Infusion Revolution Series | The Data-Driven Infusion Center with Chris Hilger, CEO of SolisRx

Speaker A: Sykes. The Bottom Line Pharmacy Podcast. We've got a great show for you

Speaker B: this week, but before we get into

Speaker A: the show, if you find this episode valuable, please, like, share and subscribe so we can help more independent pharmacy owners. Also, Visit us@pharmacyaccounting.com if you're overpaying in tax, if you're prepping to start, buy or sell a pharmacy, or just have a gut feeling that your financials aren't quite right. We have a suite of services for every need your pharmacy is facing. Go to pharmacyaccounting. And we can help. Okay, now on to this show.

Speaker C: Well, welcome everyone to another episode of the Bottom Line.

Speaker B: Continuing our Infusion and Home Infusion series here, we've done a couple episodes on Home Infusion Pharmacies. Um, and, um, you know, we just recently got back from the NHIA conference, the National Home Infusion association conference. Um, and we met someone there that has a lot to say about what is data? What does it mean to be data driven and revenue cycle management? Um, that's Chris Hilger. He is the CEO of solusrx. Um, Chris, thanks for jumping on with us today.

Speaker C: Certainly. Thank you for having me.

Speaker D: Thanks, Chris.

Speaker B: Yeah, absolutely.

Speaker D: Revenue cycle management was definitely a buzzword, but for me, for being at the show, um, I heard that about every 30 seconds, I feel like, yeah, totally.

Speaker C: Revenue cycles everywhere, uh, there's kind of this arms race going on these days between the payers and the providers. Payers have a really unique kind of unfair advantage in that they live in claims data day in and day out. And providers are, you know, they're meant to provide care. And, you know, you would think that that was all that they have to do, but over time, so much of their job now is managing claims, following up on those claims, trying to get paid. And it really puts them at a disadvantage unless they're really dialed in operationally and from a data perspective.

Speaker B: So, uh, Chris, you know, revenue cycle management there was the. That was probably the number one topic that we heard there. For people listening, give us an overview as to, like, what is revenue cycle management? Why is it important to have a solid revenue cycle management team? Um, kind of go into the details there for the listeners at home.

Speaker C: Sure. So I'll give my take on it. Um, if you ask ten, uh, different people what revenue cycle management is, you'll probably get 10 different answers. Um, it's not even really a cycle. It's more of, you know, just, um, but at a, at a high level revenue cycle. How I define Revenue cycle is how providers get paid by the insurance company. Um, there are many different steps in the process, and it includes a lot of steps. Even before that claim is submitted to the payer, you just have to check a lot of boxes. So you have to understand what insurance the patient has. Are they eligible for a certain service. You have to then submit, uh, perform the service, code that service, submit that claim, track the kind, uh, of denials and where that is, where that claim is in the process, and then continue to work it and until you ultimately get paid. And then once you get paid by the payer, then the remaining balance gets transferred to the patient, uh, and then that kind of completes the cycle. So, um, you know, there's probably 10 to 20 different steps, depending on how you define it. Super complicated. Varies by payer, by therapy, by site of care. A lot of nuance. But at a high level, it's how providers get paid.

Speaker D: Right?

Speaker B: Yeah. So similar in independent pharmacy, it's that reconciliation part when they're dealing with, um, you know, reconciling receivables. Um, yeah.

Speaker D: Anytime you deal with insurance, you're going to run into this, you know, nightmare is what you mean.

Speaker B: Yeah.

Speaker D: And that's your cash, which is, you know, what is so important is that is your, you know, the working capital that you need to continue.

Speaker C: Totally.

Speaker D: So it's so important we talk about that on both sides with infusions and with retail is, um, you got to get paid. You can't just hope you get paid. We've kind of coined the phase with the hope and pray method that some people like to use where they just submit everything and we just hope we get paid, you know, hope it works out. Um, you can't operate like that. I'm sure that's the whole point here.

