Melissa Hanley - Part 1

[00:00:13] Speaker A: Hi team. I can't believe it's already September. All the kids are back in school. Not that I have any, thank heavens. So I guess the summer fun is winding down, but the insufferable heat rages on, at least in Nashville. And speaking of heat, September also means baseball is winding down, and I'm happy to see the Phillies are still hot, football is now kicking off, pardon the pun. And I'm excited to see how the Eagles do this year. But not as excited as I am about today's guest, who is one of my favorite people on the planet and just so happens to be from my hometown of Philly. I'm Rich Vogel, and this is Stimulating Stuff. Let's go. [00:00:58] Speaker B: Foreign. [00:01:01] Speaker C: Welcome back to the Stimulating Stuff podcast. I'm Rich Vogel, and my guest today is not just a good friend, but she's also widely considered to be among the nation's experts in billing, coding and revenue cycle for neuromonitoring. Her reputation is of someone who transforms struggling neuromonitoring companies into going concerns and optimizes revenue cycle for successful enterprises. On the outside, she is a tough cookie. A ruthless negotiator, a meticulous shikari who chases down every last dollar for her clients. In other words, she's from Philly. On the inside though, she's kind and thoughtful, ethical and principled, giving and supportive. Someone you can't help but love and trust. Someone everyone would be honored to call friend. She is presently co founder, co owner and CEO of Veridical rcm. Welcome to the show. Melissa Hanley. [00:01:58] Speaker B: Oh my God. Some of that's true. A lot of it's true. But. But thank you. That. That was actually very kind of you. That was a lovely introduction. [00:02:10] Speaker C: You're very welcome. So now it's time to feed my insatiable narcissism. You and I met almost 15 years ago when I joined SMA. And for those of you who don't know, SMA was Surgical Monitoring Associates. It was a private practice neuromonitoring group that was founded and run by Dr. Dan Schwartz, who was one of the founding fathers of neuromonitoring. They we were based out of the Philadelphia area and extended from Maryland to Massachusetts. SMA was widely considered to be the best neuromonitoring practice in the nation, but they're no longer around because they sold to a larger company in 2011. Anyway, back to my narcissism. So we met over a decade ago at sma. Do you remember what your impression of me was? [00:03:02] Speaker B: I remember. I don't think I was part of your interview. I think by that. The interview process. I think by that time, I might have been out of the interview process. I remember my first thought was that twinkle in your eye. Because I'm like, oof. I just. I'm like, there's something there. And it meant you came across incredibly professional. I think that. And very intelligent, because they're both true. But I think the first memory was that you were never afraid to challenge the status quo, and that is near and dear to my heart, because we don't want a lot of little lemmings running around. You were curious, you questioned, you pushed back appropriately. But I think my favorite first memory of you was after SMA was sold and we had to go to the new corporate office. And we're all scared, you know, we don't know what the heck is going on. And we're all sitting there prim and proper in our nice little attire. And the meeting started sans Rich Vogel, and the speaker was speaking, and all of a sudden, Rich Vogel decides to enter the room. Now, he doesn't just enter the room. He enters the room like, whoosh. With this blonde hair going all kinds of ways. [00:04:21] Speaker C: I forgot my comb. [00:04:23] Speaker B: I am exactly. I am so sorry. I had to find my comb before I came to the meeting. And it just. And we all had, like, pucker factors, like 12 on a scale of 1 to 10, and you just kind of relaxed the entire room, and it was. It was just the perfect way to break the ice, the perfect way to introduce people to your personality and make people kind of give you a second look. A little bit scared, but mostly admirably so. That. That's really. And then just through the years, you've popped up kind of all over the place, but mostly as a voice for IOM to support iom And I think we're all grateful for that board voice. I think we need that voice. [00:05:09] Speaker C: Oh, that's so kind. So you would remember if you were in my interview, because one of the questions that I was asked was, have I ever given cpr? And I had to tell the story of me on Halloween night dressed as Lieutenant Dangle from Reno 91 1, when a guy went into cardiac arrest next to me. And there I am handing somebody off with a fake mustache and these short, just ridiculous. Handing somebody off to an ambulance. Of course, it was at a bar, and I was in graduate school. Nevertheless, that was quite a story to have to tell during my interview. Let's get into some actual interview questions. One thing, probably of many things that you and I have in common is a lot of letters after our names. Your certifications include cpc, cpco, cpma. Can you break each of these down for the audience and tell me what they mean and how they apply to your work? [00:06:16] Speaker B: So mine aren't near as important as yours. CPC is a certified professional coder. So it differs from billing in that a coder knows how to look at a chart and then kind of pull out those diagnosis that makes sense that are better relevant to the case, not just the one diagnosis code that the surgeon would deal with. But then it also shows us which CPT codes are billable, which ones aren't billable, which need modifiers to unbundle. And so that certification lets us gives us more information about where to find information instead of just looking at a super bill, seeing CPT codes or a tech report and then just transcribing them onto a claim form and out the door. So and then the certified Professional Compliance officer means that I, I'm required to follow the rules, I'm required to understand the False Claims act, you know, the starc, all that kind of kickback stuff. And that compliance helps with not only submitting clean claims, compliant claims, it also helps with contract negotiation and making sure that my clients are aware what the rules are, what they should follow and really how to protect the physicians that we're privileged to bill for. Because I think that's a very, very important piece to it. And then the third one is the medical auditor, the certified professional medical auditor. So I can basically audit anything. Don't ask me to do cardiac, way too many vascular families, but I can audit pretty much any kind of chart and make sure that it's compliant, not compliant, and make recommendations. [00:08:15] Speaker C: That's really interesting. I think a lot of people don't even know these things exist. And just as a follow up question because it just my ignorance, are there people out there who do billing coding that don't have this certified professional coder certification? [00:08:32] Speaker