The business of IONM…

I’ve had the pleasure of reading many posts, articles and thoughts from many bright and talented individuals and groups on the clinical aspects of intraoperative neuromonitoring. Being in the business of healthcare, and not being an IONM clinician myself, I do my best to try to constantly learn as much as I can about the nature of what you actually do so that I can most efficiently and compliantly translate your services to the revenue cycle. After all, this is the business of healthcare, and being a wonderful clinician or clinical group means little if you can’t support the system financially.

Since you’ve all shared a lot with me over the years, and knowing that there isn’t much available content pertaining to the business of IONM, I thought that I would share a bit from time to time about the intraoperative neurophysiology revenue cycle. Now, many of you in the profession aren’t involved with this aspect of the business; you finish your case, submit the superbill or modalities and time, and your role is complete – likely assuming everything will take care of itself, right? Yet, there are many aspects of the revenue cycle (RC) beyond what occurs the day of the procedure, and they begin well prior to the surgery and extend for several months afterwards. This amount of time and the number of steps that need to be performed correctly essentially mean that there are many aspects of this process that need to occur in harmony –  time after time –  for you to optimize reimbursement.

I know what you’re thinking, “There are only a handful of codes that we can use in IONM, so where is the challenge?”

While this is indeed true, there are so many other factors that come into play that will make or break the clean claim. Consider this; how is it that two different groups in the same geographical area with the same payer mix may recoup on average 15-75% different revenue per case? Often, small steps can make all of the difference, and equally as often, large shifts are necessary to streamline this process to get it right.

Where to begin? As I alluded to, what you do days, weeks and years prior to the patient encounter are a very important and often overlooked aspect of the RC. Besides the negotiated rates with the hospital for the technical component, other items you negotiate within the facility agreement are important as well. Have you discussed and agreed to the appropriate provisions to ensure uninterrupted care? Have you secured access to the appropriate records per the agreement and have you established relationships with the appropriate contacts in the hospital and surgical offices should there be missing documents or information? Do you appreciate the contracts that your partners have with the payers and do you have participating relationships yourself?  For this later part, the out- of- network relationship is more the norm than the exception- although the nature of how this affects the IONM RC will slowly be shifting – perhaps a discussion for another day. Are you current with your knowledge of payer policies and do you understand how to navigate the information that speaks to the nature of neuromonitoring reimbursement? Does your front office collect the appropriate data/demographics/pre-authorizations and does your front end infrastructure ensure that the appropriate resources (on both sides of the screen) are optimally assigned to maximize your chances of payment?  Of course, there is so much more to it than this, but you can get a sense of how many decisions that can affect your reimbursement led up to the point of the first patient contact.

The day of surgery is where you (likely the typical reader; the tech, the neurophysiologist and/or the physician) come in.  First and foremost, you’re there to take care of the patient and hopefully do it well.  I appreciate just how hard everyone works, how long the days can be, how chaotic the case or cases may be, and often the business aspect falls into the background, which is understandable and mostly appropriate. There will be times when the office will let you know that they need this document or that piece of information regarding the patient. Understanding that you’ve got bigger things on your mind, they truly are asking for a reason and hopefully wouldn’t be inquiring then and there if it weren’t necessary. With that aside, you can focus on the patient, which is the good news. Your role is to take care of the patient to the best of your abilities and to document the encounter. By focusing on the patient and doing a darn good job documenting the case, you increase the odds of optimal reimbursement. Your office operations team likely requests that you collect and/or scan certain documents that they will need to submit a claim, but it goes well beyond this. Both CMS and the commercial payers request certain report language, chat format, and data format above and beyond the diagnosis and procedural codes to satisfy the claim; quite often they are all similar, but of course there are also differences. The key is to do it accurately every single time regardless of the payer. This will not only increase the odds of a clean claim, but it’s also just good patient care and a medicolegal safeguard.  If you can satisfy all of this by doing it the right way every single time from the start, why wouldn’t you?

Coding in IONM is a lot like the clinical world of IONM.

There are only a handful of ways to do it. Numerous groups have been doing it for a long time, and yet there is such heterogeneity that you often wonder if we are all working in the same profession. As you all know, there is a time-based code, which differs depending on the payer and modality codes.  Although the modalities you monitored are the modalities you monitored, they often get coded in many different ways. Often, erroneous language is cited, or no language is cited at all when justifying coding.  Frequently, it’s a matter of trial and error. There is lack of understanding in the profession when it comes to the IONM RC, and we often see the square peg being pounded unsuccessfully through the round hole…. or even worse, a group may think they are successful and not realize what is being left on the table.  There is also a lack of understanding regarding IONM from the payers, which I’ll touch upon momentarily. But, it’s safe to say that subtle, compliant changes/differences in coding can really add up (or subtract) if you’re monitoring hundreds to thousands of cases per year as a group. However, even when cases are coded correctly, that’s only one step in the process.

Eventually, the claim goes out the door. Depending on the payer and the participating relationship, you hopefully get paid in the next few weeks, but it can take several months or longer. Here’s the biggest take home: the only thing worse than not getting paid or paid sub-optimally, is getting paid and eventually having to give it back. Just because a claim got paid doesn’t necessarily mean it should have been paid. Do it right the first time! There are a lot of constantly changing rules and regulations, but it’s worth it to keep up with all of them, giving the fact that this is the livelihood of the profession.
Again, considering the overwhelming out-of-network nature of this profession, a lot hinges on having a sound appeal process that works like a well-oiled machine. The AR department should be dealing with a claim that was so clean that it squeaked when it hit the scrubbers.  If the (beautifully produced and documented) clinical data wasn’t submitted originally, then the AR team should know where to locate it and reference the pertinent information to educate the representative of the payer who likely knows little to nothing about IONM.  AR is all about knowing when to appeal and when to write off.  What should your DSO be? The answer may surprise you. The AR process, although mostly common sense, is dynamic and always changing and often is what differentiates degrees of financial success between one group and another. Most larger IONM companies have a RC manager who stays on top of these matters and constantly meets with the billers/coders and AR, or fields calls with the payers when appropriate. They should function like a car manufacturer, where constant iterations of the process occur to hone the process to make sure that the group keeps up with the fluid nature of healthcare.

So, the IONM RC is just that, a cycle that keeps going around and around.

50 claims go out the door, 50 more come in, yet there are 500 more that require touches on a daily to weekly basis.  It’s easy to get dizzy or complacent. Foster sound relationships between the clinical team or representative and the RC team or representatives. Foster sound relationships with the hospitals and surgeons to secure the information you need. Have a streamlined process that begins well in advance of the patient encounter and ends only when you think that the payment is optimal. Meet continually with the RC team and clinical representative to identify intrinsic and industry trends and fix them before they become larger. Learn as you go and internally audit constantly so you remain ahead of the issues. Most of all, do it right so that you never have to fear an external audit or payer inquiry!