Category: Covid19

10 Apr 2020

Jerry Tillinger, CEO of US Digestive Health on the COVID-19 disruption

I spoke to Jerry Tillinger, CEO of US Digestive Health. As you know, US Digestive Health is the $130M private equity funded platform based in Pennsylvania. Here’s what he had to say on the COVID-19 disruption.
1) What are the 3 things you are focusing on right now at your practice?
Patient care is always our number one focus, so we are working daily to triage patients with a balance between risk of exposure versus risk of harm from delay.  Telemedicine is helping with that, but the rapid integration of that new modality is putting new stresses on patients, providers and staff.  Protecting my staff and providers is a close second, so infection control and PPE protocols are paramount. On the business side, managing cash flow and liquidity is the number one concern; as our operations are moving at a small fraction of normal, it is imperative that we have strong liquidity so we can restore operations when the crisis abates.
2) What questions should GI practices be asking themselves over the next 10 days?
This crisis has moved much faster than anything we have every experienced. Natural disasters are usually short and intense, so there is a preparation, survival, and repair pattern. Not this time. We are getting updates on the outbreak and how we should be operating multiple times per day. We are just making the transition from disaster management into recovery planning. We are looking at the various scenarios for a “return to normal” so we can start caring for our deferred patients as effectively as possible.
3) What steps are you planning to take if your region goes into a lockdown? Any thoughts on business impact? 
This is a moot question here in Pennsylvania, as we went into a “stay at home” order several weeks ago. We have consolidated services and facilities so we can maintain necessary patient care with a minimum of risk to staff and patients. Telemedicine is key component of our ability to provide care, so we implemented that immediately as we closed physical offices. Business impact is challenging, but our capital partner, Amulet, has had ample experience with distressed business management. Their guidance was invaluable and we were ready to adapt our operations and finances when the crisis went hot in our market.
4) Are you seeing any COVID-19 patients at your practice?
Especially, those with GI symptoms. Our work with COVID-19 patients has been very limited. We have strong hospital systems in our market, and they have been extraordinary partners. The hospitalists have been very cautious about exposing the specialists to contagion, so most of our consults have been electronic versus hands-on.
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By Praveen Suthrum, President & Co-Founder, NextServices. 

We developed an easy-to-use PPP Loan Calculator to help you estimate:
• Maximum Loan you are eligible for
• Loan Forgiveness Amount (by headcount)
• Loan Forgiveness Amount (by wage reduction)
• Download and modify for your own practice
button_downloadpppcalculator
09 Apr 2020

CMS approves $34 billion in 1 week. Do this to get paid now.

[UPDATE: As of April 26, 2020 CMS has suspended the Medicare Advance Payment Program. Read the official press release.]
CMS disbursed $34 billion in the past week. They processed 17,000 out of 25,000 requests for Medicare advanced payments.
Medicare is extending 3 months of payments in advance. They will process payments in 7 days.
Read: Coronavirus: CMS approves nearly $34 billion in accelerated/advance payments to healthcare providers (Medical Economics)
If you haven’t applied for the Accelerated and Advance Payment Program, my team at NextServices is doing it pro-bono for gastroenterology practices that need this help.
Please complete the attached form and email rcmbilling@nextservices.com with the subject line: Medicare Advance Payments.
Related messages that prompted this mail (thank you):

◘ “FYI, we just received the ADVANCED PAYMENT from Medicare.” – Carolyn H.

◘ “Great. / super effort” – Dr. Richard C

◘ “By the way, I do want to thank you very very much. You have been very helpful so far.” – Dr. Aram

◘ “You should be commended for trying to help doctors who seem so distraught. I was aghast to see staff in many practices and hospitals laid off from their jobs. ” – Dr. Murali

Let’s get this done.
Resource: Updates on Accelerated and Advanced Payments, Claims Reporting for COVID-19, Telehealth and Quality Payment Program (CMS)
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By Praveen Suthrum, President & Co-Founder, NextServices. 

We developed an easy-to-use PPP Loan Calculator to help you estimate:
• Maximum Loan you are eligible for
• Loan Forgiveness Amount (by headcount)
• Loan Forgiveness Amount (by wage reduction)
• Download and modify for your own practice
button_downloadpppcalculator
08 Apr 2020

News Flash: Gastro One forms private equity-backed GI platform in $22 million deal

Despite the COVID-19 situation, PE fund Webster Equity Partners invests in Gastro One. Here are the takeaways:
1) Waltham, MA based Webster Equity Partners agrees to make an equity investment of $22 million in Gastro One, reserving up to $80M for the new platform.
2) The new platform is called One GI.
3) The purchase price was not adjusted in the wake of the crisis.
4) Headquartered in Memphis, Tennessee, Gastro One is the largest GI practice in Tennessee with 30 physicians, in 10 locations.
5) Dr. Michael Dragutsky and David Harano will lead One GI as chairman and president.
Source:
Webster forms gastroenterology platform via equity-only deal for Gastro One (PE Hub)
PE COVID-19 Resources:
1) Bain & Company: Covid-19: Implications for Healthcare Private Equity Investors
2) PwC: COVID-19 and the private equity industry
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By Praveen Suthrum, President & Co-Founder, NextServices. 

