Pre-Certifying High Tech Imaging Procedures You Can Improve Imaging Services, but can you get the Patients in the Door? May 1 st 2014 | Mike Busky MBA,,CRA.RT.

Pre-Certifying High Tech Imaging Procedures

You Can Improve Imaging Services, but can you get the Patients in the Door?

May 1st 2014 | Mike Busky MBA,,CRA.RT

Agenda• My Background• Review High Tech Imaging Growth• Current Challenges Within Imaging• What Matters Most to Your Doctors?• Pulling On Opposite Ends of the Rope

(Patient Intake & Imaging)• Options and Steps to Take (Develop a Plan)• Refuting the Resistance• Takeaways

My Background• 1992-2007 OSF Healthcare (Rockford, IL.)

– Transport, File Room, Reception – Radiology Tech, IR Tech– Medical Imaging Manager

System Wide RIS Implementation Clinical Lead

• 2005-2011 MRI Consulting (Wheaton, IL.)– VP Operations (6-8 Freestanding MRI Centers)

• 2011-2014 Advocate Lutheran General (Park Ridge, IL.) – Business Manager Imaging, Neuroscience, Oncology

Drag picture to placeholder or click icon to add

High Tech Imaging Growth• Increased Utilization

– Advanced Applications– High Contribution Margins– Physician Ownership– Block Lease Arrangements– Low Cost of Capital

Lower Unit CostRefurbished Units

Smaller Footprint-Lighter Weights Extremity Scanners

Lutheran General Market GrowthSub Service Line 5YR Growth 10YR GrowthCT 6% 14%Mammography 6% 19%MRI 18% 39%

Nuclear Medicine 16% 31%PET 31% 78%Ultrasound 14% 27%X-Ray 1% 1%

Current Challenges• Increased Payer Scrutiny• Decreased Reimbursement/Changing Payment Model• Limited Capital Spending

• Older Equipment

• Increased Focus on Expense Management/Staff Reductions

• Higher Service Expectations• Growing Patient Price Sensitivity

• More Covered Lives at Lesser Rates• Higher Deductibles in Lieu of Lower Premiums• Increasing Price Transparency

CMS Decreased ReimbursementProcedure 2013 Rate 2014 Rate

CT Abd/Pelv w/o Contrast

$306.05 $229.84

CT Abd/Pelv with Contrast

$482.58 $367.23

MRI and MRA w/o Contrast

$706.85 $606.38

MRI and MRA with Contrast

$1,038.94 $899.36

CMS Price Transparency

Drag picture to placeholder or click icon to add

Current Challenges• Quality Mandates

• Radiation Reductions• Image Quality• Radiologist Sub specialization

• Changing Physicians Alignment• Employment Models• Group Consolidation• Physician ACO Formation

• Increased Expectations of Service Line Integration • Cardiac Imaging, Neuro, Oncology, Peds, Ortho, GI/GU

• Increased Growth Requirements While Payers and RBM’s Drive Volume to Lower Cost Providers

* Radiology Benefits Management Company

What does All The Doom And Gloom Mean?• Are you Improving in all of your Internal

Operations, but it doesn’t seem to make a difference??

What Matters to Your Referring Doctors?

Appointment A

valab

ility

Report Communica

tion

Pre Auth Assi

stance

Quality

Of Servi

ce

Patient C

onvenience

Leve

l Of T

echnology

Pt Out o

f Pock

et0.0%

20.0%40.0%60.0%80.0%

100.0%120.0%

65.4% 64.1%39.7% 38.5% 32.1% 23.1% 20.8%

32.1% 29.5%

33.3% 47.4% 43.6% 50.0%32.5%

Extremely Important Important

Conflicting Goals/Significant OpportunityPatient Intake Medical Imaging

Wait for Pre-Certification before scheduling

Same day and Next day appointment availability

Schedule patient 10 days while current capacity exist

Patients Refuse care and seek services elsewhere

Upfront request for Co-Insurance /payment

During Pre-Reg patients are asked for upfront payment

Focus on Reduced scheduling time on the phone

Patients don’t receive appropriate prep explanation

Options Abound• Physician Education

• CPT Cheat Sheets• Provide Doctors Office with Insurance and RBM Phone Numbers

as well as, and more Importantly Websites!!• Track and Identify Exams Most Likely to Be Denied

• Create an Imaging Based Concierge Service• A Direct Line for Referring Office

• Provide CPT Code• Insurance and RBM Numbers• Exam Prices• Estimated Patient Out of Pocket

Major Insurers in Illinois• Aetna PPO/POS/HMO – Pre Cert through Medsolutions

• Blue Cross Of Illinois- RQI Obtained Through AIM CDA and CTY Prefix is Pre-Certs obtained through Encompass

• Cigna PPO & HMO- Pre Cert through NIA

• Humana- Pre Cert through Health Help

• United Healthcare- Prior Notification Number through United Healthcare

Options Continued• Clinical Decision Support

• Contract Directly with Insurance Plans By-Passing RBM• Display Organizations Increased Focus on Utilization

Management and Appropriate Use• Track and Display Quality Data and Track Outlier Physicians

Provide Pre Cert For Physicians• Steps to Provide Pre-Cert Services For

Referring Doctors• Review Insurance Contracts• Request Legal Review

• Signed Contract From Referring Doctors Indicating that the Hospital Is acting on Behalf of the Doctors Office

• Must Be Offered to All Doctors, No Insinuation of Service Provided for Direct Referrals. This is a Service Improvement

• Pull Analytics On Volume for Your Site and The Market • Survey Referring Physicians! What Matters to Them?• Acquire Executive Support For your Defined Project- Emphasizing

Current Challenges, While Imaging Doesn’t Control Access

Steps to Providing Pre-Cert Services• Outline Proposed System and Desired Workflow

• Part of the Planned Solution must Include Matching Patient Intake and Imaging Service Goals, Grow Volume, Allow Access to Open AppointmentsMaximize Net Revenue Capture

Growing Imaging Volumes and Maximizing Revenue Capture Are Not and Don’t Have to Be Mutually Exclusive

• Employees Providing Pre Cert Services are hired as for attitude and customer service more than clinical expertise. They can be taught to mitigate the Pre Cert Challenges, This is more about relationship building

Typical Pre-Auth Info Needed• Patient Insurance ID#• Ordering MD Name and Tax ID#• CPT Code• Diagnosis and Symptoms• Previous Treatment • Imaging Facility

Primary Reasons For Resistance• No Appetite for Additional FTE’s

• Huge Margins, Run Cost Benefit Analysis of Current Net Revenue By Modality

• Establish Metrics Needed to Support Additional FTE’s • Establish Dashboard to Track Volumes and Where Referrals Are

Coming From

• Legal Concerns• Not an Issue for Owned Physicians• Please See OIG Advisory Opinion 12-10• https://oig.hhs.gov/fraud/docs/advisoryopinions/2012/AdvOpn12-

10.pdf

Takeaways• Ease of Access is Key For Referring Doctors• No One Solution Fits all departments, but you

need to develop a solution. This issue will only get worse.

• If you aren’t already, you need to design some Physician services in the short term.

• To align Patient Intake goals with Imaging goals is imperative and likely requires executive support