B: Yeah, I think that's part of the, the problem is I don't think people, I hope people don't do things that, that are non compliant. I think they just don't understand. Which is interesting because we build with so few codes, whether it be ICD10 or CPT, we don't build with that many codes. And it's amazing how you can screw the pooch with those. If you don't understand and people the wrong modifiers or they'll bill without the modifier and without those particular modifiers, you're not going to get paid. And they don't necessarily know the resources that are available to them. And so it always surprises me. And in the IOM world, you don't necessarily need a certified biller because a certified biller is more from the inpatient side. On the UB form, we bill with the CMS 1500 and we still call it HCVA even though it's a CMS 1500. The coder, the certified coder knows how to pull things from. They have an understanding of anatomy and physiology. They know what is important to pull from that H and P in order to get paid. And so when you don't have that, you have to have some kind of resource available in, in order to do it correctly and maximize the revenue. [00:09:56] Speaker C: Interesting. So as a business, if you are seeking out somebody and you know this is not by any means intended to be an advertisement for Veridical, this is a genuine question. The entire interview is not intended that way. This is just for people to learn about billing, coding, revenue cycle. So I just want to make that part clear. But as a business, it's clear to me that you don't know what you don't know when you get involved with hiring somebody to do this work for you. Because if you don't know to look for these things, for example, and you don't know what they mean, then it sounds to me like not only could you leave money on the table, but you may be, and we'll get to this later, but you may be receiving money that isn't actually owed to you and ultimately have to pay that back. We'll come back to that point. So I mentioned your business is Veridical rcm, and the RCM stands for Revenue Cycle Management. So specializing in medical billing related to neuromonitoring. You named your company Veridical, which I had to look this up. It means truthful, honest, accurate. Is there a particular reason why you settled on the name Veridical? [00:11:22] Speaker B: Well, we wanted to pick the hardest one to pronounce. You'd be amazed how many people forget those little eyes in there. [00:11:29] Speaker C: But you won that game. You have to say it slow. Veridical. Yeah. [00:11:34] Speaker B: And sometimes when we first started, I had to say, I had to like, break it down just like that. Just like I had to do before I could say interoperative neurophysiological monitoring. I couldn't say that for like the whole first year. But we wanted something that represented what was important to us and that being truthful. And that's not just truthful from a claim Submission standpoint, it's truthful and honest in our communication with our, with our client partners so that they receive honest feedback. What people choose to do as a business is up to them, but we feel it's important to give that feedback so at least they're aware. And I, I actually wanted Tenacity because I think tenacity is very, very important. But that name was already taken. So we went with Veritable, the second. [00:12:23] Speaker C: Part of Veridical, which I already mentioned. RCM Revenue cycle management. I think in the grand world of neuromonitoring there's people who know what that means and there's people who don't know what that means that we'll get into the services that Veritical provides in a second. But just very high level. What is revenue cycle management? [00:12:43] Speaker B: So sometimes you can think about it because it's a cycle and that cycle sometimes feels like you're circling the drain. But it's everything from scheduling, insurance verification, getting all the chart elements, submitting the claim, getting that claim adjudicated, making sure it was adjudicated appropriately, getting it reconsidered, appeal, whatever, receiving the payment, posting the payment, sending the patient statements, it's all. And then it starts again. So if your claim adjudicates and you have a couple line denials, you know, do you have the ability to get those reconsidered or do you can you appeal them? And then it starts again and it just seems like more and more it's just this ongoing cycle or circle that you, you're stuck with with the insurance carriers. That can make it a little bit challenging. But yeah, it's certainly a cycle. [00:13:39] Speaker C: You called it circling the dream. It sounds like circling the nightmare. [00:13:44] Speaker B: It can be, it truly can be. Because I think a lot of the carriers, the no surprise, the federal law came out what, a year and a half ago and there are still carriers that don't know exists and so they don't adjudicate the claims appropriately. And so it's be nice to your revenue cycle folks, whoever they are, because they are, they are. It is truly a struggle. Sometimes nothing is, is ever clear. And that cycle tends to repeat until you can make sure that you've optimized revenue capture. [00:14:20] Speaker C: Basically, yeah. And the struggle was real. I mean I just got an email today and I get them frequently, you know, last week or it'll be two weeks ago by the time this airs. I had this podcast episode on this new OIG advisory that came out and I had a few people write to me and they're like, you know, not really about that, but about previous episodes saying, wow, you know, I know that we're struggling in my company, but I didn't really. I thought we were alone. And now I'm seeing that everybody else is kind of feeling the same thing and the same pressures. And even though I'm feeling these pressures, it's actually better to know that we're all in this together. So it's nice to be able to say things that resonate with people, even if they're negative sometimes. So let's talk about the services that Veridical offers. I stole some topics from your website. So I want to name a topic or a service and you tell me what that means and why it's important. So the first one is infrastructure analysis. What is that? [00:15:26] Speaker B: So we want to make sure a lot of companies, smaller companies, don't necessarily have credentialing folks on staff. And I should preface it by saying there's nothing that happens in a company that doesn't hit revenue at some point. My background is actually in operations, business operations, laboratory operations and business operations. But anyway, every decision that's made and things that fall through the cracks need to be kind of shored up to make sure we protect the revenue cycle. So we want to look at each company and say, you know, do you have someone that does credentialing for you? Do you have all the, your the ptans that you need? Or are you linked to the payers appropriately? You know, what's. Whose responsibility do you want that to be? Is it going to be our