We developed an easy-to-use PPP Loan Calculator to help you estimate:
• Maximum Loan you are eligible for
• Loan Forgiveness Amount (by headcount)
• Loan Forgiveness Amount (by wage reduction)
• Download and modify for your own practice
button_downloadpppcalculator
08 Apr 2020

Curated COVID-19 GI Resources: April 7th, 2020

Curated COVID-19 GI Resources: April 7th, 2020
Patients with COVID-19 GI symptoms experience delayed diagnosis, viral clearance (Healio)
“This study is vital because it represents the 80% or more of patients who do not have severe or critical disease.”
$2T CARES Act: What do GI practices need to know right now? (NextServices)
Our most downloaded presentation/ebook to help you understand what the CARES Act entails for GI practices.
Q&A: New York GIs on how to prevent spread of COVID-19 (Healio)
Work with your hospital to make sure testing is available. Identify patients early. Assume that every patient who comes in has it.
This week in Washington, DC  (ACG)
Economic relief for our GI practices. PPP. EDIL. SBA loan advance. Medicare Advance Payments. Starting the complicated loan process.
Easy-to-use Paycheck Protection Program Loan Calculator  (NextServices)
Easy-to-use tool to calculate loan and forgiveness amount for your practice. An explainer video on how to use it.
Major announcements from CMS – Mar 26th (AGA)
CMS extends temporary billing privileges. Quality reporting program relief in response to COVID-19. Extends MIPS data submission deadline to April 30, 2020.
Guidance for telehealth and eVisits during the COVID-19 crisis (AGA)
Overview of the changes. Answers to FAQs. Online COVID-19 telehealth coverage and coding resources.
Inside a COVID-19 ICU: ‘I’m Terrified’ (Medscape)
With little warning, the hospital’s 12-bed intensive care unit (ICU) grew to 28 beds. It now houses 21 COVID-19 patients on mechanical ventilators.
Commercial COVID-19 telehealth coding policies (AGA)
This guide covers telehealth policies for several major payors and provides links to their current policies. Before reporting telehealth services, it is important to check the policies of your local plans.
Endoscopy and the COVID-19 Pandemic: A Printable Guide for Patients (ASGE)
Can COVID-19 be spread from the GI tract? Can I get the coronavirus from a contaminated endoscope during my procedure? Many more.
More than 5,000 surgery centers can now serve as makeshift hospitals during COVID-19 crisis (California Healthline)
CMS announced it is temporarily waiving a range of rules, thereby allowing doctors to care for more patients.
Medicare regulations important for GIs – Mar 31st (AGA)
New opportunities for ACSs. New financial assistance. New Stark exceptions. New physician supervision rules.

If you wondered about PE, here’s a report from PwC: COVID-19 and private equity

 


More Hot Headlines for GI
Endoscopy during COVID-19 pandemic requires extra safety precautions (Medscape)

Paycheck Protection Program: COVID-19 financial relief loans for GI practices (ASGE Webinar) – today 6pm CST

AGA issues formal recommendations for PPE during gastrointestinal procedures (AGA)

How does the coronavirus behave inside a patient? (The New Yorker)

ASGE COVID-19 Frequently Asked Questions (ASGE)

Most COVID-19 Patients Can Be Managed Remotely (Medscape)

Digital health funding is off to a roaring start in 2020 (MobiHealth News)

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By Praveen Suthrum, President & Co-Founder, NextServices. 

[FREE EBOOK]
$2T CARES Act: What do GI practices need to know right now?
downloadnow

 

 

04 Apr 2020

$349B Stimulus starts: It’s “first-come, first-served” + Simple Loan Calculator

CARES Act – Paycheck Protection Program Interim Final Rule released last night.
A Simple PPP Loan Calculator
We developed an easy-to-use PPP Loan Calculator to help you estimate:
• Maximum Loan you are eligible for
• Loan Forgiveness Amount (by headcount)
• Loan Forgiveness Amount (by wage reduction)
• Download and modify for your own practice
Watch this video to find out how you can use the PPP Loan Forgiveness Calculator.

