Category: Industry Updates

16 Apr 2016

A note on going upstream to fix problems before they occur


I recently came across a short, interesting TED book called The Upstream Doctors by Rishi Manchanda. The book is about going upstream to unroot the reasons for why patients (and their communities) fall sick. While most of the action is usually when we solve medical problems that stare at us, it might actually benefit healthcare (both in terms of keeping people healthy and saving costs) if we keep going upstream. In a telling example, the author discovers that a patient had constant migraine headaches that would never go away in spite of a variety of pain medications, CT scans, MRIs, blood tests and so on. After questioning her about where she lived, he discovers that there was mold in her house and that caused the headaches. Further, her son also had developed asthma. Upstream questions regarding someone’s housing/ environment/ stress levels aren’t usually part of an office visit – may be they should be.

Medicine has become so specialized that each specialist is concerned only about their specialties. I once asked a dermatologist, if he would spend the time to understand why a patient has developed a lesion on his hand, beyond simply fixing the lesion and conducting a biopsy. He responded saying that the patient is coming to him for a specific problem and if he doesn’t address that he could end up developing a hole in his hand. Nearly every specialist thinks this way – that it’s their job to focus on the specific problem that they are trained to solve and not go beyond. But inside the body, all systems are interconnected and patient doesn’t feel symptoms in an isolated manner. It’s usually expected that it’s responsibility of the family doctor/ general practitioner to go upstream and discover the underlying reasons. But since most of our reimbursement system is based on episodes – who would pay the doctor to go upstream and stop the reasons that result in these problems?

Even though pay for performance and ACOs are attempts at thinking of patients as a whole, fee-for-service thinking is inherent in how we work – even beyond medicine. We notice those people who fix complex problems more than we recognize those who work day after day to prevent problems from occurring. When picking challenging tasks, people go downstream because that’s where the problems are most visible – there’s action, drama and excitement. But may be we should all start looking backwards and going upstream (medicine or otherwise) to recognize problems before they occur. And may be we should create our reward systems around such thinking.

By Praveen Suthrum, President & Co-Founder, NextServices.
09 Apr 2016

Our latest updates on Becker’s ASC


1. NextServices Showcases Solutions at Digestive Disease Week 2014
(GI Endoscopy-Driven Surgery Centers to Know 2013) NextServices announces endoscope integration with enki EHR at DDW 2014.
2. How Do GI Coding Changes Affect the Field? Reimbursement, Technology, Denials & More 
(ASC Coding, Billing and Collections) Praveen Suthrum, president and co-founder of NextServices, explains what the 2014 changes mean for gastroenterologists and GI-driven ambulatory surgery centers.
3. How to Boost Clean Claims Submission at ASCs 
(ASC Coding, Billing and Collections)Nextservices blog post outlined on how ambulatory surgery centers can achieve 95 percent clean claims submission ratio.

4. Sending Patient Statements: Tips From NextServices 
(News & Analysis) In a recent blog, NextServices provided the most effective methods for sending patient statements in order to see results.
5. 11 Esophagoscopy Code Updates to Know 
(ASC Coding, Billing and Collections) Gastroenterology coding changes.
6. Collect From Patients: Best Practice for Sending Statements 
(News & Analysis)NextServices recently posted an article about sending patient statements on their blog. The article discusses whether providers should send patient statements daily or in bulk.
7. NextServices Exhibits EHR Through Google Glass 
(News & Analysis) NextServices announced it has unveiled the prototype for enki Glassware at FutureMed in San Diego.
8. Futuristic Healthcare: 7 Considerations for Ambulatory Surgery Centers 
(ASC Turnarounds: Ideas to Improve Performance) Praveen Suthrum, president and co-founder of NextServices provides a look ahead for ambulatory surgery centers.

09 Apr 2016

Top 10 surgical services at Ambulatory Surgery Centers (ASCs)


According this article, most frequently reimbursed services in an ambulatory surgery center (ASC) setting are below.

All belong to three specialties: ophthalmology, gastroenterology and orthopedics.

  1. Cataract surgery with IOL insert, 1 stage: 17 percent (ophthalmology)
  2. Upper GI endoscopy, biopsy: 8 percent (gastroenterology)
  3. Colonoscopy and biopsy: 5.7 percent (gastroenterology)
  4. Lesion removal colonoscopy, snare techniques: 4.4 percent (gastroenterology)
  5. Injection foramen epidural lumbar, sacra: 4.1 percent (orthopedics)
  6. After cataract laser surgery: 3.9 percent (ophthalmology)
  7. Injection spine: lumbar, sacral (caudal): 3.6 percent (orthopedics)
  8. Diagnostic colonoscopy: 3.6 percent (gastroenterology)
  9. Injection paravertebral: lumbar, sacral: 2.2 percent (orthopedics)
  10. Injection foramen epidural add on: 2.1 percent (orthopedics)
09 Apr 2016

What does it mean that 25% of ALL coding changes are related to Gastroenterology?


