know, we all have the zebras we have to deal with, but you know, for 80% of the time, like can you follow these, these you know, guidelines? And there's been a lot of evidence out there that talks about that and shows those recommendations. So, so yeah, it's, it was a really cool experience. I was on these little itty bitty planes and I was sometimes the only female on these little bitty planes with all of these mining men because I was going to really small places in, out in Newfoundland was where we were actually were. And. But it was a really cool experience as a resident. Right. I mean it was thrusting me working with administrators and lab directors. It was really fun, good experience.
Dr. Sarah Smith [00:07:28]:
Yeah. I know that through my career it's been at times difficult to figure out what is the cost of this test, how much will the patient pay out of pocket for this, who else has done this test already and where is that result? Can I find that result or do I Have to repeat it. Like for instance, hemochromatosis, genetic testing is done and once it's done, that's it, you don't get another test. But now you've got to go find the, from the last test. You know, there's that sort of, kind of icky, annoying, difficult, hard to do part of our job. And it's like, why can't this be easy? Transparent, findable, centrally located.
Dr. Heather Signorelli [00:08:10]:
Well, and that's what we started building within our hospital system, which is a little easier to control, right? So we started building those like, hey, you ordered hemochromatosis already. Like, here is the result. And we would provide that as a pop up to the physician. And, and we did that for CBCs, for vitamin D. Like we had maybe 100 different tests that we had these duplicate rules. But if the doc was like, no, I still need that again, for whatever reason they were able to override and make that decision. But that's hard when you're outpatient, dealing with patients who've gone all over the world or all over the country or it's almost impossible. I wish, and I really, I can't believe in this day and age we haven't solved that problem.
Dr. Heather Signorelli [00:08:52]:
I just.
Dr. Sarah Smith [00:08:53]:
The interesting about Australia, where I'm currently working, they brought in this beautiful rule that you can't have a PSA prostate test done within 13 months of a previous one or the patient pays unless they're being followed for prostate cancer. Of course you've still got the overrides, which is lovely and well, except if I wasn't the last orderer, I don't know that it's within 13 months. So the patient gets a bill and then they like looking at me going, why did I get a bill? I'm like, well, you must have had a test within the last 13 months. It's like, yeah, I did with my, you know, urologist six months ago. I'm like, oh, I didn't know that result. So therefore you just need to. And it's me now educating the patient to say if they have, if they say to you, this isn't due yet, you're going to have to pay, I don't want the test.
Dr. Heather Signorelli [00:09:40]:
Right, well, but it's like, do they remember that, that to say that? And then do you like those rules change all the time. So it's like, okay, you've got the psa, you know, in your mind, right, because of this situation. But then what are the total. It's like, give me a list of rules and I'll Memorize them. But it's not like that. It's like, let me just see if you can guess the rules and then see if you can follow the rules that you haven't guessed yet. I mean, that's truly what we're left with.
Dr. Sarah Smith [00:10:07]:
But the labor assistant can pull up the last number and tell me it was only done six months ago, but doesn't communicate with me. It just tells the patient they're going to pay for this one. It's like, there's still gaps in the system. It. Even in Canada. I said, I don't want you to do this test. If I was ordering a hemoglobin and the hematologist was ordering a hemoglobin, they wouldn't do it once and send it to both of us. They would run the test twice.
Dr. Sarah Smith [00:10:35]:
I'm like, that is inappropriate use. And they're like, we know and we can't fix it. It's like, yes, you can. It's a computer. You can change it. No, they can't. So the test would be run twice. It's like, I know.
Dr. Heather Signorelli [00:10:49]:
And we had to put all of those rules in. But to your point, we actually physically had to hardwire it into the emr. Now, again, that's. We're in a hospital system. We've got 200 hospitals, so we're integrated within that care system. But again, the moment you step out of that and go into any outpatient physician's office, that data is gone.
Dr. Sarah Smith [00:11:10]:
Yeah. Well, I'm glad there's somebody trying to work on the inefficiencies and the glitches that we see and are annoyed by. And I get that there's stewardship that. And I do love the choosing wisely. It was in Canada as well. Yeah. And it's so valuable because it helps us understand why this test. Why not this test? When is this appropriate? Like, very helpful rules and guidelines for us to have up our sleeve, especially when patients say, can I have a serum rhubarb? And you're like, no, but here's why not just a blanket.
Dr. Sarah Smith [00:11:47]:
No.
Dr. Heather Signorelli [00:11:48]:
Yeah. It's funny that you say serum rhubarb, because that is 100. My example, when I talk to physicians is always serum rhubarb. That's exactly what. I love that you said that. Okay.
Dr. Sarah Smith [00:12:00]:
All right, so tell us more about when you got into the billing side of things. So tell us what that looks like and why.