 

button_downloadpppcalculator

 

 


Important updates under the Interim Final Rule:
• Loans are guaranteed 100% by SBA
• 100% forgiveness of loan is possible
• Interest rate is 1%
• PPP is “first come, first served”
• 75% of loan must be used for payroll (below for people with $100K/year), 25% for other costs
• Last date to apply: June 30, 2020
Download the loan application form.
My team is volunteering to submit Medicare Advance Payments applications for any GI practice that needs help with it. Please fill this application, scan and email it here. There’s no cost. Medicare will review and process applications within 7 days.
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By Praveen Suthrum, President & Co-Founder, NextServices. 

[FREE EBOOK]
$2T CARES Act: What do GI practices need to know right now?
downloadnow

 

 

03 Apr 2020

COVID-19 Crisis: Interview with Dr. Louis Wilson from Wichita Falls Gastroenterology, Texas

Today I spoke to Dr. Louis Wilson from Wichita Falls Gastroenterology. He’s the ACG Practice Management Chairman and also the President-Elect of The Texas Society for Gastroenterology and Endoscopy. He just published an excellent and practical article on the 10 specific actions GI practices should be taking now.
DOWNLOAD the exact tools that Dr. Wilson used when he pitched to his hospital and presented to all GI stakeholders in their community.
1/ Wichita Falls Gastroenterology Service Crisis Action Plan
2/  Responding to a crisis: GI Care for the entire community
Watch this insightful interview with Dr. Wilson. Highlights:
• How Wichita Falls Gastroenterology, a 7 MD group is handing the COVID-19 crisis
• What to do with patients whose GI symptoms aren’t going to go away
Petition your hospital regarding PSA
• Supporting your staff
• Infection control plan
• Holding structured meetings with your partners
Most experts are saying this is going to be a marathon and not a sprint. We will do our best to support you through this journey.
The Transcribed Interview:
Praveen Suthrum: Hi Dr. Wilson, thank you so much for taking the time for this interview. I broadly have two questions and then we’ll get right into it. The first is about what the situation is on the ground… on your end in Wichita Falls, Texas and the second is about the article that you put out there, was it yesterday?
Dr. Wilson: Yeah
Praveen Suthrum: Yeah so, you outlined 10 action items that GI practices can take, and endoscopy centers can take now so, I wanted to talk to you about these two questions. But first, how are you? And how are things where you are?
Dr. Wilson: Of course, everything is different like everybody else, we’re under the strain and stress of preparing for and dealing with the pandemic. We’re in a small community Wichita Falls, North Texas. We are a gastroenterology group with seven doctors, we have an ambulatory surgery center. We participate very closely with our regional hospital. We’re right across the street from them. Our ASC is right across the street from them and we are the only GI group that covers hospital call for gastroenterology 24/7 365 days a year. So, we have a very close relationship with our hospital. The epidemiology predictions for our community… we have been watching those very closely and in fact it’s shocking how closely our rate of rise of this infection has matched those predictions. Today we have 38 people in Wichita County, Wichita County has 135.000 people. We have 38 people tested positive. About 1000 people have been tested but only 38 have been positive about 300 are pending. 90% of the test or more that have been done for patients of interest have been done are negative, which is great. We currently have four intensive care patients here that our patients under investigation one is COVID-19 positive. Everything is different. The volume in our practice is greatly reduced and is hampered by you know, shelter in place restrictions for our community. The community is sticking together for shelter in place and everybody is encouraging that. I think it’s going well here. You know, social distancing affects everything we do. The volume at our ambulatory surgery center, our ASC is still open. We keep one room open four days a week right now that is all as compared to three rooms five days a week before. And we’re doing only urgent outpatient endoscopy for urgent indications. We continue to have clinic, both facetoface and telemedicine. Today, my clinic is around 50-50. I’ll have half of my patients via telemedicine today and about half will be face-to-face. New patients mostly we’re seeing face-to-face. Some of them we’re not. But physical exam… our policy has still been to see and examine our patients when they’re new sometimes we offer telemedicine even for new patients and sometimes patients are choosing that option which is fine. And then we have to follow up with them for physical exam at a later time. So, that’s what is going on here. Im healthy, all of our staff has been healthy. We have not had any patients or people under investigation in any of our organizations so far thank God.
Praveen Suthrum: Thank you. And what kind of steps have you been taking to protect yourself and your staff and other colleagues?
Dr. Wilson: We’ve had an infection control policy in place for number of years now and our infection control policy applies to this infection as well. Now we have prohibited people from the building. Visitors are not allowed into any of our buildings only the patients. They are tested for fever and they are pre-screened by telephone on the day before and upon arrival at any of our facilities. Infact we like to pre-screen patients two or three days before for the appropriate questions of risk factors anybody with respiratory symptoms or fever or exposure to people in their household from the symptoms is going to be excluded from the building until they’ve been tested for COVID-19 or until they have been quarantined for 14 days. So, that’s currently our situation at the clinic. You know, I’m encouraging and walking through the building all the time, our waiting rooms are empty both at the ASC and at the clinic. Social distancing is encouraged and maintained in the staff areas as well. Most of our meetings now are teleconferencing meetings or strictly following the limitation of size and following social distancing. So, we’re doing all those things. So, PPE… patients who are considered low risk, who have screened negative, we are using standard PPE – face shields, surgical masks, water-proof gowns, gloves, hand washing etc., and we are not doing patients with high risk. If they have respiratory symptoms or exposures, then they are not being done. If those patients need to be done in the hospital, then they’re being done within N-95 masks and full PPE’s. 
Praveen Suthrum: I’m curious. You know, all these patients who are getting their surgeries rescheduled or you know the GI symptoms don’t go away but now you know COVID 19 takes precedence so, what happens after you know hopefully we flatten the curve and we don’t pass this phase… you know these patients with GI symptoms wouldn’t they be worse off?