Speaker C: Yeah, exactly. And, uh, a lot of operators in the space, you know, will say, hey, um, I'm, you know, money's coming in the bank, so everything must be good. And it's like, no, you're probably missing out on double digits, percentages of your

Speaker D: revenue, and especially when you're dealing, like, you do a lot, Chris, with, um, infusion. We're talking about infusions, we're talking about, um, an extremely large amount of these claims. And then you're having to pay, you know, these owners are having to pay the drug cost pretty quickly, but it may take a long time, much longer, um, before you're paid from these receivables, from the insurance and the claims. So, um, there's a, definitely a crunch, um, with Cash, um, that pops up from this. So it's very important.

Speaker C: For sure.

Speaker B: Yeah, absolutely. Um, and one of the things we also wanted to talk about, so we kind of covered like what revenue cycle management is. Um, there's also another layer to this which is being a data driven, um, infusion clinic and infusion center, um, that kind of ties into what you do, your product. Um, what exactly is the data driven piece behind this? Give us a rundown of that.

Speaker C: Sure. So if you are an infusion center or a home infusion company, or a specialty pharmacy, you're going to have a handful of different systems that none of them really talk well to each other. So when I say handful systems, I mean you're going to have an EHR or pharmacy management system. Um, you're going to have some type of billing system, some type of intake tracker, some type of CRM. Uh, maybe you have some pilot going on with the Genai platform. All these systems work well in their own silo, but to have a really dialed in revenue cycle process or intake process or referral, uh, process, you need them all to talk to each other. So one of the services we offer, think of us as like a boutique consultancy. We embed in with the given provider, the pharmacy and act as their go to data partner. The equivalent of them having to hire and train up their own data team. Instead, you know, they can bring in a team of experts who understand the data and the systems at an intimate level. Um, so in terms of data driven, how we think about it is ingesting all the data from these siloed systems into the pharmacies or infusion center's own environment and then connecting it all together through what we call the data spine. And what that allows you to do is ask really sophisticated questions and build out sophisticated automations to say, hey, which referral sources are driving the most from a gross profit perspective? And of those super high gross profit, uh, potential referral sources, which ones haven't we visited in the last six months and why? Right, right. And so by connecting together your CRM with your encounter data and your uh, fee schedules for revenue and your COGS data from a cost perspective, you can then arrive at that gross profit potential, uh, from a referral source perspective, you can ask other questions like hey, of uh, the upcoming appointments, which of these patients have historically driven denied claims. Therefore let's either get to the root cause of said denial or reschedule the patient to a later date. If it's a high cost biologic, that can easily be, you know, a $30,000 denial, plus the drug cost that you're spending. So tens and tens of thousands of dollars in a cash flow hit just from building out the spine and having better visibility uh, into your operations.

Speaker D: Absolutely. One of the things that um, I learned a lot about too in this cycle is kind of, I think someone referred to it as revenue leakage. Um, so talk about that if you don't mind. Like what are the biggest culprits there as far as um, kind of the issues causing that leakage and that kind of missed cash.

Speaker C: Sure, sure. So we bucket it into three core areas. So one is referrals, second is intake, and third is revenue cycle. So on the referral side we say, hey, how can you use data that both you own or, and, or you acquire like third party market data to understand who are the top referral sources you could go after from a gross profit perspective and then have the specific conversation about the specific therapy. So just because they're driving a lot of volume, it could be for really low cost or low value therapies and you want to instead have a conversation with them around the really high cost therapies that maybe they're shipping to a competitor. Like you're getting all the low cost stuff, uh, and they're get there, they're sending the high cost stuff somewhere else. So that's an example of leakage on the referral side. Um, and then on the intake side it's hey, how do you get those referrals to convert? Only about 60% of referrals convert. The 40% don't convert due to various reasons. You're either out of network, you're really slow to react and respond to get through the uh, biv or the package. Um, and so you want to reduce that time from referral to first appointment as much as possible and increase the referral conversion rate. So that's on the intake side and then on the rev cycle side, main culprit of leakage is denials. And there's a bunch of different reasons why they get denied. But then also just working the open AR balances.