responsibility? Is it your responsibility because you have that staff right down to how do you receive your money? Do you have a lockbox which is best case scenario but not always affordable by smaller companies. But when you get those payments, we need to be made aware, more importantly, how you're going to get the remits to us so that we know how to work those claims. You know, who is, who is negotiating your contracts? Or are you just getting a contract and saying we I have a contract sign in it without even understanding what that contract means. And so some people that are in this business don't necessarily understand and this isn't a knock, I don't mean this in a negative way because they just haven't been exposed to it, what it means to truly run an interoperative neuromoditoring company and have the support system, whether it be from somebody outsourced or internally, to make sure that everything is covered. Because if you don't have a good Scheduler, they may not schedule the right reader for the right type of case. Is that reader licensed in the state, not just credentialed in the hospital, but also licensed in the state. So there's all these little kind of idiosyncrasies that need to be kind of put in a matrix or understood by the business, by the biller, whether they're internal again or external. So that, you know, the worst thing you can do is do a case and not get paid for it. [00:17:56] Speaker C: Because volume without revenue is not your. [00:17:59] Speaker B: Friend, I'm telling you. Volume. And when you said that on your podcast, I was like, hey. And then you gave me credit for. [00:18:06] Speaker C: It, but I quoted you. [00:18:07] Speaker B: You did. But it is so absolutely true. Volume without revenue is not your friend. And I understand, you know, people want a big footprint and. But the larger number of cases you do compared to the amount that are not payable, all that does is decrease your net revenue per case, basically, and takes valuable resources away from what is now, from what is payable. And so people make choices to, to say, okay, well, I'm going to do this. I know I'm not going to get paid. It's number one, the right thing to do for the patient. And I'm going to consider it a cost of doing business. But with the shrinkage in revenue these days, it's really not. I don't know if that's the best decision to make, but that's not my call. But so really, the infrastructure, and we're very candid with, with our, our client partners to say, you know, like, redo, don't do this, and you can take our advice or leave it. But so that's really like the infrastructure, like what makes, what are their internal processes? And do they have all the people to make the right decisions to protect that revenue? [00:19:22] Speaker C: That's great. It sounds like a really important service. What about billing and collections process audits? [00:19:31] Speaker B: So what we have found to be successful is before a claim is even dropped, in fact, at the time of scheduling, the people scheduling really should capture understanding that there's some trauma centers out there and you're not going to get the patient's name or anything else. It's just, we have a case. You go, I get it. But many of the cases, the overwhelming majority of the cases are scheduled. And so at that time of scheduling, the scheduler should be able to get the patient's name, date of birth, all that kind of stuff, their insurance information, what type of case it's going to be. God bless them if they can get a diagnosis because they're going to know at that point whether there's a pre authorization is going to be needed or not. And so that, that begins the process. So the pre op has to be obtained and it has to be requested a couple days before the case. And then insurance verification, the worst thing you can do is waste time by necess by believing that face sheet because you can get a face sheet where the patient's information, you fund a verification and you find out that insurance is either incorrect, it's not valid for the data service, or you get a coordination of benefits, which means what you think is the primary payer really isn't the primary payer. You want to get all that information before you drop the claim so that you don't have to get a denial saying you billed the wrong payer or this patient isn't our patient. And so once that starts, it's easier to fix it and do it right on the initial submission on the claim that it is to chase it on the back end because then it gets into that kind of aging process and people have to follow up. And, and so if you get it right the first time and that, that's kind of what we, what we mean by that. When you know, get as much information at the time of scheduling so that you can assign the appropriate reader, you can verify the insurance information, you can get any pre op that's necessary. So when it's time to actually code the claim, everything is pristine and it goes out. In fact, if you listen, you can hear it squeak. It's so clean when it goes to the clearinghouse, really quiet. [00:21:56] Speaker C: I like that. So we have two more services to get to, but I just thought of a question and I don't want to forget to ask it later because we're talking about diagnoses and we're talking about face sheets. And usually at the bottom of a face sheet somewhere there's a diagnosis listed. Usually it's the admit or admission diagnosis. It's generally speaking, correct me if I'm wrong, but this is the diagnosis that the surgeon will assign to the patient, which they know. Generally the insurance company will permit them to admit the patient or perform surgery, but oftentimes the patient has other diagnoses. And usually during surgery there is what we could call like an intraoperative, even a postoperative diagnosis. So for example, a patient could have a diagnosis of cervical stenosis and pain and intraoperatively, and we'll know by looking at the MRI and seeing the patient's symptoms but if you ask the patient, I'm sorry, if you ask the surgeon intraoperatively, what is the patient's postoperative diagnosis, they may say something like cervical spondylytic myelopathy or cervical stenosis with myelopathy. So that cervical stenosis as a preoperative admit diagnosis that sits on the face sheet may be very different from what you would get if you asked a surgeon intraoperatively. And I think if I were to guesstimate, I would say well over half, probably closer to 80% of technologists out there, neuromonitrists, I like to use that term, will take the diagnosis off the face sheet and ask no additional questions. So I'm on a huge tangent here, but you mentioned diagnosis. How important is it to not just rely on the diagnosis that's on the face sheet and to ask questions when it comes to revenue cycle? [00:24:02] Speaker B: Okay, so you use the term tangent first. So when I go off, you can just stop me whenever you need to. [00:24:09] Speaker C: Never. [00:24:10] Speaker B: The diagnosis that the surgeon uses. We're an ancillary provider. I'm not a clinician. But you're