Dr. Wilson: Well, I’ll tell you what… this is not a two week or three-week social distancing, shelter-in-place kind of thing for us. Whave to be planned for the long term. This is a marathon not a sprint. That means those patients with urgent elective indications – trouble swallowing, persistent diarrhea, persistent abdominalcolitis etc., bleedingGI bleeding, those patients are not going to be able to wait two, three, or four months. Sowe’re trying everything possible to put those patients off. Now, we’re watching our epidemiology curve, if things continue as they are, we will have a patient surge here that fills our ICUs and our hospital about the third week of April and that’s what we’re preparing for. However, we’re not anticipating being able to lift the prohibition on elective procedures until perhaps mid-June. So, right now June and our ambulatory surgery center is already filling up because we’re still seeing patients and right now we have hundreds maybe 400 patients already scheduled for June patients that normally would be of schedule probably next month July is also starting to fill out. So, it’s important in my opinion it’s critical that we plan for the continuity of our practices, right? Whave to stay we have to protect our staff and the infrastructure of our practices and our ASCs. I think that’s a public health concern because those indications are not going to go away. So, patients with more urgent indications we’re going ahead and doing those procedures in our ASC now. I don’t think this is the right time to push those patients off to the hospital and we’re working very closely and with full support of our hospital. We have at our ASC a full supply of N-95 masks. The hospital has offered those to our ASC if necessary. We’re working closely with the hospital the emergency room, the clinical decision unit, the Transfer Center and the GI team on call to try to avoid using the hospital for low-risk patients, COVIscreened negative patients we don’t need to do those in the hospital setting unless it’s a true emergency. 
Praveen Suthrum: Okay. Thank you. So, let’s get to the article that you published and all these resources that you’ve been sharing you talked about 10 specific action items the GI practices and hospital centers can take right now. Could you share a few of those? And then with this video I’d like to you know share the article.
Dr. Wilson: Okay. Well they are of course my opinion and things that are working for us here locally. First of all, I petitioned our hospital for an emergency expansion of our PSA our professional service agreement immediately. And they were very cooperative. So, we have expanded our normal PSA on call, financial support paper call etc., we’ve dramatically expanded that that support from the hospital. Why is that? Because they share our goals they are very stressed, they need specialists to help and support hospitalists, intensivists, people in the hospital as the volume of patients rises, so will the number of gastroenterology issues that will rise. As you said those problems are not going away. Liver disease, GI bleeding, abdominal pain, whatever. Those patients will need to be served and done so with rapid short hospital stays, rapid discharge, rapid endoscopy or care coordination. As an outpatient we can help with them with that. So, what they’ve agreed to do is give us full support for a second gastroenterologist on-call we call that person G2 we are then so the expansion of the PSA with your hospital. I urge practices to approach their hospitals immediately for that. I think they should be cooperative you share their goals. Here we are maintaining number two we’re maintaining outpatient endoscopy capacity. Even if it is much less than before we’re going to try to not push those procedures off to the hospital. The anesthesia serve is going to be very important part of expanding the ICU capacity at our hospital and they’re not going to want to be doing anesthesia in the hospital for endoscopy unless necessary. Number three, were supporting our staff we are paying our staff and keeping them on as much as possible it’s a high priority. So, I call that a business continuity plan. We plan to utilize whatever federally passed care legislation benefits can help us do that most importantly the payroll protection program. We are perfect for that so, you know we’re a business of under five hundred employees, we will retain our staff, you must retain your payroll and so what happens there is that the Small Business Association through local lenders will give usforward us a loan amount of 2.5 times our monthly payroll average monthly payroll over the last 12 months as long as we retain at least 75% of our payroll during that time. If we don’t, we have to pay the money back if we do it’s largely forgiven that’s an outstanding benefit that we plan on taking advantage of. We are also at the ambulatory surgery center allowing our staff to borrow PTOup to 80 hours of PTO from the future things that might be automatically deducted from their paychecks a lot of those things are being forgiven right now for instance previous medical bills or previous loans against their retirement accounts. Those things they’re not having to pay right now. So, supporting the staff is critical, continuity plan long term again for your business. The next things are things that relate to closely working with the hospital. Patients are losing their insurance. People that lose insurance have lack of financial resources, they’re a little bit harder to get out of the hospital so we are actually participating in our transitional care clinic here. transitional care clinic is a clinic that the hospital has for patients immediately after discharge regardless of their ability to pay. So, when a patient you know is on the edge of whether or not they should stay in the hospital or not or care is not fully coordinated they don’t need to stay in the hospital because they can come to the transitional care clinic. We are participating there for patients with digestive problems so those patients will be seen by the G2, the 2nd gastroenterologist on call and help care coordination and make sure those patients are getting the best possible care, shorten hospital stays etc., the ER, the clinical decision units in the hospital we’re working with those closely and the Transfer Center. So, now the Transfer Center knows we’re eager to talk down line facilities. Other hospitals that normally refer in outside providers. We’re eager to talk to them first if they have digestive questions, so that we can coordinate their care as an outpatient rather than in the hospital. Avoid some of those transfers and have them taken care of. Some of those patients can actually now be sent to our ASC if they’re COVID negative, properly pre-screened, low-risk, they can be seen at our ASC and CMS has expanded the ability for a ASCs to work in that kind of capacity. Of course, telemedicine, teleconferencing, we’re doing a lot of that. We are like I said about 50% of our visits now or telemedicine that’s working extremely well. That will continue to evolve I think maybe I’m using technologies in the hospital by the way, teleconferencing technology that allows us to see patients in the ICU or in their patient rooms without physically going in there. So, we can round on patients remotely, reducing exposures etc., they are wiring up that kind of technology at our hospital and then maybe teleconferencing consultations with outlying facilities so those are some of the things we’re also doing. You know, right now a lot of meetings happen. I’ve encouraged my colleagues to make meetings regular, structured and highly efficient. We don’t have time right now for lots of unstructured conversations. So, we are having twice weekly structured meetings, all the stakeholders the endoscopy center, the hospital, the practice, the administrators, to go over things quickly. Status in the hospital, how many GI census patients are there, how many of them are being affected by COVID, how many are patients under investigation, what’s happening in the Transfer Center, the transition clinic etc., we’re going to be having those structured meetings regularly. We are really ramping up and making sure the infection control plan is in place and then taking care of ourselves those things are all things I recommend. 
Praveen Suthrum: Well, Dr. Wilson thank you very much for your time and you know, these action items that you’ve shared please keep the resources coming and I wish you well and your staff well and do stay safe. Thank you. 
Dr. Wilson: Thank you Praveen. I wish you lot of support I mean health good health during these times. Thank you. 
_

