Entrepreneur and revenue cycle management expert, Jamie Vasquez shares her mission to help practices be financially successful from the ground up. Tune in as we discuss the differences between billing in-network vs. out-of-network and key takeaways for your medical practice to focus on in the new year.
Listen to the full episode using the player below, or by visiting one of the links below. Below is the episode’s transcript which has been edited for readability. If you have any questions or would like to learn more, email us at firstname.lastname@example.org.
Intro: [00:00:00] Welcome to Legal 123s with ByrdAdatto. Legal issues, simplified through real client stories and real world experiences. Creating simplicity in three, two, one.
Brad: Welcome back to another episode of the Legal 123s with ByrdAdatto. I’m your host Brad Adatto with my cohost Michael Byrd
Michael: As a business and healthcare law firm, details matter. This season’s theme is zoom in. Once we know our big picture vision and strategy, we have to roll up our sleeves to get the work done. With each episode this season we’ll have our typical stories and make sure we talk about specific actions to focus on for 2022.
Brad: Michael Yes, and we have a great guest for today’s show but before we bring her on, have you ever heard of this phrase where no man has gone before?
Michael: Is it Brad referencing old movies and old TV shows? [00:01:00]
Brad: For 20 points. That is correct.
Michael: You are the person to have gone where no other podcast has gone before
Brad: Nah, I think there’s a lot of podcasts probably on this. And as you noted, this did come from an older TV show, actually, even before your time, Michael. The dialogue comes from the show called Star Trek voiced by one William Shatner or to his friends, Bill. The entire quote was space the final frontier. These are the voyages of the star ship enterprise. It’s five-year mission to explore strange new worlds to seek out new life and new civilizations to boldly go where no man has gone before.
Michael: I don’t think I realized you were a Trekkie. It doesn’t surprise me because of your Star Wars offense, but my big question to you is it, could you do the Star Trek hand signal? Because I was physically not able to do that.
Brad: This? Yeah, no can’t do that at all. Oh, for the record for the audience, you can’t see it but I am perfectly doing the [00:02:00] spark. You know, I was actually more into a Star Wars, but that’s a whole another story. But you know, many of us did grow up with the knowledge that captain Kirk of the enterprise was the fictional figure, right and he would go out and explore these new and strange worlds and although the original show only ran for three seasons, it since has become this dominant force with multiple TV shows, movies, toys, books, and all because of this show with this Bill Shatner, being the face of Star Trek.
Michael: And yet I still think of Denny Crane when I hear Bill Shatner and we’ve talked about this before, but Bill Shatner was the host of a TV show that our partner, Jeff Segal was on like 25 years ago.
Brad: Yup. So he’s been everywhere. So when we’re preparing for today’s podcast, I was reading the article about how Bill Shatner at age 90 was the oldest [00:03:00] person to date to be launched into space. And so for three minutes, he was part of a new mission to launch civilians into space. And something that was a funny enough to discuss in 1966 TV show, that civilians would be out in space. And his quote kind of sums up from this article, kind of what I thought about this was that the microbiologist who was on the same flight with Bill Shatner said flying with captain Kirk was the ultimate manifestation of science fiction becoming science.
Michael: Wow. That’s super deep. And what was crazy, can you believe how fit Bill Shatner is for 90? I mean, they were showing him like climbing up those stairs and I mean, he’s in great shape. Something that you should aspire to
Brad: One day, maybe by the time I’m 90.
Michael: Well, good. So I guess the bigger [00:04:00] question is how in the world does this tie into our guest today?
Brad: Good question. When it comes to running a medical practice, there’s a lot of people who unfortunately, will sell you fictional stories on how you can blast your practice into the next hemisphere. But as we were discussed in our dumpster fire season, this is not always the case, Michael. And when it comes to billing and collecting, you have to get it right. And what I like about today’s guests is she knows the science of how to safely launch a medical practice, but still explore all the options when it comes to practice might utilize.
Michael: I’m thinking we need to call the ambulance because I think you just tore a hamstring, trying to stretch Bill Shatner into billing and collecting, but well-played sir, you got to tell your story about Bill Shatner going into space. And we now get to introduce our guest, [00:05:00] Jamie Vasquez. Jamie has a BBA from the University of Texas at Dallas. She is a certified professional coder, CEO of Metrix RCM and Strategix Medical Solutions was founded in 2018. Jamie sold her prior company, FDGU Medical Billing back in 2016 and has over 20 years of experience in revenue cycle management, practice management and consulting. Jamie, welcome.