Dr. Heather Signorelli [00:12:07]:
Oh, gosh. You know, it actually all started with. I was at a conference. We had. I was around a bunch of physicians post Covid. And they were like, billing sucks. It's terrible. I'm not getting paid anything.
Dr. Heather Signorelli [00:12:17]:
Like, help, please. And you know, I, I think I tell everybody I meet I love a good spreadsheet. I'm a big data person. Um, and so I was like, no, we can figure this out. And then when I was looking, I was just seeing inefficiencies and things, you know, not to the biller's discredit, but just to the process in general. And I was like, I think I can, I can do this and run a company that, that helps educate, fix processes, but then also does all the billing. So we opened our company up almost four years ago. We've got 25 plus practices that we have maybe 70 plus employees.
Dr. Heather Signorelli [00:12:53]:
And we really pride ourselves on a few things. So education, you have to have an office that is educated and understands the billing process. I think communication, you know, you've got to have good communication because at the end of the day, this is a marriage between your biller and your office, whether they're in house or outsourced. It is a marriage. And it takes communication. And oftentimes that takes a process around communication because emails get lost. I don't know about you, but my email is like a, like the death, you know, it's just so much. And so we've got to have trackers and so we've put in a lot of that.
Dr. Heather Signorelli [00:13:32]:
And then, and then data. That's the last piece. You've got to have the data so that you know how things are doing and you got to know what the data means.
Dr. Sarah Smith [00:13:40]:
Yeah. And doesn't matter where you are probably. I know in the Canada system, I know in the US system and I know in the Australian system within that FIFA service model model. So your, your item numbers are appropriate to what you've done for this patient. And even if you're on a salary, typically the billers are in the background trying to data mine those item numbers for uploading from the hospital system to get the money out of the government for that service that was provided, even though the doctor's getting like one peak chunk no matter what they did.
Dr. Heather Signorelli [00:14:15]:
Right.
Dr. Sarah Smith [00:14:15]:
And it determined by the documentation that you've done. And that documentation is so important because there's so many ticker boxes and finding out what are the phrases I have to use, what are the things I have to have done in order to be compliant with that request. That's a lot of work.
Dr. Heather Signorelli [00:14:35]:
It is. And it, and it. And unfortunately, regardless of which system you're in, you have to be able to tell the story in the language by which the person on the other end is paying you from. And it is not a language we are taught in medical school. It is not a language that we are taught in residency, but it is the language by which you should get paid and, or that you not should get paid, that you do get paid. And so, and this is, you know, if you're listening and you're employed and you think, oh, it's, you know, whatever, I will tell you, it will hit your, your paycheck eventually. It may not hit your paycheck day one, but how you bill and code and document will eventually hit your paycheck. And, and so whether you're employed or whether you're, you know, out on your own, and obviously, you know, everything counts.
Dr. Heather Signorelli [00:15:21]:
You know, I do think it's important for us to understand this language. We can sit and fight it, and I do think there's value in that. But I think in the, in the interim, understanding it is really key. And physicians in general, very smart, hardworking individuals, and we can figure it out. Like, I guarantee you, all of us can figure this out. We just have to have the time and to take the time to do it. Luckily for most docs, like, you're, you're, you know, doing 10, 20, you know, maybe a little bit more than that, depending on if you're inpatient or complex surgery. But it's, you've just got to know your area very well so that you document correctly and then get feedback from your billing team, whether you're employed or out on your own.
Dr. Heather Signorelli [00:16:05]:
I think getting that feedback from a billing team is really, really crucial.
Dr. Sarah Smith [00:16:09]:
What are some of the common under earning or missed build things that you see in the States from physicians.
Dr. Heather Signorelli [00:16:19]:
So misbuild things, I would say incorrectly using modifiers or assuming that I can bill these three or four CPTs when they're all bundled into the same thing. So not understanding modifiers and not understanding what CPTs or what procedures are bundled together and reimbursed, I think those things are really, really important because there may be a situation where you don't need to do all three of those the same day, and you could have the patient come back a different day and they not be bundled. And I know that doesn't always work. And there's extenuating circumstances about why a patient's there or if you have to put them under anesthesia. I mean, there's all of those complexities. So this is not a one size fits all, I think. But Understanding how you use modifiers to tell somebody what you're doing and how you understand the bundling rules of whatever you're doing can help you figure out, okay, in these cases, I have to bundle it because the patient's going under anesthesia and I'm going to get paid what I get paid. But in these scenarios, like, maybe I don't need to take those.
Dr. Heather Signorelli [00:17:21]:
Do those two things together, and I can separate those, because it is hard, because sometimes when the patient comes in, if you're not using those modifiers correctly, you could either not be paid, or if you're using the modifier correctly, you have to realize you may only get 50% for one of those procedures versus 100. So unfortunately, you've just. You. You do have to know the rules. And I hate. I hate that it comes down to that, but I think if you understand the rules, you can, with your clinical brain, figure out how to manage the patient and maximize revenue at the same time. But again, not knowing the rules put you in the dark.
