Optimize Reimbursement Schedules

April 23, 2020 Dental Whale Season 1 Episode 10
Optimize Reimbursement Schedules
Optimize Reimbursement Schedules
Apr 23, 2020 Season 1 Episode 10
Dental Whale

Being proactive on insurance and revenue increases during and beyond COVID-19  has not been widely reviewed in dentistry.  One of the industry's greatest missed opportunities is that practices do not reassess and recognize UCR and carrier schedules, fee management and optimization, credentialing and compliance, and code submissions. APEX CEO, Harold Gornbein shares practical tips and insights to perform today to bring in revenue opportunities and leverage reimbursement best practices during downtime. 

Show Notes Transcript

Being proactive on insurance and revenue increases during and beyond COVID-19  has not been widely reviewed in dentistry.  One of the industry's greatest missed opportunities is that practices do not reassess and recognize UCR and carrier schedules, fee management and optimization, credentialing and compliance, and code submissions. APEX CEO, Harold Gornbein shares practical tips and insights to perform today to bring in revenue opportunities and leverage reimbursement best practices during downtime. 

spk_1:   0:08
Good afternoon, everybody. And welcome to this edition of insider Baigent Whale. I'm Vance Taylor. It's day. I'm joined by Alex Goran Fine. From a pecker. Okay, goes I said Alex because it was Ah, you know, I did that when I started emailing you too, Because the apex, right by your name in the signature. And I just kept wanting to say Alex had to go back and change about my

spk_0:   0:32
I you know, I may pay. I'm a I'm a plea. Played a few characters in this lifetime, so we'll see. You never know what might be in Alex Sunday.

spk_1:   0:39
I fear the plankton team is gonna love all the b real from these. Yeah, I have yet to successfully do a first try on the interest, so let me try again. I l gorn byline from Alex came from a picture and persons number is not my first time. Okay. All right. Good afternoon. And welcome back to this edition of Insider by Dental Whale. My name is Dance Taylor. And today I have the good pleasure being joined by Harold Gorn Byline from Apex Reimbursement specialists Harold, it's good to have you.

spk_0:   1:13
Thanks for having advances great opportunity.

spk_1:   1:16
Yeah. So we're excited about this because I think this is an area where our viewers really to do some help and guidance. Why don't we start just to give some context and let them know why? Why they should care what you have to say my name. Tell us little about who you are, how long you've been around and what you've been doing in the dental industry.

spk_0:   1:31
Sure. Uh, eight banks Reimbursement Special started back in 2012. Um, in some industries, that doesn't seem like a long time, but in dental, um, it z many, many moons ago. Uh, we got started. It was our primary focus. Pboc negotiation. Um, and it grew really Teoh above that. People. The negotiation credentialing, coding, UCR etcetera. Um, that's been about eight years or so now. Prior to that, I spent about 25 years in the insurance industry side of things on the actual insurance carrier side, uh, work for civic your health systems out of the West Coast, which is acquired by UnitedHealthcare. Uh, way back when, um spent time it emeritus and united Concordia A swell as dental benefit provider. So my experience really being entrenched in the dental insurance world, from the sale side of things to the building of the networks to retaining the provider. So that's been able to give me and my team here. It's a nice background Teoh to use to help our plants.

spk_1:   2:35
Excellent. OK, great. So that so that you and again, Like I said, this is an area where I think every dentist needs some help, right? And so, especially the dental practice owners.

spk_0:   2:47
I think right now that you know, as you know, being proactive and preparing hopeful, we hope someday and probably hopefully sooner rather than later that we're gonna emerge. Practice will open up slowly but surely on. There's been a lot of good information out there regarding compliance and loans and financial management. Um, in HR management, our world that deals with insurance and and revenue increases from this side and a proactive side hasn't gotten a lot of exposure, s so I think your take is right to be able to speak about that today. Hopefully we can give your viewers and practice owners just some practical tips and insights that they could do now. Uh, during this period of in activity months, a lot of things that they're doing. But our world of revenue generations, general regeneration, is not fear. They could be proactive with now, that's for sure.

spk_1:   3:42
Yeah. I'm really glad you mentioned that. I mean, I think every conversation currently has that element of But how does this make sense now during the situation where we all currently find ourselves in? So maybe talk just a little bit about that. What? From a free from a fixed fee management and optimization perspective. What are some things? If I'm a dentist, I own a practice that could be doing to take advantage of the downtime and be a practical productive?