Jamie: Thank you so much for having me. I’m excited to be here with you today.
Brad: Jamie, we’re going to have a lot of fun today and we’re excited that you could join us. And as Michael mentioned, you’ve successfully started FTGU Medical Billing Company and you grew it until it was sold in 2016. What did FTGU stand for?
Jamie: Great question. I started my first revenue cycle management in 2006, [00:06:00] so I started it based on a mission to help practices be financially successful from the ground up and FTGU stands for from the ground up. In my early career before starting FTGU, I actually worked on the other side of the fence and I was a practice administrator for about a decade. So I’m unique in that I understand both sides of the fence, but my main goal, my biggest vision was to bring the same principles to groups on a larger scale.
Michael: Wow. That’s awesome. Well then kind of dovetailing from that, tell us more about Metrix RCM and Strategix Medical Solutions.
Jamie: Sure. With the same premise starting FTGU I had a vision. I feel like the current trend in healthcare is leaning more towards consolidation in both the provider and the hospital marketplaces. I also believe if the trend continues, [00:07:00] it’s going to play significant stress on independent practices and force them to either a join a large healthcare system or MSO to increase their leverage with commercial insurance carriers. Most providers are looking to obtain more competitive contract rates and unfortunately physicians feel like they really had no choice. So traditionally I think the healthcare provider is getting paid is similar to a complex choreography between the provider and the payer where the payer challenges the provider to not only substantiate that the services were delivered, but that it was actually necessary. So I started another company to help providers solve this issue more on a claim by claim basis, because my personal view is most denials are technical or tedious in nature. And if you create the right tactics and strategies, you can get these claims paid. [00:08:00] In addition to that past business associates and providers started reaching out and asked if I could help them with some of these issues as they’re starting to surface more in the climate that we find ourselves in with so much consolidation.
Brad: Yeah. All that makes sense. And so between these two entities, so if someone’s trying to figure out who they should be using to kind of help explain the differences between these two entities and the services that they provide.
Jamie: Sure a great question. So Metrix and Strategix Medical, we offer a hybrid of services. In the past we just did full revenue cycle management. However, now we also offer large group private practices, and even larger organizations the ability to have a hybrid medical billing offering. So we’ve gone in and we’ve successfully helped national large groups manage their billing in-house. It’s not necessary that [00:09:00] they completely outsource their revenue cycle management. We can’t assist them in the management and the process re-engineering of their so we offer more consulting services and those hybrid services in addition to full revenue cycle management in both of these companies.
Michael: And I have a question, I’m thinking about our doctors out there who may be about to start their practice and just talk a little bit at kind of an introductory level about what is revenue cycle management and how does that play?
Jamie: Sure. So revenue cycle management, it’s the lifeblood of your practice. I find myself going into practices where I think practices don’t spend the time needed and necessary to potentially vet the right people that are doing their billing. So sometimes it may be a training issue. It may be a lack of knowledge issue. It could be the [00:10:00] inability to execute issues. So it’s really important that you align yourself with your team members on your team as that practitioner that can get your claims paid. And as far as the revenue cycle management, that starts from the time the patient calls a net phone to schedule that appointment all the way through until you treat in and discharge the patient. So it’s getting the information right and correct before that patient even walks in the door.
Michael: That’s cool. So let’s also kind of delve into a little bit about the differences between in network versus billing out of network and kind of how that interplays and effects the revenue cycle management that we were just talking about.
Jamie: Sure. I would say the majority of our practices bill in network. We do offer some out of network service lines, and some of [00:11:00] those lines entail at a network surgical assessed neuromonitoring, we also work with a large group of trauma surgeons that elect to stay out of network for their hospital contracts. But if you develop a model in which your practice is in network and then you have out of network ancillary, it’s vitally important to ensure that you review your insurance contracts and that you review that not only with your legal team, but also your billing, your billing consultant, your administrator, just to ensure that you’ve met the compliance piece in order to do something like that.
Michael: And I’ve got to throw a curve ball at Brad and just interject a little bit of legal. Brad, talk about legally, what does it mean when someone says they’re in network billing?