 

By Praveen Suthrum, President & Co-Founder, NextServices. 

We developed an easy-to-use PPP Loan Calculator to help you estimate:
• Maximum Loan you are eligible for
• Loan Forgiveness Amount (by headcount)
• Loan Forgiveness Amount (by wage reduction)
• Download and modify for your own practice
button_downloadpppcalculator
31 Mar 2020

$2T CARES Act: What do GI practices need to know right now?

Tougher reimbursements. Higher operating costs. Increased regulations.
We have a system to help GI practices thrive, not just survive.
There are 4 main things you need to know now:
1/ Small Business Paycheck Protection Program ($349B)
2/ Economic Injury Disaster Loan Program ($10B)
3/ Public Health and Social Services Emergency Fund ($100B)
4/ Medicare Advance Payments
In this presentation, learn:
> how to compute the maximum loan amount you apply for under the PPP program. Even if you are a smaller or larger group.
> what are allowable expenses?
> how can a loan become a tax-free grant (free money)?
> how do you apply for the Economic Injury Disaster Loan program?
> can you get paid for your canceled procedures? (yes, start capturing for now)
> can you get paid from Medicare in advance?

[FREE EBOOK]
$2T CARES Act: What do GI practices need to know right now?
downloadnow

 

 

_

 

By Praveen Suthrum, President & Co-Founder, NextServices. 