an ancillary provider. And what the surgeon uses to say is a covered diagnosis to get the surgery approved can be light years away from what we need to support interoperative monitoring. So if you go, of course, a lot of times, and I've actually seen this, the patient comes in and they have like a heart murmur or something which is on the face sheet that actually somehow sometimes makes it to the report, believe it or not, has nothing to do with what we're doing. Sometimes it'll just say stenosis. And then we know by looking at the type of case it is, if it's cervical, thoracic, lumbar, whatever, the problem is that lumbar stenosis with neurogenic claudication will get you paid pretty much 100% of the time. Now, lumbar stenosis without can get you paid by some payers, but unless neurogenic claudication is documented, we have to fall back to without. And if that's the only if we don't have, if we have a face sheet that says something like, I don't know, something totally unrelated diabetes, and then we have stenosis, if we don't have that HMP to look through, to look at the Mr. To look at their notes from their office visits, there are many times when that stenosis will make it to the tech report, which will make it to the reader report. And if I don't go in and look and see. Oh no, this patient does ignore genic claudication. And oh, by the way, they also have spondylolithesis and they also have degenerative disc disease with radiculopathy. If I don't have that HMP and it's not. And, and one of the things I thought was great in your earlier podcasts were where you took the neurophysiologist or the tech and kind of describe their role and then the very next one you describe the physician's role. They both have very difficult jobs, but if we don't have that, the information documented and we can't pull the other diagnosis out of the chart, then all of it's for naught. It's not going to get paid. And I understand everybody's busy, I totally get it. But you have to remember that if it's not documented, it didn't happen. And we have to be able to point, especially because so many payers are now asking for reports. Back in the day when they asked for medical records, we would send a tech report, reader report, because the less you send, the less is discoverable, basically. But I'm pulling diagnosis from like all over the place to support that. Interoperative monitoring really was necessary. And this is the reason why, because they do have all these, these things. The worst chart I get isn't the 180 some page chart, which I do get a lot of and I don't mind calling through them. It's those charts that just say, have one thing. It's the face sheet that says stenosis and it's a couple waveforms and then the tech report and the radar port and I'm like, I got nothing. And as I'm keying it in, I'm saying words that I learned in the military. I know I'm not going to get paid even as I sit here and code this. And it's unfortunate because especially when we have where it says degenerative disc. But you don't give me a level. You know, how silly do we look? You're in the room, you're in the room, like, hey, maybe ask at what level? Because anytime we have to bill unspecified, it makes us look like we don't know what we're doing. And as billers, you're, whether you're an internal group or an external group, you know, the chance to ask anymore, that chance is gone. And if we think that the, the person in the room is going to remember, that's not even a fair request because you guys are, you know, you Guys are churning and burning. You're doing what you got to do and move on. And you're not going to remember day to day. And I wouldn't rely on that memory because you're so busy. [00:28:27] Speaker C: Right. So it takes no time to ask a question. Right. So we had to be time anyway. Right, Right. But I, I think that, you know, we live in this world and, and this is particularly true for neuromonitoring where people think that employment is a right and not a privilege. And it is a privilege. And one of the critical things that you're saying that people need to do is get an accurate diagnosis. And, and there's nothing wrong with asking a surgeon in every single cervical spine surgery is this patient myelopathic if you don't see it somewhere in the chart. And if the surgeon says yes, then I would imagine the next step is to write in the chat or somewhere a documented surgeon verbally confirm that this patient has myelopathy. Right. Because then it becomes part of the reimbursable diagnosis or more likely to be reimbursed. [00:29:27] Speaker B: Anyway, it's interesting because we see, we see some that like, I want to marry these people because they give us a beautiful. They've actually spoken to the patient and found out a lot of information about comorbidities. And they do an appropriate introduction in the, in the, you know, in the tech report and in that tech report they also say where per surgeon diagnosis, blah, blah, blah. And then there's others where we offer these modalities. A doctor accepted this modality and that was it. And I'm like, there's such a continuum of, I don't want to say competence because I'm not, I don't want it to come across as negative. I think there's a, there's a level. When I was introduced to interoperative monitoring, my background was in the laboratory. And so I wasn't introduced to interoperative monitoring. I believe, and I said this the other day on a phone call actually, that I believe the people that I was introduced to interoperative monitoring with @SMA will truly train the best of the best. And I remember people in tears. I remember you guys getting trained on, you know, for getting ready for the dabm. And it was, it was a tough place to be. But there was. SMA was always patient centric and SMA was represented by the best of the best. And I, so I got spoiled. I got very spoiled. And I don't necessarily see that level maybe because that level isn't necessary for the Bread and butter. But people need to understand that, that it should be patient centric. It should always be patient centric. And the only thing that represents that is your ability to paint the picture not only in your report but also in your conversations. The physician, because that poor physician is sitting there in a vacuum. Like they can hear, they can, you know, they can see that whatever, but they're not physically in the room. And so you should introduce your patient like you know, your patient. Not. I literally had to stop a chat from going to support a claim because it said I'm here at whatever hospital with patient and it literally had question marks in the chat. So then I make a call and I say if I submit this chat. And a lot, a lot of companies are not only asking for chats now, like specifically because they ask for medical records. I don't usually send the chat unless I absolutely have to. And chats don't go out unless they're reviewed by me. And that's part of the reason, you know, you can't have a 12 hour case and a six line chat. That's not going to fly. You can't say, here's my