Brad: Yeah, I think when Jamie was referenced in the contract, I completely agree about if understanding in network versus out of network, but in network is going to be that you have a contractual obligation, you’ve entered [00:12:00] into a fee schedule with a Blue, Aetna, United or whoever it is and that’s your contract that says, this is how if you’re going to be in our network, this is how you’re going to act when a patient comes through, this is how you’re going to collect, and this is how you’re going to get paid. And as Jamie can attest, the payment piece is the part where everyone concentrates on, but there’s a full contract about all the other moving pieces that they don’t pay attention to it to later, which we can talk about on the second half, but being in network means you literally have a contract with a commercial payer. Jamie let’s continue down this line and you mentioned it, I think this is something for our audience. This is a unique area that not that many people understand when we start really talking about in network versus out of network. And I know we have worked together over the years on setting up separate companies that bill for services that are ancillary to those main [00:13:00] services that you mentioned a few of them already, but let’s kind of dive a little bit deeper as to what are the issues that you have seen over the years when it comes to these out of network models?
Jamie: Sure. I think one of the bigger issues and talking with provider groups is the importance that the Texas insurance code and the Texas general code opinion, Dan, 2:15 if you are wanting to nerd out and look that up there, it’s pretty clear. So it’s very specific that a provider cannot waive copays deductibles and co-insurances and that you must make that attempt to collect those payments. So one of the factors that I face sometimes when talking to providers about the out of network models is sometimes they have been led down a path where they believe they don’t have to build patients in the out of network model and that’s simply just not true.
Michael: Jamie, this season’s theme is Zoom in. [00:14:00] And so kind of tapping into your operational experience, I’d love for you to share some thoughts on things that medical practices can focus on for 2022.
Jamie: Sure. One of my biggest recommendations and one that’s dear to my heart is really creating a methodology for tracking the way that you work your claims. Over the last 15 years we’ve developed a proven methodology that allows us to measure and track not only the strategies that the denial codes, payer trends, the success of every biller in our organization. So one of my biggest recommendations for private practices, especially if you decide and opt to keep your billing in house is you need to measure and have measurable data against your denial codes. Why are you not getting paid in your practice? So often I find so many providers that have a huge AR, but they have no idea why. [00:15:00] So it’s really important to dissect that down and really have a good understanding. Why are you not getting paid in your practice? What should you maybe do differently? Are you pre authorizing everything correctly? Are you billing the wrong codes? Are you not performing that procedure according to corporate policies that the carrier guidelines lay out for every CPT code? You know, taking your top CPT codes in your practice and really having a thorough understanding of how each major carrier processes and pays those claims is vital. What I see is that so many providers leave these appeals and these denials on the table. And if you think about it, if you could collect 10% of additional revenue in your practice because you’re effectively working your AR and your denials, that could be the difference of you being profitable or not at the end of the year. So one of the most important key factors is you must have a thorough understanding of what exactly your billing department is [00:16:00] doing in your billing office besides just doing your job.
Brad: Yeah. And I agree with you on that. I think something you said earlier on this podcast is a good takeaway too is that your ability to work with those providers, either being there purely helping them outside or going to help train their individuals. Can you just, since we’re focusing on details here, maybe talk about some of the details where when you show up and you realize that they didn’t understand the details, they weren’t focused on it because their people were missing certain things? What are the certain things that you see that they see, if you know, for a new client, when you’re helping them start getting a better job of what their revenue, what are some of the things you’ve noticed that their team didn’t even understand?
Jamie: Great question, Brad. I think one of the biggest things that I uncover is reviewing some of the AR reports. I call them write off months. It tends to happen about three times a year. [00:17:00] So when I go in and I run analytics about the write offs and then adjustments about once a quarter practices, we’ll go in and just have a huge amount of what I call a write off party. And management doesn’t understand why those write-offs are happening, but more importantly, the doctor providing the service, that’s spending their time providing services and spending time with those patients doesn’t understand what’s being written off behind the scenes. So one of the most important key factors is you need to having managed control process around how write-offs are approved in your practice versus just giving every biller the ability to write off anything whenever they feel like that claim is no longer worth being worked. So that’s one of the biggest issues I see is our write-offs. But the other issue that I see is properly assigning specific denial codes to your AR, understanding as I [00:18:00] alluded to earlier, what percentage of your AR is not getting paid due to what reason? What’s the claim volume impact? What is the revenue volume impact and really focusing on those problems inside your practice, based upon reviewing your denials more systematically to break down, fixing the problems on the front end so you don’t have so many AR problems on the back end.
Brad: So important. And I know you started with that in the podcast and I was hoping the audience caught on to that, but people don’t realize that if they keep doing it over and over again incorrectly, they’re never going to get paid, or paid at the value they perceive the service should be done. So that’s why I love how you start it from the moment that patient comes in they understand the process they have to do. If they believe they’re treating them at this level, they need to document that throughout the entire process of spending the time. And I know you’ve heard this before Jamie, because I think I’ve been in a room or, you know, a lot of doctors, they just [00:19:00] say they, I just want to show up and practice medicine. And I think they don’t realize that billing correctly is part of the process of practicing.