American Medical Association (AMA) added 175 new codes, revised 107 CPT/ procedure codes this year – 25% of them are related to gastroenterology (26 new codes, 41 revised codes and 17 deleted codes). Let’s consider an example.

If a patient showed up with a tumor in her esophagus, a gastroenterologist typically performs an esophagoscopy using snare technique to remove the tumor. A new technique has been doing the rounds during the past few years called Endoscopic Mucosal Resection (EMR) – it uses a suction mechanism to yank the tumor out from the skin before it’s cut. The technique helps in controlling unnecessary bleeding. Up until this year, EMR had no code. But this year, AMA recognized it with  43211 – a new code.

Up until this year, it didn’t matter whether a gastroenterologist used a flexible/ rigid scope or went in through the nose/ mouth during an esophagoscopy. But with the coding changes, it matters now – there’s increasing specificity.

What do examples of such coding additions/ changes mean for gastroenterology? At a very broad level, it simply means that there’s a shift underway. The patients are the same, the disease conditions are similar but how something can be diagnosed and treated is actively undergoing a change. Ambulatory surgery centers consider traditional upper and lower GI procedures as their bread and butter. But with steady innovation, better understanding and wider spread of newer techniques, the specialty will become even more specialized. Traditional procedures will continue to see declining reimbursements.

Knowing what we know of medicine, as procedures become mainstream, reimbursements decline and newer techniques become the preferred approach. It may be entirely possible that EMR may replace traditional esophagoscopy in the future. What if enough artificial intelligence algorithms may be built in to identify polyps from a video produced by a Video Capsule Endoscopy? What if the algorithms identify all possible polyps big and small throughout the digestive tract? Such thorough and extreme accuracy would be impossible with traditional colonoscopy that involves human hands and eyes. What would happen then to doctors who are not used to learning or experimenting with new procedures?

It’s also expected that in 2015, there would be lower gastroenterology coding changes. These coding changes are simply an acceptance of newer methods to treat and fix conditions and also a gentle nudge to gastroenterologists to stay current in their fields.

By Praveen Suthrum, President & Co-Founder, NextServices

09 Apr 2016

ObamaCare and Things to Watchout For


Obamacare, also known as Affordable Care Act (ACA) has a massive impact on the medical practices. As per CMS, 7.1 million people signed up for affordable insurances through the Health Insurance Marketplace. Till date 26 states have expanded their Medicaid programs under the ACA. From outside, it might seem more profitable for patients versus for healthcare organizations but here’s a look into the Affordable Care Act and the things to watch out for.

The basics.
The Affordable Care Act commonly known as ObamaCare was passed by Congress and then signed into law by the President on March 23, 2010. The act was enacted to have a minimum standard for health insurance policies and the law subsidies to help people with low incomes. The idea being getting as many Americans insured as possible. While ObamaCare dose not create insurance entities of it’s own but it regulates private insurance companies to provide quality medical care at an affordable cost.

There are in total five plan types commissioned under ObamaCare – Bronze, Silver, Gold, Platinum and Catastrophic coverage, based on the percentage of medical coverage a patient is entitled to.

Bronze plan: Health insurance plan pays about 60% on an average and the patients pay about 40%.
Silver plan: Health insurance plan pays about 70% on an average and the patients pay about 30%.
Gold plan: Health insurance plan pays about 80% on an average and the patients pay about 20%.
Platinum plan: Health insurance plan pays about 90% on an average and the patients pay about 10%.
Catastrophic plan: This plan pays less than 60% and is only available to citizens under the age of 30 or have a hardship exemption.

The good.
1. More patients: Millions of uninsured will get access to health insurance through health exchanges.
2. No denials for pre-existing conditions. Under the provision of the ACA, insurances cannot deny claims under pretext of pre-existing conditions.
3. Uninsured patient population can get free or low cost health insurance using their State’s Health Insurance Marketplace.
4. All coverage starting after 2014 must include new preventative services and essential health benefits.

Watch out for.
1. More patients will not necessarily translate to higher reimbursements. Many plans will include Medicaid-type reimbursement models.
2. Increase in insurance premiums due to insurers having to provide covered services.
3. Healthcare organizations may choose to not see patients having ACA plans as the reimbursements may not equate to the time and effort put behind claims submission and follow-ups.
4. May lead to greater premiums on the other commercially available insurances.

ObamaCare is here to stay. There is still a considerable amount of uncertainty surrounding the whole model. Practices are confused about the effect on patient volume, the reimbursement models and associated overhead costs. It would be extremely crucial for healthcare institutions to plan ahead of the curve so that they are equipped and better prepared if things don’t go as per plan.

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