supporting documentation. Look how great and wonderful we are. And we've got question marks where the patient's name should be. So I'm a representing your company by sending that out. I can't, I can't do it. So I think documentation needs to be taught. I think everybody. I wouldn't want to go into the LRC and all those naked bodies and God forbid that. 51785. I don't want to get near that part. That's. And I know you guys are under the drapes. I've heard that term a lot. And I know you're busy and I know a lot. The only time I've been in the operating room was when I was patient and then I didn't know anything and when I had a run emergency on cross blood in. But I know it's busy and it's hectic and a lot of things are going on, but you're there too. You're there. Say something. You're part of that surgical team and you have every right to be there. You're there protecting their nervous system. And I know that there's like, I think it goes, if I'm not mistaken, neurosurgeon, orthopedic surgeon, God the Father and the Holy Spirit. Like, I think that's the chain of command. And I understand there's very important people, very knowledgeable people in the operating room, but you are there too. And you should be knowledgeable of what you do and you should be knowledgeable of how to document what it is that you're doing. But, but train your people. It's an important thing that you're doing. It has value. And for some reason, it seems we have people that want to put baby in the corner and baby's going to be quiet in that corner. And you're not just there to call an alert. You're. You're there as a respected member. I know when you guys were trained, you were trained. You, you, you better talk to anesthesia, you better get that the, the right type of anesthesia going and your surgeon knows you. You have the right to be heard. And, and unless you stand up for what you do and take pride in what you do, you're not going to get paid for what you do. Your documentation tells a story because no one else is there to hear it. So we have to go by that. [00:34:37] Speaker C: Yeah, I mean, the world that, that we lived in back in the day was if you went into a surgery and you were doing motor evoke potentials and you did not talk the anesthesiologist into giving Teva, you were called into the office and screamed at. So we always got Teva because the consequences of, not just for your personal well being and your personal psychological being, it was worth it to go and do that. [00:35:07] Speaker B: There are expectations and I think that expectations should be standardized for that across the board. [00:35:15] Speaker C: Absolutely. [00:35:16] Speaker A: Okay, let's take a quick break here. [00:35:18] Speaker C: For a word from our sponsor. [00:35:20] Speaker A: This episode is sponsored by the Neuropod. The Neuropod is a podcast for the neurodiagnostic community hosted by Jason Mayer. I'm a big fan of the Neuropod and I'm a big fan of Jason. I strongly recommend checking it out. [00:35:36] Speaker C: Jason, take it away. [00:35:38] Speaker D: Thanks, Rich. We love your podcast and we appreciate the opportunity to sponsor an episode. If you like stimulating stuff as much as we do, you're gonna love the Neuropod, the podcast for neurodiagnostic professionals. You know, not everyone has the opportunity to develop professionally in an environment rich with resources, physician involvement, and great leadership. In some labs, technologists can feel as if they're all alone on an island with no mentorship or anyone who even understands what they do. You are absolutely not alone. There are so many resources available to neurodiagnostic techs. You just have to know where to go to find them. In comes the Neuropod. Our mission is to provide you with information that can help you provide better care for your patients. Knowledge is power and more knowledge can lead to better patient outcomes. Each episode features a different subject matter expert from the neurodiagnostic community. These insightful interviews will help guide you through your professional journey. Invest in yourself. Go to your favorite podcast service and download or stream the Neuropod today. And if you have top topics you'd like more information on, drop us an email@ TopicSeuroScienceAdvisors.com. [00:37:01] Speaker A: And we're back. I'm talking to Melissa Hanley, CEO of, of Veritical RCM. Let's jump back in. [00:37:09] Speaker C: So we talked about infrastructure analysis, we talked about billing and collections process audits. The next thing is, and again we're talking about services that Veridical RCM provides. The next one is hospital contract support. I think we all know what the hospital contract is, but how do you support that process? [00:37:31] Speaker B: Well, I, I think there's, there are usually the other than the, this is what the tech is, you know, these are the credentials that the tech has to have and they, they want certain verbiage that says that it's going to be, there's going to be oversight, usually by a neurologist. Sometimes they get themselves boxed in and so what I always try to look at those contracts before they sign them. Number one, most say that the IOM company has the right, which is lovely. I think you have the right to bill and collect technical component. Yay us. No boo hiss. No take that out. Because you may have the right but you don't have the ability to. Because every payer contract has an ancillary services portion of the contract. Think lab, think etcher. So I was a lab tech. I didn't get to bill for my services separately. The pathologist could, he was the md. He's a professional. He could build a professional component. Technical component is a facility charge. And so we've kind of gone full circle where we never build technical component because that was what we understood. We would build the facility for the technical component. Then everybody kind of got very competitive and said wait, Ionm company A is charging you X number of dollars per case. We can come in and we'll only bill you 200 hours less or whatever. Then another IOM company under goes them and says, you know what, we're not going to bill you anything. We're just going to come in, we're going to get credentials, we're going to get our ugly scrubs that we, that you give us and we're not going to charge you anything. Per case, we're going to build a technical component ourselves. And that went on for a while, except that the definition of technical component never changed. Technical component is a facility charge. So now tons of recoups are going on. They've been going on and people are billing the technical component with 9594, which is a professional code, not a technical code. [00:39:40] Speaker C: I've heard of people doing that when. [00:39:42] Speaker B: We look at contracts. I've been on calls actually with I always encourage people to get compliance from the facility involved because the compliance people aren't going to want you to do services for free. The compliance people are going to know you really shouldn't be billing the