Jamie: Absolutely. Absolutely. And especially with the New Year coming around the corner, another suggestion recommendation would be make sure you have your fee schedule allowables from all the carriers so more and more patients have such high deductibles. So it’s vitally important to collect those amounts upfront, but collect according to your contract. You don’t want to end up with a huge refund problem because you also don’t want to end up with a low payment problem because you weren’t getting those deductibles at the beginning of the year. We see that happen quite a bit.
Brad: Totally agree. Well Jamie, I just want to thank you so much for joining us today and for the audience, Jamie admitted to us beforehand, this was her first podcast and I think she crushed it, Michael.
Michael: For sure.
Jamie: Thank you. I appreciate you guys having me and thank you for having me on today. [00:20:00]
Michael: Yeah. We’re so grateful for you joining us. What we’ll do now is we’ll break for commercial and on the other side, Brad and I will discuss our observations from a legal perspective. Thank you.
Jamie: Thank you
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Brad: Welcome back to Legal 123s with ByrdAdatto. I’m your host Brad Adatto and I’m still here with my cohost Michael Byrd. Michael we had a great chance just now to kind of catch up with Jamie and hear some pretty [00:21:00] detailed information on billing and collecting.
Michael: Yeah, and it fits right in with our theme of zooming in. Jamie has a unique perspective with her background and for our audience that may be not as familiar with this. I want to pause and just reset why this is so important. And you heard Jamie used the word vital several times. You talk about revenue cycle management and you know, we’ll talk to doctors who are starting a practice and they will have a plan in place to start treating patients and not realize they may not see cash for the first three to six months that they started their practice. And so that’s the revenue cycle management, like the day that you have a patient start the process to come in and get treated to the day that you [00:22:00] perform the treatment to the day that you code for the treatment and it gets billed insurance. And then it actually gets paid, has a substantial impact. And so it is so significant from just running a business perspective but there’s other issues that I think you have a lot of experience in, on the legal side, Brad. I’d love to have you kind of jump in. I know you’ve worked with Jamie on the in network and out of network models and love to kind of hear an example from you.
Brad: Yeah. And for the audience who’s not familiar with this, this model mostly comes in when we have a surgeon that are contracted in network with some insurance payer for certain reimbursement and they’re seeking to build some type of ancillary service that’s ancillary to their surgery side, but it’s going to be an out of network. So examples, physician owned is in network with their medical practices, but through [00:23:00] another facility when they show up, they may have a separately at a network entity that shows up with a surgical tech or physician assistant to be a first assist at the facility. So meaning that the doctor shows up and is in network, but a separate out of network shows up as a surgical assist.
Michael: So what issues do you typically encounter?
Brad: Well, Jamie had a couple of them in the beginning of this, but there’s obviously in a model like this, you have your traditional laws that you have to be aware of, which is the federal stark law, the federal anti-kickback law, and of course states baby stark and states anti-kickback law.
Michael: Is it really that obvious, Brad?
Brad: Right. Well, sorry. Dorking out. However, there’s a big however, most of the models that if someone comes and talk to us about this, they’re not going to be doing this with your typical program payers because the federal government with Medicare and Medicaid or Tri-Care, the laws are nearly impossible to meet to have an out of network model show up. So this is [00:24:00] really focused if you know our clients in this space is really focusing on state laws, and understanding how the insurance payers will view it. One of the most common issues with this model, Michael, that we see is that involves disputes with your payers. So again, you asked that question earlier in this podcast was so I’m in network, so I have a contract in this model with a potential payer, but I then have a separate entity that either I own, or through someone else is out of network. And the payers usually raise Issues if the billing for the provider that same per doc is on both sides. Sometimes they’re in network. Sometimes they’re out of network and this gets very confusing to them as to why they have two separate entities with different numbers and why the doc is in network sometimes and now in network. And so let me get a little farther and get into the details. So typically when you have these [00:25:00] dual billing explanations with the in network and our network, you’re going to have to have a very good explanation as to why they’re so different as to what uniquely is this in network entity providing, which is different than this out of network provider. And so again, if we can’t really describe that and both entities are getting paid, you’re going to have pushback from the commercial payers saying that we think this is fraudulent or we don’t understand why you’re doing it and we’re going to either going to not pay your out of network bill and force you to be in network or were so mad at you were just an outright, cancel your contract in network because we just don’t like working with you.