spk_0:   4:07
Yeah, I think with practice owners should should recognize is during this downtime eyes that they do. They may have time now that they didn't have before. They're busy. Brennan. This is practice, as you know, just the busiest place on earth. So taking time to look at their there fees, fee schedules. Whether it be there, you see our cash schedule or there carrier the schedules and the cure is a participate with Amy, and I look at very often they need, you know, just just kind of a good price every day. They not be spending too much time with that. But now you've got time to slow down. Unfortunate kind of forces load in a little bit. They can really look into it. And I am participating with the right carriers for my market are my fees, said appropriately, Um, so I'll give you an example. There are some some good, some nice solo practice practice. Boehner's out. They're calling us saying, Hey, what can we do during this time? So we're advising a few of these other a few a few these points, which I think hopefully answers. Your question is, what do we do about our fees? Is this a good time to look at that? So we recommend some very practical, easy to do things. Look at your UCR fee schedule that cash pain fee schedule. In your practice, you might be thinking yourselves where most my patients are insured paid patients. But you know, every time I ask the practice owner, how much of your business's cash? These you tell me 10 20 maybe even 30% in some categories. But when I asked when was the last time you said you're used to our fee schedule with one's last time you go to those these, they might say 2345 years. That is an eternity in this business. We definitely recommend looking at your cash paying fees on a yearly basis. So the same practices that might have might have 10 2030% cash Being patients, you might be artificially low. Uh, set your fees might be very low for your market. You mean, I've been realized because you have. You haven't looked at it in a while so you could be leaving the tremendous amount of money on the table. I was looking at a practice recently. Just just you see our guide and something very basic. And after we analyze this big, their clients current fee schedule that they had in place, which has been a couple of years, looked at it. There are about 25% below really where the market waas and I always asked, you know, I was asked, Why have these just so well we're worried about our patients going down the street for maybe a lower cost provide. The reality is, if you're looking at your fees regularly, just like your competition down the street is your feet Should all be set appropriately. Um, so there's there's there's a lot of opportunity in the UCR Um, you might have some questions specific to that, but, um, I'll stop here. Just I won't bore you with these ER, But these carrier of these schedules are also very important to look at and also the practice analysis report when it comes to their code utilization. What coach always committing? Are we submitting the right codes? Are we taking looking all the procedures that we could be doing? So these three areas air real practical. These for me on what we advise our clients on, is a very practical thing that the average practice owner can look at an initiate and be proactive with.

spk_1:   7:17
Yeah, those are great. There's a great tips. I I'm curious if you have any insights that you could share or maybe even some use cases about specifically, you mentioned that there's assumptions and what I find a lot in dentistry is is assumptions round rampant misconceptions in all all facets of of the dental business, An operational model, Um and so I'm just I'm curious. Do you have any information you could share about the reality of patients, price shopping, their dentists or the rate of attrition when patient or when doctors razor ucr to market standards. Can you maybe help dispel some of those myths?

spk_0:   7:56
Yeah, it's really interesting. I think it really is. Um, it we have not seen it in riel time. Practical experience Where? Let's say, you know, we take a look at your feet schedule hypothetically for a 1 20 you know, Dio Ah, 1 20 you go from. That's a $50 to $55. Just your your cash, your cash painful as as a patient walked down the street for that $5 or for that $2 down the street. We don't have the experience or any any real data that shows that people are leaving. Our clients are not telling us since we increased our fees, are we losing? We're not hearing that because it's incremental. It's almost like if if you know if gas goes up two cents or you're gonna drive down the next two blocks that say that to sense, most people won't but really, for your for your for your clients with dental appliance and practices in general that $5 over hundreds and maybe even thousands of procedures a year really add up and really impact a pot online Where your patient getting great service, you're retaining your patients and your priced appropriately, Um, and yet your bottom line really goes up incrementally. But we're not. We're not seeing the loss. We're only seeing the wind in that.

spk_1:   9:08
Yeah. Excellent. Great. Okay, so So very good. Let me ask you a question about credentialing, if I can, so and again, I'll kind of keeping the same pain. I think this is an area where, um practices often get caught where they either didn't follow the right timeline or they made miss assumptions about how long this process takes or what it looks like. And then they're ready to see patients, and they don't have everything in order. That I need to talk just a little bit about some of the mistakes are common misconceptions that practicing his make when it comes to their credentials.