We developed an easy-to-use PPP Loan Calculator to help you estimate:
• Maximum Loan you are eligible for
• Loan Forgiveness Amount (by headcount)
• Loan Forgiveness Amount (by wage reduction)
• Download and modify for your own practice
button_downloadpppcalculator
30 Mar 2020

COVID-19 Crisis: Interview with Dr. Naresh Gunaratnam, Huron Gastroenterology, DHPA

Today I spoke to Dr. Naresh Gunaratnam from Huron Gastroenterology in Michigan. He’s also on the executive committee of Digestive Health Physicians Association (DHPA) that has been leading efforts with the $2T stimulus package. It’s because of DHPA’s phenomenal efforts that physician practices and ASCs may soon be able to apply for SBA loans and grants.
Watch this “home-made” interview to gain insights on:
˃ How Huron Gastroenterology is dealing with COVID-19
˃ How two clinicians in the practice contracted the virus (a patient showed up at the hospital with digestive symptoms)
˃ What steps are they taking clinically and business-wise
˃ Challenges and opportunties with telemedicine
˃ What telemedicine tools are they using and for what kinds of patients
˃ What to expect in the coming days with the stimulus package and DHPA’s role
The Transcribed Interview:
Praveen Suthrum: Thank you Naresh for taking the time today. I broadly have four questions covering from you know, how the COVID 19 crisis which has affected every single practice across the country, how it is affecting you and Huron Gastroenterology and the steps you are taking in trying to control this crisis and finally what you’re doing at DHPA and what DHPA is doing. So, if it’s okay with you I wanted to get started with the first question.
Dr. Naresh Gunaratnam: Sure
Praveen Suthrum: So, you know pretty much everybody, every business, every medical specialty has been affected by COVID-19. The last two weeks have really flipped the lid of all kinds of businesses. How has it affected you at Huron Gastroenterology both from a clinical standpoint as well as a business standpoint?
Dr. Naresh Gunaratnam: Within two weeks we went from one extreme to the other. We were having active conversations about recruitment and growth and actively engaging and recruiting new doctors to handle the work that was a lot. And then within a day it became full stop, we needed to shut everything down. We made a recommendation early on and our board met, and we basically made a decision that we just needed to stop everything. So, we were ones that made a decision to stop before the CMS guidelines about endoscopy. We just felt that if we get one patient who is COVID positive that entered our hospital, our ASC or office, it could be catastrophic. Because then, that person would have exposed our staff, other patients and trying to track that patient down and trying to stop this, we thought would be too difficult. We made a difficult decision to stop all ASC procedures and then stop all office patients. We then needed to scramble and figure out how to do telemedicine which we can get into a little bit later on.
Praveen Suthrum: Okay. But you had told me earlier that couple of your colleagues did get infected and how did that happen and how did you deal with it?
Dr. Naresh Gunaratnam: Yeah, I mean both of my colleagues who were rounding in the hospital they were… our first patient in the hospital who was somebody who had gone… who had traveled abroad and then came with non-respiratory symptoms historically respiratory symptoms with cough and fevers so forth were felt associated with COVID but in our case we had a patient who came in with GI symptoms and so, no one was suspecting that this was a COVID patient. So, my colleague went in and saw the patient as you would any other GI patient with diarrhea and then three days into her stay, the ship that she was travelling in has called all passengers and said “Oh by the way a lot of the passengers who are traveling on the ship are COVID positive” so, then she alerted us and got herself tested and found that she was tested positive. By that time unfortunately she had been in the hospital for three-four days not being suspected to have it. My colleague who was taking care of her so then, she was quarantined and in the last week we had a second colleague who again was rounding in the hospital who was an incredibly fit person who runs marathon and so forth and three four days into his rounding week became short of breath and now he’s isolated. So far this is obviously impacting our work force because we’re on the front lines.
Praveen Suthrum: Do you have enough PPE’s available? Enough equipment that you need?
Dr. Naresh Gunaratnam: No. We’re scrambling. Every one of my partners and I, we have an N-95 mask but we’re holding it dear such that we don’t have to reuse it. So, we treasure that like it’s our family heirloom and we try to hold on to it. And we’re cleaning it as well as we can. The utilization of PPE is now being modified in real time. Initially it was like well, you don’t need anything, and you just put a surgical mask on if you go into a person you don’t suspect has COVID and then you can put on your N-95 mask that you do know as now we know that it’s very hard to figure out who has and who doesn’t so, it’s almost a universal precaution. We’re just assuming everybody has I and we are trying to put on you know, our head covering, N-95 mask, face shields when we’re doing procedures, and gowns in procedures, but the trouble is that when you’re in a hospital everything from the keyboard to every door knob you touch and you’re constantly touching everything. And it’s very hard to really feel like you’re completely protected. My colleagues who were infected, they were very cautious you know, they were doing all the things we’re supposed to do and yet, I think the viral load is so high and so prevalent in surfaces and not just surfaces you know, in people around you that I’m almost resigned to the fact that I’ll get infected and I just hope that I can come out on the other side.
Praveen Suthrum: Yeah. Wish you all the best with that.
Dr. Naresh Gunaratnam: Yeah.
Praveen Suthrum: So, what kind of a business impact has this had for your group and your surgery center?