technical component because it is wrapped in the DRG or the payment, the, you know, the contractual payment to the facility. And so once we drop, if we were to drop the technical component claim, that's double dipping. So I go through that, especially in an ASC. ASCs are paid under the outpatient prospective payment system. So that's different than like fee for service. Everything is bundled in the payment, everything technical, whether it's a sponge, whether it's the TC of lab, the TC of, of ilm, it's all but in a bundled payment, we can't separately bill it. It's. So we look at those contracts and say, hey, don't try to be sneaky, just pay us. You provide such value and protect. And it's not that the surgeons aren't wonderful surgeons, but you're there as a safety net and what you provide is genuine. It's not smoke and mirrors. And we've kind of discounted it in the way that we compete with one another. And I say we, but you as IOM companies have almost devalued it. And so now we're at the point and life was good back in the day, but now we have state surprise blow laws, we have federal laws, we have shenanigans, which is a nicer way to say it, from insurance carriers, not to pay a claim. And then we're not going to get paid from the hospital either. It's gotten so devalued that now it's, you have to go back to the hospital because insurance companies are not. Very rarely will they pay a technical component claim and 9 times out of 10 if they do, they're only going to pay the 95940 because they think they're paying the physician, even though the claim submitted under the tech. And that's when the 400 gets paid. But it shouldn't just wear a tie into the operating room doesn't make you a professional. A professional equals a license. And that's not a. Nor attack, so it shouldn't be bill. So that's what. When we talk about contracts, we're looking for those things. We're looking to see, do you have an out? Let's see. Let's see. You go into the hospital and you haven't done diligence, you haven't looked at the market, and you realize you're going in there and 90% is either self pay, Medicaid, and in some areas, that's exactly what it is. And you're like, oh, my God, I'm not making any money. How do I get out of this? [00:42:45] Speaker C: Losing money? [00:42:46] Speaker B: Mm, exactly. Or you're actually paying them to do the cases. You know, what is that? What are the terms? Does there have to be a breach before I get out? Or can I get out with, you know, 60, 90 days, whatever, notice with no breach? So it's looking at those details and saying, okay, is. Is there a part that says you have to leave information at the hospital? The tech has to leave information at the hospital before you go. A lot of times there's a lot of things thrown in, in sections where you wouldn't expect them to be. And then all of a sudden you're like, didn't. Didn't see that. And I don't necessarily think it needs legal review. I think it just needs somebody that understands the business that we're in to review that contract and to push back and say, now let's get compliance involved. Because I can tell you from a compliance standpoint what we can and can't do. And at the end, it's my job to make sure that everybody's covered. And at the end of the day, there are your reader and the reader's license and the billing provider, which is in box 33. That's the company. It's their tax ID and their NPI. It's not the biller. It's not anybody else. It's those people that are at risk. And it's our job as compliance people and as billers and auditors, whatever we are, to make sure that their license is protected, that that tax ID is protected to do the right thing. And I think a lot of times things slip through the cracks, and then people get surprised when they. They signed an evergreen contract and didn't realize it, and then they're stuck at nothing. And then they try to, you know, you try to renegotiate in good faith, and nobody that was Originally there that signed that Evergreen contract eight years ago is. They're dead. They're all dead. So. [00:44:39] Speaker C: Right. Hospitals have turnover just like neuromonitoring companies do. So, and then the last of the four major services that we're talking about is outsourced billing and collections. And I think we already covered this, but just want to make sure we didn't miss anything in that piece. [00:44:58] Speaker B: There are times when I will tell people, when they ask about our services, depending on their size. And sometimes it's more appropriate actually to keep it in house. If you can get people that understand what they're doing, keep it in house and I'll turn business away because it makes more fiscal sense for you to do it. Because, again, I mean, I am, I have an mba, but I do feel a certain sense of obligation to people to say, if you can find somebody to do it in house, it might be better for you to do it in house. If you can't, though, at least ask questions of those people that you're having do it. It doesn't have to be me. It doesn't have to be veridical. But questions you should ask are, you know, what is your background? Do you understand? Like, when I first got into iom, I didn't even know I had a gastrocnemius. I thought it was a boy part. So, you know what? No, what, what is your background? Tell me when we're doing an mep, why we would do an mep, you know, why. You know, how are you going to build that? How do you extract documentation, you know, the, the diagnosis from it, from the chart, or you just looking at that tech report, God help us all, and putting it on the claim form. Because the, the, the techs aren't, they're not, they shouldn't be expected to be coders that you're not. That's not what you do. That's what, that's what coders do. You document the best you can. I'm not going to bill what you have. Bless your heart. I'm not going to bill what you have on that claim form or, or on your tech report. Because I'm seeing like, tech reports where they're, they're obviously, I mean, it's a, it's a form, right? And so you're just plopping in the muscles. But I'm seeing lower EMG with hand muscles, like, and if I'm just counting muscles and I'm not realizing where that muscle is located in the body, I could be billing a 9, 5, 8, 60 instead of a 95 or 95861 instead of a 95870 times 2 or whatever. So you know, ask people when, when, when you're, you're talking to a potential biller or, or a revenue cycle company, you know, what is it that you know? Do you understand that the trapezius is really a cranial nerve supplied muscle? Do you understand that if it's documented in the chart that you're using a NIMS tube, do not bill 95865 because 95865 is needle EMG. And if you have I'm billing needle EMG and NIMS tube is slapped all over that tech report, you can't bill needle emg. So there's certain things that you can do and there's certain things that you can't do and you have to understand the difference. And I think a lot of times people will say, oh yeah, I've done this before, I know how to build, I know how to, I know how to build. I can