Dr. Sarah Smith [00:18:01]:
Yeah. Okay, what about the complexity rules? Because things changed with us billing around or just before COVID or just after Covid 2021. Yeah. And so there's now new rules, and people were doing all of these system reviews in order to hit that complexity, and now that's not quite so required. And, but you do have to show complexity, and there are ways to do that in the words you use in your documentation or in your understanding of what you've done with the patient. Who teaches that? Where. Where do physicians go and learn that type of thing?
Dr. Heather Signorelli [00:18:37]:
You're. You're assuming someone. I mean, obviously there's coding. The AAPC guidelines that came out, they. They have education. We actually created a coding guideline just on MDM levels and understanding, you know, the levels of that. And I could sit here and talk a whole hour on that. I actually taught the course.
Dr. Heather Signorelli [00:18:57]:
Our coders helped me. We created a guide, you know, PowerPoint, and we actually have it recorded for folks. But it is hard. I mean, I actually think the new MDM system, I may be biased here, I think is easier than the old one. I do agree with that. Yeah. But you do have to learn it, and you have to understand, okay, what am I diagnosing, what am I reviewing, and, you know, how much time am I spending and which one do I want to use? You know, want to use complexity versus time. And once you know those rules again, you.
Dr. Heather Signorelli [00:19:29]:
You can, you know, get it right and. And, you know, get the revenue you deserve. You do have to be A little careful. Like if you're a subspecialist and you're always bill building a level five, like you may get flagged, it may be appropriate that you're always billing a 5, but you got to just be prepared that you may have a audit and how to handle that. But I don't, I don't think we get enough education on this. And so I think you've got to find, I mean, obviously we have a podcast and we have some education modules, but you've got to find a mechanism by which to learn this.
Dr. Sarah Smith [00:20:01]:
Got it. Okay. Yeah. And I think that's important that it is a learnable, teachable and learnable skill. We can do this. It is annoying, but once you've done it, it does help you with knowing am I compliant with the rules about this billing? Am I appropriately billing getting what I'm getting paid, what I have done. Correct. Appropriately.
Dr. Heather Signorelli [00:20:24]:
And it's again, these are not the sexy things that we all went into healthcare for, but it is reality. And so, you know, again, unless you want to go concierge, which again, some docs can do, and they can do that very well. And I do not knock that. I actually just released a podcast that talks about if I'm an insurance based provider or physician practice, how do I think about if I should or could or would drop insurance? What. What does that do? And so that actually should be releasing here in the next few days. So it is not, it's not easy. But you know, I think most people are dealing with insurance and most people have a limited number of codes that you bill. And I think just learning those rules and really understanding it is key.
Dr. Sarah Smith [00:21:05]:
Mm. What about the Medicare bonuses for the monitoring of chronic diseases?
Dr. Heather Signorelli [00:21:13]:
Like the quality.
Dr. Sarah Smith [00:21:14]:
Yes, the quality stuff.
Dr. Heather Signorelli [00:21:16]:
Yeah.
Dr. Sarah Smith [00:21:16]:
What are you noticing about that within the practices that you're looking after or tips or tricks on that?
Dr. Heather Signorelli [00:21:21]:
So I would say one. And we actually also also did a couple, we did a two part series on that specific topic as well. So I'm glad you're like hitting all of my like recent topics. But so number one, not everybody has to do that.
Dr. Sarah Smith [00:21:37]:
So.
Dr. Heather Signorelli [00:21:37]:
And you can go onto the CMS site and plug in your MPI number and know if you are eligible for that. And then the next thing is if you are eligible, if you do need to submit that data, you're actually EMR vendors, your pm, your software vendors typically have really good modules. If you have a good vendor have good modules, who can help you submit that data? I would say for. We probably have maybe 30% of our practices probably are small enough to where they don't qualify and and then probably 70% are having to submit that data and I would say half submit it and half don't would be my, my estimate based on what, what we've seen. Some just don't want to deal with it and some are OCD and very aggressive about it. And again those, those additions or subtractions can be up to 9% so it's not a small number. You know the average is like 2%. So it's not typically a huge, but it could be higher than that depending on the year and your subspecialty and so forth.
Dr. Heather Signorelli [00:22:38]:
So yeah, I highly recommend if you are eligible. It's not that hard but it again it's another thing on the to do list.
Dr. Sarah Smith [00:22:48]:
Well that's what I was curious about is how is it not on the physicians to do list? What have you seen happening within the practices that do submit regularly or consistently? Is there any workflows using Table Team that has been shown to be very helpful, taking it off the physicians to do list?