Michael: So what about just out of network billing? What’s the biggest issue provider’s face when they’re billing out of network?
Brad: There’s two major issues and I think Jamie started kind of talking about both of them. You actually talked a little bit about it just a second [00:26:00] ago, which is number one major issue is in Jamie said, there’s people out there saying, oh, you don’t have a duty to collect if you’re out of network for your patients, that’s actually incorrect. You absolutely have a duty collect, almost every single state has some law to that extent that routine waivers or telling your patient, don’t worry if you send there, we’re not going to collect your portion of it that typically can either violate again, federal laws, state laws, and a lot of times the medical board who might believe that it’s unethical and unprofessional. It also can create some overpayment issues. Again with the insurance payers. Their arrangements have a host of other issues that I won’t bore you with on the fights, but if it’s a lab or something else. But one of the things I wanted to concentrate on Michael is the issue with you said, hey, you open up your doors and day one and you probably already opened 30 to 40 days beforehand with training your employees. So you [00:27:00] finally get that first out of network patient that comes through the front door. And because you’re out of network it may take the out of network, the payer to pay you somewhere between 6 to 12 months before we would even see a dollar. And why? Because they don’t have a legal statutory obligation to pay you promptly where the prompt pay laws exist in most states when you’re in network. So you better have a great line of credit because your cash shortage will be very high in the beginning. And eventually, hopefully it does make up and catch up down the road.
Michael: Can you give us a quick example?
Brad: So going back to in network vs out of network model, because of the nature of the reimbursements, historically providers will inflate their billing charges believing that a small reimbursement percentage of over a higher number is better. This creates a potential higher patient responsibility. The amount that the provider now faces [00:28:00] as an obligation to collect a solo. I’ll give an example. So, you know, they’re saying this procedure, we’re now charging $10,000 for it. Out of network says you, the patient you’re responsible for 40% of it and now the patients will be surprised because all of a sudden I’m getting this huge large bill, either that they are going to try to collect on, or they’re not going to collect on and obviously there’s consequences both ways.
Michael: I just want to add a thought on this duty to collect the copay on the out of network billing, because I don’t think it’s intuitive until you actually can relate it to something you’ve probably experienced. We’ve all as patients probably gotten that bill in the mail when we had something that was out of network and didn’t realize it, and it was a massive bill. And so if every patient has that same emotional trigger when that happens and they call [00:29:00] naturally the practice and the practice is like, well, we really don’t even care about that. We’re just trying to get paid out of network reimbursements from the insurance company. And so there’s this temptation to say, oh, don’t worry about it we don’t really need your money. And there’s laws that are kind of getting in the way of that.
Brad: Yeah. So let’s in the last few minutes we have left Michael, I’m going to jump in and zoom in, as some of you know, we’ve talked about a lot of details in this episode anyway, but for those who are interested in understanding about the network model, of course we talked about already you have a duty to collect and the of network model so it’s a very important perspective, but what do you mean by duty to collect? Well, you might have to make a reasonable attempt to collect. I don’t know. There’s no state that’s defined reasonable, but you can’t be telling a patient don’t worry, I’m never going to try to collect for you. That’s wrong. And the second thing is because as you just mentioned, this surprise that you got and that you were surprised that you were even out of network. [00:30:00] A lot of states have been passing over the years something basically a surprise billing laws that says that if you do get a surprise bill, you’re allowed to negotiate with the provider a mediation and then the federal government recently passed the no surprise act law which basically is there to protect the patient that when the provider or the system is fighting with your health care plan, you the patient, you get to sit on the sideline while they negotiate back and forth as to how much they’re going to eventually pay and then after that, you still have to pay a percentage of that. So they being the provider can no longer drag you into the middle of the fight where you’re mad at the healthcare plan for not paying it. So that’s kind of a very lot of details in this episode, but it is the steam has zooming in Michael, what are some of your final thoughts or takeaways?
Michael: Well, I think more than anything, it’s paying attention to understanding the importance of revenue cycle management. And we started this [00:31:00] episode talking about Bill Shatner, 90 years old, going to outer space and that’s awesome. That not if that’s your cycle for revenues collection, you don’t want to wait 90 years to collect. So this is one where you want to do a little bit tighter and faster than captain Kirk.
Brad: Absolutely. Well, next Wednesday we have a show that says don’t play with Fyre with Dr. Dominique Nickson.
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