spk_0:   9:38
It's interesting. There's there's misconception. We'll talk about maybe some mistakes that we see people making on the misconception beside. Don't assume that your credentials the first time that you have a started or you acquired a new back when you know your your clients might be thinking of buying an additional practice for their first practice in general, um, realize when you start that credentialing process, you really need to allow 90 to 120 days for that credentialing to take back. Yeah, it may not take a lot of time to fill out the paperwork or fill out for us. We use Web portals for how we how we spent applications. But in general, that manual process itself doesn't take long. But when you send it to the carrier for their pasta, it getting 90 to 120 days. So let's say on the acquisition side or transition. Yeah, we had were client that eyes their second practice, and they're scheduled to close on June 1st. Well, today is April 21st. They think we're gonna close on Jean first, we'll be ready to go. The reality is there's no way between now and 21st of April and June 1st that that practice you're gonna be a credential practicing provider in that practice within 30 40 days. So you may be able to be maybe caught in a situation where if you're going to service those patients, you're serving them in and out of network basis, which will create some unhappy patients. But they feel that they're seeing you is never providers. That's one thing they want. A misconception is it does. Oh, no problem Doesn't take long. No, it does take a long period of time, so you might want to jump on that as soon as possible. Um, the other side on this conception of the world of credentialing that they need to be concerned about is Are they Are they? Do they understand that credentialing itself does renew every year, every two years with some carriers and that if they're not following up to re credentialing themselves, they can follow compliance and really find themselves out of network? So when those claims could start getting denied after their submit, you know they're spinning their denied and in their submission or there he'll be says, Well, claim was denied because the provider was out of network or their claim was reversed on at a network level. Well, that could be that the early watching are they credential today? Is there a need for re credentialing. So for us, we really want to be careful in the world of credential compliance and part of our credential management services Really overseeing that? So our dentist do not fall out of compliance and are always up to date with their credentials. Spider. So, um, something's the mistakes that really is a mistake, that you may find yourself out of network and I didn't realize it into your view. Those GOP so be cognisant of when you join. What? You're what you're Reuel re credentialing date is be on top.

spk_1:   12:29
Okay, Yeah, very helpful. And it sounds like you got services and solutions. There's had to help help manage that. So that's great. Um ah, a couple A couple of rapid questions here. Then I think we'll let you go. I gotta really appreciate your time. But maybe before we break I'd be interested in and I ask everybody this and it's a little bit of a curveball, because I I didn't and in a prep you for this question. But I'm just curious from your perspective, cause everybody's looking at this challenge with Kobe, it and the impact on dentistry and office closures and what's emergency was essential. What is a safe practice? Look like there's all these moving parts. I'm just curious from from the land through which you see dental. And you, uh, in interface with the dental industry. What does the new normal look like? If you want to spend a couple of minutes, I'd love to get your thoughts.

spk_0:   13:15
Yeah, I think we'll everybody doesn't. We don't. None of us have the crystal ball. But I think if there's any indication from other industries, um, it could be the follow And in dentistry is we all know industry your in the chair with the patient. You have as much protective gear Lee have. You may be required to prepare that patient, uh, in more protective gear. You might I don't know. I know you were sent a chair where the where they just put a mask on me. Um, it could be that that then the patient needs to wear a mask. Could be the patient needs to work. Love. It could be this staggered approach to seeing these patients meeting. Are the days released in the near future? Will waiting rooms be packed? Probably not. The may stagger they have to stagger. Those appointments will be mandated to stacking. Those appointments may get our apart, So that adds a new area of additional area of protection. Um, I saw something this morning. Also, it could be that dental practices themselves may become testing sites for Kobe. They man purchase some type of, ah, testing equipment before the patient comes the office. Or maybe insisted the chair, that there's some type of quick, uh, any easy administrative type of test that they can verify that that patient also doesn't have Kobe. And that might be for a pretty time, um, for that

spk_1:   14:36
day or that they have the antibodies,

spk_0:   14:38
right? There could be some testing that today they're not required to do. But I can see has a gradual approach. They become more relied upon for testing. Um, if I could relate almost to the movie industry, right movie theater for close. But you're seeing today I saw published a conversation that Cinemark, one of the one of the the CEO there, you know what as they look to reopening movie theatres may be June 1st or July verse in that in that area, they may only sell out 50% intentionally and at the stagger the seeding to keep people apart over a period of time. Dentistry? Maybe that's in a similar way. It could be that today you've got a 12 out practice. In the heyday, you would love to have almost 12 outs occupied, and patients in the in the in the waiting room could be that maybe every other op is occupied. For a period time. I could see a ramp up. Um, those fighters impractical things that I'm hearing, and that could definitely come into B. But like all of our clients asking similar questions, you ask, they're gearing up for it on, and I think they're They're also asking a lot of questions regarding infection control. Will there be additional codes to think about to be reimbursed, additionally for in a code specific to infection? Because they're gonna have been bet they may have to invest MAWR into their practice in the world of infection than what they have in the past, even though they've done a great job, they didn't have to go a little bit further in this in this new environment. So, um, were enquiring that as well with the carriers. So there's some things that we're hearing. Hopefully, that's helpful.