Dr. Heather Signorelli [00:23:07]:
I think it's having a really good office manager, I'm going to tell you, having somebody who really understands workflows data and who can be your right hand and unfortunately not all practices can afford that. And I get that. And so you see some of the smaller practices struggle with that, although for the most part many of them don't need to submit. So you're good there. But then you get those medium sized practices right and then you've got an office manager who maybe has experience but doesn't have experience in your subspecialty or your area or maybe they're healthcare but now haven't run a private practice before and I think that's where we see a lot of breakdown is, is really in the skill set of the team you hire and make and then knowing yourself that that needs to be a priority for them and that's where leadership comes into play. Right. It really comes down to okay, what do I as CEO and owner of this practice need to focus on and what do I need? What can I leverage my team to delegate? And then what is that priority this quarter versus next quarter and how do I measure and monitor those? And that's hard to do when you're seeing patients five days a week. And so I think the struggle is figuring out when and how you're going to learn how to run a practice, coming up with the to do list and then hiring the right team and then delegating that Out.
Dr. Heather Signorelli [00:24:29]:
And so I would say, if you're listening and maybe your first three years into practice and you're trying to figure this out, leverage coaching, leverage others who've done this, learn from them of how do I set my priorities? The first few years will be rough, but the better you learn it and then learn to delegate and build up a good team, the easier it will come. I mean, it's like residency, right? Like the first, you know, year or two sucks and then you kind of get the hang out of it, hang of it. And then like 10 years after, you know, training's over, you look back and go, okay, I can actually do a lot of really good things. It's, it's a, it's, it's a phase, right? It's like having a newborn.
Dr. Sarah Smith [00:25:11]:
Yeah. I've seen in Canada, for instance, that data collection that's required for reporting is often handled by the primary care networks because that is their governance is that they must, you know, be, be mindful of these numbers and be finding those numbers and then handing them up to the government as part of their duty of the why they're funded. So while, yes, a physician is required to actually order the HBA1C and order the foot check and those types of things, there's somebody else checking and pulling that data and submitting it on their behalf, which is kind of wonderful because you're not the one having to go and pull all that data. You're required to be doing your job, which is important, and then having others in the team, where possible, to say, hey, your mammograms do, or hey, your colonoscopies do, and setting up those reminder and safety nets for the patients, which then capture the data that goes on to the people who need it.
Dr. Heather Signorelli [00:26:11]:
So, yeah, and I think here you, you can have your PM software if, if it's the, if it's a good enough software, they are, there are programs that will, that will flag a patient for those things and then they will prepare the reports and submit on your behalf. Now, I know that's not the same as having, you know, an agency doing that for you, but there are ways you can do that. Unfortunately, a lot of the software programs are, are a little bit more pricey, they are a little bit more expensive. And so you kind of have to think through, you know, what am I paying to. To do that versus what would I lose if I just decided to opt out again? You know, I would say opt in and figure it out in the beginning. And then, you know, if it's if it's too challenging, too expensive, you know, go back. But it's hard to catch up if you've never. Because it's remember for here, for the States, it's two years behind.
Dr. Heather Signorelli [00:27:03]:
So it's like you don't even know what you're getting penalized for. What you're getting penalized for now happened like years ago. So you're like, I don't know.
Dr. Sarah Smith [00:27:12]:
That's quite, that's quite the tail chasing, isn't it? Yeah. And often it feels like a ticker box exercise, which is why a lot of people don't do it.
Dr. Heather Signorelli [00:27:21]:
Right.
Dr. Sarah Smith [00:27:22]:
When you're literally just ticking boxes in order to get a bonus or in order to fulfill your employee obligations within this particular environment, then it feels like a make work exercise and not a useful for patient quality of care exercise.
Dr. Heather Signorelli [00:27:40]:
It's funny because having spent a lot of time with the MIPS and all the things, I think the root of what they're trying to do makes sense. They're trying to make sure that patients, they get XYZ tests or procedures at whatever the recommended interval is and they're trying to encourage that. But then you add that on top of all of the other paperwork physicians have to do and all of the other things they have to do, the prior auths and the eligibility and everything, it just feels like a mountain. And so I think getting processes around these things is so, so important. And again, if you're new in practice or you're listening to this and you're like, I've got 18 things to do. Pick three, start with three. If MIPS, isn't it this year? MIPS and eight this year, you know, and then, and then once you get those three. But it, that means that if you are seeing patients five days a week, you may be, you know, having a day a week that you're having to do admin stuff or trying to scale back and keep your staff smaller so that you have, you know, a day or two to do admin stuff.
Dr. Heather Signorelli [00:28:40]:
It's not easy. That's. I wish it was easier.
Dr. Sarah Smith [00:28:43]:
Yeah. And often those admin days, you're not getting paid directly for any of that work.
Dr. Heather Signorelli [00:28:49]:
No, none of it. Zero. Zero. Yes.
Dr. Sarah Smith [00:28:54]:
Not the fun part.
Dr. Heather Signorelli [00:28:55]:
No.