Dr. Naresh Gunaratnam: Well you know, it’s dramatic. We went from being economically doing very well with our ASC’s we had five rooms running with 16-17 cases a day five maybe six days a week to five/six cases a day and those were people that were urgent, the cases we’re doing are people we have high suspicion has a cancer. Anything short of that we’re not doing. Same is true for the office side. We’re trying to do telemedicine, but you know, from never having done telemedicine to 24 hours a day doing all telemedicine you can just imagine the logistical challenge, all the inefficiencies that we kind of have to work through. So, we’re working through everything from drop calls, to our patients not knowing how to use technology, to how you bill for it and going through all the codes and so forth, so it has been quite challenging.
Praveen Suthrum: What kind of tools are you using for telemedicine?
Dr. Naresh Gunaratnam: We’re using Zoom for our patients. However, some of the more technologically advanced procedures or technologies, our end user which is our geriatric patient doesn’t know how to download and run the operations so we may start a call… attempted call using Zoom or these other technologies. Sometimes, I just break and use FaceTime with patient who has a phone that can accommodate FaceTime otherwise let me just call. So, then you get into the dilemma that if you call is it a telephone call or is it a failed telehealth call. We’ve defaulted to the fact that if you made a good-faith effort to do telehealth and then you have to switch to a phone because the patient is a Medicare patient and just doesn’t know how to engage technology we’re billing that as telehealth call and the guidance has been that we should be okay doing that because this is a crisis and hopefully CMS will give us a break as long as we had good faith to do telehealth.
Praveen Suthrum: Yeah. And I think that is what the notice from CMS also said you know; they expect physicians will do it in good faith I think they would be okay with that. What kind of cases are you seeing are these IBD cases? Or all the cases are through telemedicine now?
Dr. Naresh Gunaratnam: Well yeah. We’re really seeing everything from abdominal to nausea to constipation and it’s intriguing and if there’s anything good about this it is the fact that we’ll be able to scale up telemedicine is probably one of the good things because it’s frankly very convenient for the patient and very convenient for us and I think most of gastroenterology is history and counseling and so forth. And I know… it’ll break the heart of my med school teachers who taught us physical exam but I can’t remember the last time a physical exam affected my decision making in the office. In the hospital it may be different because somebody may have an acute abdomen and so forth but, in the office setting people are coming with nausea, vomiting, you know chronic abdominal pain, constipation, reflux, fatty liver and frankly the physical exam is really not making me change what I do, what I assess. So, I think the good thing I that most of GI can be delivered through telehealth which I think would be a paradigm shift for us.
Praveen Suthrum: Okay. But then where you do need to see the response of the patient through a physical exam or you’re checking different systems, do you ask them to do it? Do you navigate that at all?
Dr. Naresh Gunaratnam: Yeah. You know, interestingly I think you can do most of it without a physical exam because I think… for instance if someone has an inflammatory bowel disease and we’re asking questions… you know, did your stool frequency decrease? Did the blood in your stool decrease? Did your pain get better? So forth and there is nothing to feel or touch because of that. I think, it’s rare that a patient comes in and says you know I have an abdominal mass or pain in the right lower quadrant. I mean people with acute pain usually show up in the hospital I mean, the pain is so severe that they come in through emergency. People who show up in the office rarely show up with acute pain… usually they have had this pain for three months and here are the tests we’ve done, and they still can’t figure out and that’s when we get involved. So, I think the majority of what we can do, can be provided via telehealth. um: Okay. But then where you do need to see the response of the patient through a physical exam or you’re checking different systems, do you ask them to do it? Do you navigate that at all?
Praveen Suthrum: Do you have any advice for GI doctors who might watch this or administrators of GI practices who’d be watching this?
Dr. Naresh Gunaratnam: Well I think as in any crisis, we’re trying to stay calm, and hoping that in a month or two, we will be able to come out of this. I think the most exciting thing is that this new bill if you know, 48 hours old and we’re trying to wait through this and the good news is that there is going to be support for the staff as well as ASC loss productivity. So, I think we need to go through the law very carefully and basically see how we can use these laws and subsidies given by the government it to keep our business running. And the good thing is that there are forgivable loans that will go towards our staff and it looks like there’s going to be some for the lost cases that we got from the ASC. So, in the next 24-48 hours we’re going to see how to best apply the law because there are some timing issues to optimize getting the loans, what parts of it should be grants what should be loans, do you furlough patient employees, when do you furlough, when do you not furlough, do you bring them back. So, these are the questions that we need to kind of work through. But I’m optimistic we can get through this and I’m hoping that this whole experience is going to make us leaner and as we’ve spoken, some ways that we deliver care like the telehealth will be a paradigm shift for how we go about doing business going forward.
Praveen Suthrum: Thank you so much Naresh and I wish you well and you colleagues too and stay safe.
Dr. Naresh Gunaratnam:  Thank you.
_

 

By Praveen Suthrum, President & Co-Founder, NextServices. 