bill, I can bill, I can code. How difficult could that be? I can tell you there's not one company that I have looked at, whether I, I've taken them on as a client or they've asked me just to help them out, that has done things correctly. [00:48:12] Speaker C: That doesn't surprise me at all. I'm going to zoom way out right now and just kind of from a high level business perspective. I'm a big fan of businesses that have some sort of a vision and mission statement and no judgment if you don't. But what is yours if you have one? [00:48:33] Speaker B: We do. I mean I have my own in my head but we actually have it written. We have a handbook and everything. Our mission. I'm going to try to read this without my glasses because I did have to look at it to assist our clients in fulfilling their organizational goals by efficiently managing their revenue cycle vision. Vertical RCM will be this country's premier revenue cycle management organization. We will always provide insightful, honest and compliant services to our clients. Clinical and business operations. We facilitate true partnerships with our clients, allowing us to move forward together as a team. [00:49:10] Speaker C: I like it. It sounds like you're well on your way to that, so I want to read something to you. And this is a quote from one of your blog posts on your website that is entitled the Business of iom. In that blog post you said quote, being in the business of healthcare and not being an IOM CL clinician myself, I do my best to try to constantly learn as much as I can about the nature of what you actually do so that I can learn. I'm sorry, so that I can most efficiently and compliantly translate your services to the revenue cycle. My question is this. How does the knowledge that you've acquired about neuromonitoring help you to translate IONM services into revenue? [00:50:07] Speaker B: I. I think I was, have been blessed again coming up through SMA and being able to ask questions. I can look at the waveforms, you know, and yes, they are still squiggly lines to me and, but I'm looking for. If I'm used to seeing something documented, if it's a cranie and I'm used to seeing EEG and that for some reason isn't documented in the tech report, then I know you're running EEG and I know I'm going to bill 95822, but I'm going to look for eight channels in your waveforms. I'm going to look to see when I see those upper extremity muscles. When you document lower extremity emg, I'm going to go back to your waveforms and I'm going to look for two things. I'm going to look for the muscles listed and I'm going to look for laterality because a lot of times people don't document laterality and sometimes I'm going to have to take some snips from your waveforms to support billing it because if it's in your waveforms and you neglected to put it on your, your report, well, shame on you, number one. But don't think I'm giving up the fight. I'm German and Irish, I'm stubborn and I'm going to fight. So I'm going to take those waveforms and I'm going to submit them to prove that you did what I build because I'm not going to build something that's not documented. But if it is documented somewhere, I'm gonna find it because I know what to look for. And unless the doctor said I don't want MEPS or the MEPS are contraindicated and it's a cervical case, I'm going to look for them and I'm going to wonder why you're not doing them. And you know, I'm going to wonder why, why you would do an upper if you're doing a lower lumbar case. And, and it also helps when we know that certain cases, the time codes and add on code, you have to have a primary code to add on to. And if you Only built. You're doing a thyroid and you're only monitoring the recurrent laryngeal nerve and the time code. But we've already discussed previously, as I would have it, they're using a NIMS tube, so you can't bill the needle emg, because needle EMG is not documented. You have a primary code you can't bill. So then I know if it's clinically indicated, you can monitor another muscle, and then that can then be your primary code and you can still get paid. And we were blessed when we first started. Craig Matsumoto, I love him. He helped us build our training for our, for not only our, our billion coding staff, but also our AR staff. So we have full presentations of what an MEP is, what it looks like. We, you know, all the different modalities. He kind of broke out for us. So whenever we get new people and even, you know, we go back and revisit it for people that have been with us for a while. This is what it is. And you may say, well, that doesn't, you know, who cares? Well, I care. I care that they understand when they're trying to get an MEP paid, what to look for in that chart from, you know, on the back end when they're trying to do the collections. You know, we should all care that we can speak the language that of the business that we're in. And so that's how it kind of helps us to translate it and look at it a little different and not just see something, bill it, and assume that that's going to be correct. [00:53:47] Speaker C: That's a very good explanation. Thank you. And Irish and German. That's another thing that we have in common. That's why we're both trouble. So in a separate blog post, you discussed chargemasters and how neuromonitoring groups charge for services. And in this post, you pose an interesting question regarding how to price neuromonitoring services. Here's the whole quote. So too low of a charge means that you may not properly be valuing your services and therefore not receiving fair market value for services rendered. Then you go on to say, and I'm still quoting here, what about the other end of the spectrum? Is, quote, too high, reimbursement an oxymoron? Can't we charge what the market will bear? Is there such a thing as charging too much for a service? End quote. I'm sure you get this question fairly often. How do you tend to answer it? [00:54:43] Speaker B: I get that question all the time. And this is the way I answer it candidly. Number one, you absolutely can charge what the market will bear. God bless America. The problem with that is your interoperative monitoring is all about relationships. It's your relationship with your surgeon is your relationship with your facilities. And if you charge too high, the patient gets the eob. They don't necessarily understand how to read the eob. It says this is not a bill. But then their eyes go right to that patient responsibility part, which isn't really their patient responsibility. And they're teetering on the edge. So they're either going to jump or they're going to go right, run into that surgeon saying, look at what they're charging. And then the surgeon has a fit and says, why are you charging? Blah, blah. So yes, you can charge what the market will bear, but you also have to temper that with your relationships because nine times out of 10, even before the no surprises act, you're usually not going to get payment in full, right? But you have to charge it high enough that those payers that will pay those