Dr. Sarah Smith [00:28:55]:
What else about billing efficiency, workplace flow that have you noticed that is important at the mom.
Dr. Heather Signorelli [00:29:04]:
So, and I think this probably qualifies, I think for any country, but you correct me if I'm not, but patient collection. So what a patient owes, and I recognize how that works may be different in the States versus Canada. Or Australia. But really understanding in your place of work what a patient could owe. And so here in the United States, that's co pays, deductibles, co insurance, you know, out of pocket maxes. Like really understanding that, checking that information ahead of time and not seeing a patient before they've paid their balance. And so if you see that they have a deductible, coming up with a number to charge them. If you see they have a copay, charge that $20.
Dr. Heather Signorelli [00:29:45]:
And you just set those expectations when patients come to the offices, you know, I take a credit card on file, I pay that today. I don't see a doctor otherwise. And because patients, patient balances can, can creep up for a practice and they can be six figures, multiples of six figures. And it's not, you know, it's, it's challenging. So you do have to have a really good process around not letting, not forgetting that somebody has to pay attention to the patient ar. And from a billing perspective, we send out patient statements, but we're not a debt collector. And so we're really relying on the patient's or the front desk to look at the patient balance before they're seen collecting that, collecting as much upfront as they can. And this, again, it comes down to workflow.
Dr. Heather Signorelli [00:30:30]:
It comes down to whose responsibility is going to be each part of these, and then checking and making sure that it's done. And so it is a very difficult thing to look at a, to look at, you know, people's metrics and see that they have hundreds of thousands of dollars of patient ar. And that's real money. Right? Like the, the insurance AR is like the funny money. Like, if you have a million dollars in insurance AR, you may get 300,000 of that, but if you have 250,000 in patient AR, that's your money. Like the whole to all 250,000 of that. And so I, you know, again, I love a good Excel spreadsheet, so I would, if I was in those shoes, I would obsess over it. But again, that's because I have the time to obsess and I'm not seeing patients.
Dr. Heather Signorelli [00:31:15]:
So I get the complexities around this. Again, if you're listening, I think it's, it's setting priorities per quarter to say, okay, these are the three things I'm going to work on. And then when I accomplish those three things, I'm going to move to the next three things so you're not overwhelmed. And again, you're leveraging your team to put a process around each of those.
Dr. Sarah Smith [00:31:33]:
Yeah. Okay. That was horrifying hearing that insurance AI AR is like 80% of that. Like, wow.
Dr. Heather Signorelli [00:31:43]:
I mean, it depends on how you set your fee schedule. Right? Because if I, if I set my fee schedule to be 300 of Medicare, then I know I'm setting it higher than what I'm actually going to get paid. And so, and here in the states, that's very common. Like you set it up really high because, you know, some people are going to pay you a hundred dollars, some 120, some 80. And so you set it at 300, hoping that you capture everybody. Because if, here's the tricky thing in the States is if you, if you set your charge to 100, but if blue Cross says, well, no, I'll pay you 120 for that, but because you charged 100, they're only going to pay you 100. And so you lose. We just had a client, we caught this, we just started with a new large urgent care and we caught that they were, their fee schedule was set at a.
Dr. Heather Signorelli [00:32:27]:
I'm making this up $100. Yeah. But somebody was willing to pay them 125. And so they've been losing out on that $25 for years. And so we, when we got in there, we saw the, the explanation of benefits and we're like, they're paying, there's no adjusted amount. They're paying you exactly what you charge. And that's how you know that you're not setting your fees higher. They could be higher.
Dr. Heather Signorelli [00:32:51]:
So you set that so, so most people set it really high so you don't run into that instance. But in this case we found that. And so they'll be getting paid. I think it was $25 more per CPT. And it was a pretty high CPT for them. So they were excited.
Dr. Sarah Smith [00:33:05]:
Yeah, absolutely. And so in the States, is the patient going to tap their Visa card for just the out of pocket part?
Dr. Heather Signorelli [00:33:15]:
So it depends. So every patient. This is, this is the very confusing part. In the States, it depends on the patient's agreement with the insurance company, what they owe, when they owe it. And so you can run an eligibility check and see that information. And this is where a lot of practices lose out because they're not, not truly doing that eligibility check. They may say, oh, they have insurance and yes, it's active, but they don't dig into the details. And so they don't see if there's a copay, which means I may owe $20 every time that patient is seen or they don't See that they've got a 200 deductible, which means they need to pay.
Dr. Heather Signorelli [00:33:50]:
They, they have to come completely out of pocket before insurance will cover anything. And so it gets very tricky for a front desk person, especially if they're not. Haven't had experience in this. They don't know what those terms mean. They don't know what that means. They don't know what they're supposed to be collecting. And so then they're like, I don't know, I just won't collect anything. And then the patient gets the $20 bill and either it goes to the wrong address or whatever, and then it never gets paid.