We developed an easy-to-use PPP Loan Calculator to help you estimate:
• Maximum Loan you are eligible for
• Loan Forgiveness Amount (by headcount)
• Loan Forgiveness Amount (by wage reduction)
• Download and modify for your own practice
button_downloadpppcalculator
26 Mar 2020

COVID-19: Resources for GI Practices

When this winter ends, who will you become?
It may not seem like it now but this winter will end. We will find practices that’ll come through stronger from this phase. Newer models of GI practice will emerge.
This outbreak reiterates more than ever that medicine is moving into an irreversible digital era. Telemedicine is the new norm. Remote medicine will expand. It’s also clear that healthcare is no longer just local. It’s local and global at the same time. But today is a time to take stock of your practice. To prepare your business and LEAD. For the many who depend on you.
We will continue to update this page with highly curated articles that have practical and immediate use.
• Top Five Things Gastroenterologists Should Know About Telehealth (American College of Gastroenterology)
• ‘PATIENTS COME FIRST,’ LOCAL DOCTOR TAKES PATIENT CARE TO NEW LEVEL BY OPENING DRIVE-THRU CLINIC (WTHI TV-10)
• Coronavirus (COVID-19) outbreak: what the department of endoscopy should know (Science Direct)
• MEDICARE TELEMEDICINE HEALTH CARE PROVIDER FACT SHEET (CMS)
• COVID-19: Impact on GI Practices + Resources (NextServices)
• AMA quick guide to telemedicine in practice (AMA)
• Recommendations for GI endoscopy and clinic practices (NextServices)
• MLN Booklet – Telehealth services (Medicare Learning Network, CMS)
• Coverage and payment related to COVID-19 (CMS)
• Coronavirus (COVID-19): new telehealth rules and procedure codes for testing (AAFP)
• COVID-19: Telehealth rules + billing/coding guide (NextServices)
_

 

By Praveen Suthrum, President & Co-Founder, NextServices. 

We developed an easy-to-use PPP Loan Calculator to help you estimate:
• Maximum Loan you are eligible for
• Loan Forgiveness Amount (by headcount)
• Loan Forgiveness Amount (by wage reduction)
• Download and modify for your own practice
button_downloadpppcalculator
18 Mar 2020

COVID-19: Telehealth rules + billing/coding guide

To tackle the COVID-19 crisis, CMS has expanded its telehealth benefits on March 17th, 2020. I’ve synthesized the “must-reads” from the announcement below. For example, CMS will pay even if you Skype with patients.
KEY POINTS
There are three types of virtual visits: Telehealth visitsvirtual checkinse-visits.
Telehealth visits: Interactive audio/video real-time communications.

1/ Telehealth visits are considered the same as in-person visits and are paid at the same rate as regular, in-person visits.

2/ Applicable in all types of settings across the country, including homes.

3/ No audits will be conducted to check if prior relationship existed for claims.

Virtual check-ins: Brief communications with providers, often initiated by patients. Any mode: phone or video or image.

1/ Applicable only for established patients.

2/ HCPCS code G2012: Usually a brief 5-10 minute medical discussion. HCPCS code G2010: Remote evaluation of recorded video or image submitted by the patient.

3/ Applicable across broad range of methods, unlike Telehealth that requires real-time audio/video.

E-Visits: Non-face-to-face patient-initiated communication with providers.

1/ Applicable only for established patients. No geographic restrictions.

2/ Communication via patient portals.

3/ Medicare co-insurance and deductibles would apply.

HIPAA:

1/ Authorities will waive penalties for HIPAA violations against providers that serve patients in good faith.

2/ FaceTime or Skype or other everyday communication tools are OK.

_
References:
Medicare Telemedicine Health Care Provider Fact Sheet (CMS.gov)
AMA quick guide to telemedicine in practice
Download Resources:
COVID-19: Telehealth billing 1-pager for Medicare, Medicaid and Commercials
COVID-19: ICD-10 Codes
COVID-19_CDC Printable instructions for patients
You may also be interested in:
COVID-19: Resources for GI Practices
_

 

By Praveen Suthrum, President & Co-Founder, NextServices. 

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