spk_1:   16:19
Yeah, that's interesting. Like I said, I think everybody has, Ah, different lands. And so we're all in the industry. But maybe looking at it from different angles, that's good. It's good to chat about. So last question, and then we'll let we'll let you go. Harold again, Thank you for your time. But, um uh, you know, at the end of the day, I think especially because of the area focusing and then specialisation and expertise that you have. Ah, a lot of our our viewers are going to want to know what the impact is financially. So I'm curious. Um, from your perspective, if you have some data points, maybe you could share with our viewers, help them understand What is the actual impact in terms of dollars left on the table when practices, their fees aren't cracked or they're not coating correctly. I mean, if you maybe have a couple pay cities, like are like we're talking about, go through this process and maybe confined fiber, $10,000 a year. Maybe it's name is not critical, but yeah, maybe you could share some insight. There

spk_0:   17:11
Yeah, the good. It's a good point. It really adds to this. Number one. You want to be proactive in your practice and you want to know kind of what what opportunities do exist. I think there's some short term opportunities, and there's some. There's some probably more long term, proactive opportunities that it practices to think about in the short term. Practices need to understand that the on the negotiation side, the fee schedule evaluation side of the business for us, it's been nonstop in some great opportunities there because the reps that we're dealing with at the insurance companies themselves haven't skipped a beat, most of them at work remotely. Um, always they were promoting always. So our team is actively in communications of them and in actively reaching out to them and see and result, Um, and so those results might might range from anywhere from 33% improvements and a fee schedule to one Recently, I've gotta get a practice in Mexico. Surprisingly, uh, had about a 30% average increase in their fee schedule. Now that's extraordinary. I need you practices like stock market. Past performance is no indication of future performance, but I think in that case, and this is a good lesson for practices in general. It could have been a while since that practice actually looked at their fees. Could be having looking to use er fees on the U. C R. V. You might ask. Well, how does that relate to insurance fees? Well, some carriers do look at where you holding in your UCR level relative to the insurance schedules. They want to keep that dealt with that space in between. So often you see, our would have an impact on negotiations. So there's one practice in. In New Mexico, there was a 30% average, I think in that case it's been a while since they've looked at their fees and updated their fees on. Timing was great for us, and we had the right contacts the carrier. So there there could be anywhere in negotiation. Three Top me, 30% improvement in in a few schedule and you have a look at the actual revenue practice to know what that looks like. You see our side of things that they can do right now. They can be proactive and looking to use our schedule. I can definitely see a 5 to 10 10% improvement in a in the UCR fee schedule. As we typically see, we typically see that that practices undervalue and underprice or current UCR. So that's something to do today. The coding side of the world a little more long term, long term outlook and approach because it really takes more of an active involvement for practice to change that. But I mean by that is, if we're taking a look at production of the last 12 months, we're gonna see certain codes that are unusual under you. Life means that they should have been done relative to the other procedure they were doing, and the practice really starts looking into that. Looking at that area of utilization, for example, as in the world of period, you've got 1000 adult patients in that fact. The American Academy of Criminology says that 48% or so of the average adult has some level period Titus. But if we look at a production report, we see maybe 10% period codes like a 43414342 or even a 1 80 which a burial exam we see 10% utilization that practice that doesn't really make sense relative to a practice with 1000 adults. If the American Academy says there's there's there's 48% typical hepatitis cases out there, that's an opportunity to look at now doesn't mean you go from 10 to 48 overnight. You have to start looking at these practice or excuse me, your patients. In a way, you start examining and looking at at a certain way, you have to put up aerial program in place that you may not have to sew these air these air areas. One you do right. You know, proactive. In the short term with you see our fee schedule to go feed the schedule. Negotiation evaluation is available that when miss numerous is that carry Don't negotiate. Well, there are plenty carriers that dio some curious, some curious don't to be to be perfectly frank, but there are some that deuce and now still a good time to look that encoding to something want to look at right away as well. These are all areas that you could be proactive on your own, and I recommend if you feel that you've got the competency to do that. If not, um, you know, APEC is definitely here to have to make ourselves available to to your clients in a, well, clients and the practices in general. We're here to help.

spk_1:   21:27
Yeah, great. And I think it's a nice I mean, I used to get a nice Segway in transition because again, not only are we all wondering what the new normal looks like, we're also all wondering How do we make up the Delta's much of the Delta's we can of the last six eight weeks where we've seen just the production dropped down to emergency, an essential only in most states? And this this seems like one of multiple of a multi pronged strategy that these rec centers need to implement to do everything they can to help themselves recover. And if you can come back from this with, um, more and better aligned fees and practices, all the better for recovering that lost revenue production.

spk_0:   22:08
Yeah, I think the biggest take the biggest mistake, whether it's in dental practice or anything, Life is, is sitting on the sidelines and do enough, so it has a great kind of practice.

spk_1:   22:19
Okay, this is really, really helpful I appreciate you again taking the time and sharing your insights and expertise with our viewers. We will catch well next time on insider. But I did a while.

spk_0:   22:28
You think so? Laughter you. Thank you so much.