Dr. Heather Signorelli [00:34:14]:
And $20 or $100, it adds up.
Dr. Sarah Smith [00:34:18]:
Yes, yes. So if the patient doesn't pay the copay, you don't also get the insurance money.
Dr. Heather Signorelli [00:34:24]:
So the. You get the insurance money, but then you still have that $20 copay. So you may get the $80, but then the patient still owes the 20, so you'll get the insurance part. And that's why we track insurance AR and patient AR in two different buckets so that we know what lever to push and to pull to see if we can get the money paid. And these are just, I would say the number one thing I see in practices is they're not doing that eligibility check correctly. And it's either creating denials where they don't get paid any all, or it's creating a situation where they're built, their patient AR builds up and they don't know how to handle that. And then, and then that's the thing is they come to us and it's been years of this and they've got seven figures plus of accounts receivable. I mean, it's, it's heartbreaking.
Dr. Heather Signorelli [00:35:14]:
I mean, and we've had practices who come to us with very little in their checking account. And after six months they're like, we have, we have money. We have money again. And it's like, oh, thank God. I mean, you know, I just, it just breaks my heart. Like I just, I just want all the money for them, just all the money.
Dr. Sarah Smith [00:35:30]:
So, yeah, it's such different across the country. So in Canada, you can't charge a patient out of pocket, except for the rare occasional thing like a form. And learn quickly if you want to spend three hours doing a form, get paid first. Because often you get that, well, I can't afford that from the patient side if there's no insurance to pay for it. So why did you do all that work? So it's A. So they're starting to be companies within Canada who are helping physicians do that, get money upfront payment. They're starting to incentivize staff to be able to collect that money so that the staff are getting a little bonus for having collected the money as the patient was in their presence. So that is kind of an interesting and novel way of doing it.
Dr. Sarah Smith [00:36:16]:
Come across to Australia and you tap your credit card for whatever the person wants to charge you for the day, and the government will put back into your bank account the Medicare insurance fee.
Dr. Heather Signorelli [00:36:30]:
And that's for all ages.
Dr. Sarah Smith [00:36:32]:
All ages.
Dr. Heather Signorelli [00:36:32]:
All ages.
Dr. Sarah Smith [00:36:34]:
You, you will, at the end of that visit tap your credit card and the, your bank account is linked to your Medicare account and Medicare will pay to you, the patient. What?
Dr. Heather Signorelli [00:36:46]:
And that's. And it's called Medicare there too in Australia.
Dr. Sarah Smith [00:36:48]:
It is called Medicare here.
Dr. Heather Signorelli [00:36:51]:
That's why I asked the age thing. I was like, wait, 65 and up. Okay, got it. Okay.
Dr. Sarah Smith [00:36:56]:
And here is for everybody. And, and yes.
Dr. Heather Signorelli [00:36:59]:
So that's because you can charge the three. I mean, not that you would, but.
Dr. Sarah Smith [00:37:04]:
Yeah, I can, I can charge whatever I like for a visit to see me. And Medicare says yes, but that was a such and such type of Visit. And here's $80 back.
Dr. Heather Signorelli [00:37:14]:
Got it.
Dr. Sarah Smith [00:37:15]:
Or here's $40 back.
Dr. Heather Signorelli [00:37:16]:
And are they looking at your documentation or are they taking something submitted from the patient?
Dr. Sarah Smith [00:37:20]:
They look at the item number we submitted and then they can audit us based on what we documented as to whether we were correctly charging that fee for the day.
Dr. Heather Signorelli [00:37:29]:
Got it. Interesting. So funny how they're all different.
Dr. Sarah Smith [00:37:32]:
I mean, they're all slightly different and they're all. Well, because of course in Canada it's illegal to charge a patient.
Dr. Heather Signorelli [00:37:39]:
Yes.
Dr. Sarah Smith [00:37:40]:
Above what the government will pay you for that visit.
Dr. Heather Signorelli [00:37:43]:
And same in the States. You can't. Same in the States. Like you can't balance bill a patient. Like if you're in network with Medicare or United Healthcare or whatever, and Medicare, they decide, I'll give you $80, you can't then go balance bill the patient for another hundred dollars for a covered service. I mean, you can do non covered service, but for covered services you can't. You cannot balance bill patient unless you know, it's part of their patient responsibility.
Dr. Sarah Smith [00:38:09]:
Yeah. And that's where knowing how to be compliant with the item number you want to charge for the day. How to document that, what are you seeing on that front?
Dr. Heather Signorelli [00:38:21]:
Very important. We have a lot of denials. They ask for medical records, they get the medical records. And they were like you didn't document or you didn't tell the story the way that it's needed and we're not going to pay for it. And so one of two things happens. Either, either depending on the payer, you can't, you, you may be in a situation where if you didn't get something signed up front, you cannot go and charge the payer or the patient. Now if you did get something signed where you said, hey, this may not be covered and if it's not covered, here's, you know, your, what you'll have to pay, but you have to have that conversation. You can get some angry patients, but documentation is a big part.