Speaker D: Right, Keep working it. Yeah. And one of our, um, I would say one of our most successful infusion pharmacies, um, that I personally work with, um, tells me all the time, um, that the most important, and you may disagree, but this is his take is the most important point of anything he does with this infusion side is the intake. He's like getting that dialed down from day one or as early as you can and, and his team and having that whole process that they used out in um is the most important thing that he does.

Speaker C: Yeah, intake is critical. It's uh, and it unlocks value everywhere else in those three growth areas. So if you get a dialed in intake process, then you can go to the referring provider and say, look for this specific therapy. Here's hard data, here's hard proof that shows we have experience getting patients on therapy faster than anyone else in our, in our local market. Right, right. And it gives referring providers a lot of confidence to then send you more and more scripts. Also, you're just going to have a higher referral conversion rate. The patients are going to like it better and you're probably going to clean up a lot of things in your revenue cycle. So you have clean uh, claims when they go out the door because you're not having issues with authorization or eligibility or things like that.

Speaker B: I just think, um, and Chris, we've, we've talked about this and we've talked about this on other podcasts, um, for sure. But I just think that there's a. Pharmacies are sitting on a lot of data. They're sitting on a ton of data and there's opportunities within that data to um, capture more revenue to grow your pharmacy, um, all those things. So let's kind of shifting gears a little bit here, but staying on the same topic, let's talk about like, you know, utilizing that data more. What are. You have something that's the six pillars of data maturity. So what is that? Like what are the six pillars of making sure, you know, the uh, I've got good fundamental data here and then you kind of how to maximize that.

Speaker C: Sure, sure. So, um, how we think of it is everyone in the world, definitely in our industry, but kind of the world broadly is racing towards generative AI. It's saying like, hey, I want to automate everything. I want to get humans out of the loop as much as possible. I just want to pay some fee to have it automated and then not think about it. The reality is, first, the technology isn't sophisticated enough to have some silver bullet that just automates everything. And then two, that's also a very expensive way to go about operating your business, whether you're a pharmacy or infusion center, uh, to just rely on some very expensive automation platform to do the work that just a more kind of sophisticated operation from building out in house analytics and capabilities, uh, could deliver. So we have this, you know, six stages of data maturity. We actually map it to a mountain. So we call it kind of like the Mountain slide. And we, you know, anytime we start.

Speaker D: Backdrop, Right, the backdrop, yes, all recently created.

Speaker C: So this is hot off the press. So when we start talking with a new potential client, we unders, we try and understand like, hey, where are you on this maturity curve? Right? So, hey, level one is, hey, we're just pulling static reports out of our ehr, out of, out of our CRM, our pharmacy management system. It's all in Excel. We have really big version control issues, sharing issues, things like that. But hey, we can get static reports and manage our work queues and we're getting some value. And then level two is okay, hey, we're still doing these static data pools, but we're starting to build out what we call red flag reports so we can track, hey, patients who have had a denied claim, but they have an upcoming appointment. Let's prioritize those upcoming appointments to understand what the root cause is to try and prevent a new denial or what we say, intercept a denial before it happens. The real unlock though is once you move to the third level, which is uh, a data lake. And so that's basically saying, let's go, ingest data out of all these platforms into your own environment that you manage and you control and then you can build out workflows, data driven workflows that work specifically for your business. That's a huge step up though. Like this is something that takes a small team of analytics engineers and data scientists and experts to go build for you. But once you do that, then that creates that data spine that we talked about and allows for very significant, um, insights into your business, but then also unlocks future capabilities around level four, greater automation. So think of automatically alerting a salesperson when a new referral comes in or automatically alerting a salesperson when a new referral comes in. Where, hey, we, this one's very complicated. Maybe we need to do some extra handholding to get this PA approved. Right? And you can have custom business rules built around that. 5 would be machine learning. Like, hey, how can you use your own practices data on uh, denials to predict if a claim is going to deny before you even submit it? And then six would be, we say, hey, after you've done all these five levels, now it makes sense to bring in some additional generative AI, uh, to better automate certain things around biv or prior authorization. The reason we say wait till level six is two reasons. Uh, sorry, wait to do level six until you have all those five is for two reasons. One is, uh, you want to have the infrastructure to verify and validate the output of these Genai platforms. They do hallucinate, they can drive tremendous value, but they do make mistakes. So you need to be able to hold those platforms accountable and, and work with them collaboratively to improve their systems over time. And the second is it's just a really high level of effort for like the value you get out of it. So like a simple, more simple red flag report, uh, to flag patients who have authorization related issues before the appointment occurs can drive just as much value as some of these advanced platforms. If, uh, you haven't yet built it

Speaker D: out, that is a great point. Like go ahead and capture it. I mean that's pulling data and already knowing you're going to have a problem before it happens.