codes and will pay them well, pay them well. If you charge too low, especially in this day and age, you're, you're knocking yourself out. Not just of getting. Sometimes I've seen people want to build lower than like the in network fee schedule. I'm like, what are you doing? Like, you're not going to make, even if you don't, even if your internal team is doing your revenue cycle, you're not going to make money, you're not going to cover your cost. So I try to talk to them saying, look at, do a break even, see what you're, you know, see what your cost is to perform this, add whatever margin on and then take it from there. Usually what I use as a guideline is the medical fees book. It's put out by PMIC and they take like hundreds of thousands of charges throughout the country and they break it down into the 50th, 75th and 90th percentile. And then I take their geographic area and do the geographic adjustment for that area at the 50th, the 75th and the 90th percentile. And I say, here's all these pretty colors on the spreadsheet that can be a little confusing. Pick one. And they say, which you recommend. And I say, no can do. Because again, it goes back to those relationships. If your patient goes to that surgeon, what is that going to do to your relationship? Maybe you don't care, but if you do care, I'm not going to be the one that that's not up to me to set. Now some people recently have raised their fee schedules purely because of the cost of going into idr, which is a whole another mess. But I will say God bless the country of Texas for having the set to take the government to court and represent because they won again and hopefully that'll make life easier for everybody. [00:58:04] Speaker C: I wish you hadn't said that because I, I think I had finally convinced Beth that, that Texas isn't a country. And now you've just validated that they are. [00:58:13] Speaker B: You know what, they fly the flag high because who else is, is collaborating and getting it together and saying, you know what, enough is enough and we're going to hold you, we're going to hold you accountable because you're killing us. And they have, you know, everything's bigger in Texas and they're, God bless them for doing it. [00:58:39] Speaker C: I did some research a number of years ago to find out why surgeons go without physician oversight for neuromonitoring. Why they prefer to just have a technologist. And the number one reason at the top of the list was their patients getting EOBs and calling them and complaining. And they don't want their staff feeling these phone calls. So they decide to go without a neurologist because they don't want the patients, even if they're not getting billed, they're getting these explanations of benefits that are freaking the patients out. So the downstream effects of having what we might consider to be too high of a charge is that you lose the oversight, which is your ability to charge. So you kind of have to have a longer game strategy to have a sustainable business as opposed to try to get, you know, front loaded money and then go out of business down the line. [00:59:33] Speaker B: Well, I mean there's an easy, there's, it's, it's, there's a very, very easy way to deal with that and it's, it's communicating. So when before, you know, we usually send a letter out and the letter has our contact information and the letter will say this is what a co insurance is, this is what a deductible is. No, you're not going to get balance. Bill, don't. You know, I, with the laboratory background, you know, everything is a laboratory's fault, right? People are starving somehow your laboratory's fault. So I'm very used to getting yelled at and I've been yelled at by the best and I can get yelled at. I, that's fine. And then after they're done yelling at me whether it's a patient Whether it's a surgeon, whoever, I have a conversation and say it's okay, relax. The only thing that they're going to be billed is this. And this is because we have to. We're never going to balance bill a patient because that's just, that's just poor manners, frankly, other than being against the law. But don't devalue the service that you're doing because you're afraid to have that conversation. Now if you're, if you're billing over a hundred thousand dollars for interoperative monitoring per case, that could be an issue. I agree. I don't know that I could have a straight face argument for that, but. [01:00:51] Speaker C: That'S how you end up on the news. [01:00:53] Speaker B: Exactly. So, so just be reasonable. But, but don't devalue what you are doing and the services you provide to help the patient wake up, number one, and wake up without a deficit. And that. And I'm not just talking from a lawsuit perspective. I mean that, that medical legal part aside, you're giving people back their lives without pain and you're a part of that and that's valuable and that is reimbursable. [01:01:30] Speaker C: And I think it's important to say absolutely, totally agree. Great point. [01:01:36] Speaker A: Hi everyone. I'm going to jump in here. This is such a great conversation with Melissa Hanley that I decided to split this into two episodes. So we're going to pause for now. Be sure to tune in next Monday as we talk about common documentation errors that create challenges for billing and collections, what Melissa thinks about the Blue Cross Blue Shield requirements for live bi directional audio communication, and the potential repercussions of keeping money that doesn't belong to you. In the meantime, please continue sending your comments, insights, critiques, pushback, validation and thought process provoking questions to stimulating stuff. Podcastmail.com I always love hearing from you. I'm Rich Vogel and that was stimulating stuff. [01:02:28] Speaker E: The information and opinions provided in this podcast are those of the individual speakers and do not represent the opinions of the their employers, affiliates, or other third party individuals or organizations. Sponsorship and other advertising messages do not constitute support of or preference for specific products or services. This podcast is not designed to and does not provide medical advice, diagnosis, opinion, treatment or services. This podcast is host and all participants, including guests and sponsors, collectively participate. Participants provide general information for entertainment purposes only. The information provided in this podcast is not a substitute for medical or professional opinion and you should not use the information for that purpose. Participants shall not be held liable or responsible for any advice, course of treatment, diagnosis, or any other information services or product you obtain or render. This podcast should not be used in any legal capacity capacity whatsoever, including, but not limited to establishing a standard of care in a legal sense or as a basis for expert witness testimony. No guarantee is given regarding the accuracy of any statements or opinions made on the podcast. Thank you for listening. [01:03:52] Speaker B: Sam.