Dr. Heather Signorelli [00:38:58]:
I mean it's, it's a huge part. Take for example, say you have a well woman examination and you also do a preventative visit where you are dealing or not, excuse me, you have a problem visit where you're dealing with a problem at the same time as a preventative. If you don't truly document enough about that problem for it to be significant and separate issue, you know, you may not get paid for both and in an audit situation, they may have already paid you and now you have to pay all that money back. And that's very painful. Like we and. Or you're billing in a situation where you're not, you're using a mid level but billing under the doctor. And if you're not doing that correctly again here in the States, you get paid and then they ask for oftentimes medical records later. And if it's three years later and you've been doing it wrong for three years, it could be hundreds of thousands of dollars of paybacks depending on the size of the group.
Dr. Sarah Smith [00:39:59]:
Right.
Dr. Heather Signorelli [00:40:00]:
Okay.
Dr. Sarah Smith [00:40:00]:
So that comes back to knowing the rules and making sure you're compliant with the rules.
Dr. Heather Signorelli [00:40:04]:
Correct. And again, this comes back to know your very, know your scope, know your 1020 procedures that you do. Get feedback from your billers, do a, you know, meeting with them frequently. Have people checking your, at least here in the States, do a coding audit at least once a year. Double check that what you think you're doing right, you are doing right. Even if it's 20 charts just to just a gut check and so that you don't be in that situation again. I know these rules are not fun. I know the compliance stuff's not fun, but it is where we're at right now, unless you're concierge.
Dr. Heather Signorelli [00:40:40]:
And that has its challenges too. So I mean work life in general, it has challenges. So you just got to figure out what challenge you want to deal with.
Dr. Sarah Smith [00:40:49]:
Now, I know that you said just audit 20 charts, having run many physicians through this process in Canada, because as part of the professional learning plans or part of our CPD continuing education points, we can do our internal for ourselves only not seen by anyone else chart audit. And it sounds like very boring work. It, it actually helps with knowing, starting to notice things like who in the team could I have used to do some of this work for me? How else could I be seeing patients in a way that is more efficient? Or am I compliant with the rules for the item numbers that I'm billing? What are the rules? Let's go back and review them. Even though it sounds daunting and terrible, it's so much better to do it for yourself than for the people who are going to look over your shoulder like your college or your billing or your insurance companies. So having done this work over and over with physicians, it was just, this was for their compliance, they needed to do 10 charts. So we get it all done, done and dusted in a three hour period. So it's not that onerous, can take you weeks and weeks, but it's very good information, especially when you're new or learning or there's been new rules or you're not sure that you've done it for a while.
Dr. Heather Signorelli [00:42:14]:
Yeah, 100%. And again, these things, I think again, if you create a list, it will look daunting at first, but then you just start crossing off one at a time and you get through it and then you kind of set up a pattern and a process and then it just becomes like, no big deal. I mean, again, it's like bringing home a newborn. In the beginning, like in the beginning you're like, I have to feed it and I have to change it and I have to wake up in the middle of the night and oh my gosh, what is that? And you know, you know, it can't sleep with this, it can't sleep with that. I mean, and all those things, you know, are overwhelming. And then by six months you're like, I could do this in my sleep. And you, you are doing it in your sleep. And so, you know, I, medicine in the practical aspect of this is much like that.
Dr. Heather Signorelli [00:42:55]:
You just need to come up with your rules of engagement, the things you need to do, set up a process around it. And then you just, you, you do it. And again, it will get easier with time. And the last thing I did want to bring up that I forgot to mention was the chart sign off. And that Reminded me, as you said, charts, we, we have practices that struggle with this and that. It could be months, six months, maybe even close to a year before they're signing up those charts. And I don't know how it is in the other countries, but here in the States, if those aren't signed off timely and if we don't get them to the insurance company on time, you can have timely filing and you cannot appeal your way out of those. It is, it is free patient care that you are spending.
Dr. Heather Signorelli [00:43:38]:
And so, and one of the things I'll, I'll say is if the office isn't doing a great job with eligibility, meaning they don't always know the insurance company. And if you sign up, sign out that chart right before timely filing and you submit it and then there's an eligibility issue, you'll get a timely filing denial and you cannot appeal your way out of that. So I highly, highly recommend, you know, sign out those charts within the week, ideally within 24 hours. But I know that can be challenging, but certainly within the week and it'll help.
Dr. Sarah Smith [00:44:09]:
What are the time periods of lockout for billing there? What, what do you see as some of the timeouts?