Speaker C: Right, Exactly. And what we find is there's a lot of low hanging fruit, um, and you know, a lot of the solutions we'll walk through like on these lower levels, it's not rocket science, you know, it's like, yeah, that makes sense, we should be doing that. But as the organization scales, you now have different layers of leadership. So like hey, the CEO might be motivated to dig in and you know, resolve the issue. But once you have like not just the CEO, but you have like a VP and manager and then frontline, that frontline worker just doesn't have the full grasp of the business to understand how they might want to prioritize things, what's important and really have kind of like the uh, the, the real kind of like nose to the grindstone to, to work the problem until it's done. And they're super busy too, so.

Speaker D: Right.

Speaker B: Yeah.

Speaker D: You know, I heard a lot of horror stories um, from people that talk about, I just want to make sure everybody kind of understands what we're talking about here. You know, people are going through, they have a bad intake process and then they, but they're getting their infusion, they might get a second infusion, they might get a third infusion. And then you're talking about it could be $20,000 a pop.

Speaker C: Yeah.

Speaker D: And then you're not working it, you're paying for that drug.

Speaker C: Yeah.

Speaker D: And you haven't been paid one dime yet. And so such a big um, cash flow issue, um, when we look at it on the accounting side, um, so that's why it's really important to us. And just a quick plug for ourselves, if I could say, um, to anyone out there who does not have kind of a pharmacy, CPA that works in this niche and a far in kind of a pharmacy or an infusion area. Um, the reason why this is so important to us and why we talk about this is because when you're, you know, obviously your financials are so important for your business and truly understand how you, you are operating. And if you, um, one thing we've seen when people come to us and they haven't had this data or they don't have good, um, you know, receivable or their handle on what is owed to them is they can't, they're not adjusting for these things. So they have no idea. If you truly don't have any idea what is owed to you, um, and you don't have that book, that receivable books on your financials, um, you really kind of, you really need a full accrual set of financials to truly know what your revenue was like and how you operated that month. Um, and so if you're just out there just, you know, taking in, doing intakes and doing some infusions and you're not following the claims, um, and making sure you get paid, you have no idea what your receivables are. You don't know if you're getting paid. And so really, I mean, for lack of a better term, your financials really are trash. I mean, they're not giving you a full. I mean, they may look pretty and maybe you even think they look good. Um, but are they right? So, um, it's just, that's probably the biggest number on your balance sheet. Um, totally.

Speaker C: And all this real anytime you, you want to go to sell, you know, you don't want to be learning about your business when you're, you're trying to sell it.

Speaker D: Uh, yeah, you want to sell and then you don't have the data ready or correct for the seller, you're going to be in a mess. Um, yeah, big deal.

Speaker B: Well, Chris, we won't hold you up any longer. We'll definitely have you on for a second episode. Uh, because we could go down a huge rabbit hole with this. Um, but for the listeners out there, um, Chris's information is going to be in the description of the episode. Um, and also, uh, this episode will be released before the Nika conference. So, you know, if you see Chris out on the show, make sure you stop by his booth, talk to him. Um, and if you see Scotty and I at the Nika conference, you're not letting me go.

Speaker D: I can't go to the Nika conference. I'm kidding. I have a, uh, previous speaking engagement with ncpa, so, so I'm going to miss, unfortunately I hear this is a great show, so I'm sad to miss, but I have, um, to be somewhere else. Chicago at the same time, so that's not going to work out.

Speaker B: Well, thanks, everyone, for listening in. And Chris, thanks again for jumping on.

Speaker C: Sure.