Dr. Heather Signorelli [00:44:16]:
So Medicare is the best. It's 365 days. But other private payers are anywhere from 90 to 180 days. I would say is common. We have some that are 30 days and so, and it's usually those really small payers that often they're your secondaries that are in that 30 day range. And so you don't know that until the primary is crossed over to the secondary insurance and then you get a timely filing denial. And so, and those are, those are just the most painful things. And, and we cannot report ourselves out of.
Dr. Heather Signorelli [00:44:48]:
Meaning I, I cannot send enough reports sometimes to let a physician know that they have, they, they need to sign up their charts. I mean it's, it is one of, it is one of those things like in a marriage like you just gotta unload the dishwasher every day and it's annoying, but you just gotta do it, sign out your charts. It's, it because it's, sometimes it's, it's crucial to get paid.
Dr. Sarah Smith [00:45:08]:
Yeah, I know. For instance in Alberta it was 90 days that you had to submit your item numbers for billing, otherwise they won't accept them after that 90 days. And if there's a reconciliation, I think you can do that. But it's still, they want it done within 90 days of the. If possible. But yeah, that submitting your billing within 90 days and I see physicians sometimes not closing the charts, but submitting the billing numbers. But that's just a big problem if you get audited for those charts. And so we really do love to teach, you know, how to finish your charts after every patient.
Dr. Sarah Smith [00:45:44]:
That's what I teach. And I love people in the program to be able to learn how to do that. It is possible.
Dr. Heather Signorelli [00:45:50]:
Yeah.
Dr. Sarah Smith [00:45:50]:
For those of you who are listening going, I can't do this. This is part of my problem. We got you. We can teach this, too. Teachable skill. You can do it. Find the people who can help you get there. Because we would love for you to not have that burden hanging over you, because it is a horrible place to have to be.
Dr. Heather Signorelli [00:46:09]:
And again, I think that's where it does come down to, like, really learning and hearing about what others have done, whether that's, you know, coaching with your chart program or, you know, coaching private practice in general. Like, I think having a buddy system is really important. Like, we had buddy systems in medical school. We had, you know, mentors in residency. We had senior people teaching us the ropes, like, how to scrub in your first time. You know, like those terrifying things that once you figure it out, you're like, okay, I got this. I do think that all of this is learnable. You just have to make the time and prioritize doing it.
Dr. Heather Signorelli [00:46:42]:
And again, those first few years out may be really painful, but then once you get a system in place and you know how to do it and you have the tools and the people behind you, it. All of this I like. We see really successful practices that are doing excellent. Managing a lot with the right team.
Dr. Sarah Smith [00:46:58]:
Yeah. Yeah, I love that. How do people find you? If they're looking to learn all about this billing thing and maybe wanting to get some help with it, wanting to watch some of those webinars you put in together, how do they find you?
Dr. Heather Signorelli [00:47:12]:
So our website is nat revmd. So that's natrevmd.com super easy to go over there. So head on over there. We have our podcast, I have a book, and we have our billing course, all kind of listed under Resources. You can also shoot an email over to infoatrevmd.com and those. Those will make their way to me slowly. So. Or one of our team members will answer them for you.
Dr. Heather Signorelli [00:47:38]:
So. So we're happy to help. And check out our podcast. I think that's probably the most helpful resource we have. And start there.
Dr. Sarah Smith [00:47:46]:
What's the podcast called?
Dr. Heather Signorelli [00:47:47]:
Nat RevMD. So excellent. Just N a T R E v M D. And again, you can find that on our website or anywhere you listen to podcasts.
Dr. Sarah Smith [00:47:57]:
Excellent. Okay, that's wonderful. Anything we didn't talk about that you want to leave listeners with?
Dr. Heather Signorelli [00:48:02]:
I think the number one thing is hopefully you walk away not feeling overwhelmed today, but feeling hopeful. All of this is something you can accomplish. I think it's just, again, chunking down. Okay, what are my three things I'm going to do this week or this month or this year? And. And then partnering with good folks like yourself on learning those skills. Because if we can get through the Krebs cycle and all of those nerve things we had to learn in medical school, I remember the big whiteboards we would draw out. If we can do that, we can do anything. So.
Dr. Heather Signorelli [00:48:32]:
But you just got to have the right people and tools to do it.
Dr. Sarah Smith [00:48:34]:
It. Yeah. Love that. Thank you so much for being here and everybody. You have a wonderful rest of your week. Yeah.
Dr. Heather Signorelli [00:48:40]:
Thanks for invite. Bye.
Dr. Sarah Smith [00:48:42]:
Hey, if you found this podcast episode helpful, I would encourage you to like and subscribe. Every time you do, you help a colleague or friend find our podcast and it can help them too. Don't forget to share it along with your friends if you're looking for extra help. Don't forget we have Charting Champions for physicians and Smarter Charting for nurse practitioners and other clinicians to help you get home with your work done. We are helping you create sustainable clinical medicine. Thanks for listening.
