Working Healthcare · 2026-06-30 · 1h 0m
Key moments - from our scoring
Substance score
55 / 100
Five dimensions, 20 points each
Chris Acevedo, a compliance and coding expert with 23 years of experience, explains why the physician's work doesn't end when the patient leaves the exam room. He and the host discuss the critical backend processes - pre-approvals, timely filing deadlines, downcodes, and payment takebacks - that determine whether practices actually get reimbursed. A key vulnerability: payers like United Healthcare enforce 60-day timely filing limits (stricter than Medicare's 365 days), and missing this window results in permanent claim denial. Worse, practices can face "double whammy" situations years later when payers retroactively demand refunds for technical errors, forcing clinics to repay both the visit reimbursement and the cost of any drugs or biologics provided. Acevedo, who leads Acevedo Consulting alongside his mother Jean (the firm's founder), draws on lessons about staying in your lane, understanding the healthcare ecosystem as interconnected players, and ensuring accurate patient information upfront to avoid costly downstream denials. Essential for practice managers, billing directors, and physician leaders navigating reimbursement complexity.
Timely filing refers to the deadline by which claims must be submitted to payers. United Healthcare allows only 60 days, while Medicare allows 365 days; missing the deadline results in permanent claim denial regardless of clinical validity. If a denied claim is discovered after the timely filing window closes, the practice loses all reimbursement for that visit.
A takeback occurs when payers go back months or years after payment and demand refunds due to technical errors or coding issues, claiming they should not have paid for the visit. This forces practices to refund the reimbursement already received and repay the cost of any drugs or biologics provided - a "double whammy" of financial loss.
The practice spends minutes to fractions of an hour on pre-approval work, securing any necessary authorizations, verifying insurance eligibility, and arranging financial assistance if the patient is on drug-based procedures. Front desk staff must also verify all patient information is correct, because errors can prevent the physician from getting paid for the visit.
After leaving Verizon Wireless during corporate layoffs in 2002, Acevedo joined his mother Jean's consulting firm, Acevedo Consulting (founded 2000), just as HIPAA enforcement began in 2003. He spent 18 months reading the law to develop privacy programs, then gained coding certification and worked as a coder for hospice before becoming a sought-after speaker and compliance expert.
That healthcare professionals are interconnected pieces on a chessboard; most are pawns, and actions taken have reciprocal consequences down the line. This translates to always putting clients' needs first, knowing what you don't know, and staying focused in your niche rather than expanding into adjacent services like billing companies.
Our reviewer’s read on each dimension, with quotes from the episode.
The episode contains real operational nuggets - automatic downcoding without formal denial, retroactive CMS guidance dates, timely filing windows that differ by payer, incident-to billing traps - but these are interspersed with significant filler: 25-year friendship backstory, son Marcus's internship, life-philosophy tangents, and general 'healthcare is complicated' commentary that dilutes density considerably.
there are a number of payers, you can name them, I won't, that um have have policies in place that automatically downcode services if they're billed at a certain level
if all you're doing at the end of the day is submitting claims and checking a box that those claims got paid, you're not doing enough
The automatic-downcode-without-denial mechanic and the retroactive effective-date tactic are genuinely under-discussed and practically useful; however, the broader framing - payers squeeze providers, fee-for-service is broken, doctors need business help, Germany model comparison - is standard industry commentary recycled across countless healthcare podcasts.
they look at the claim that's submitted and they say, oh, this claim doesn't look to us from a from a pure bird's eye perspective, whether you they're using AI or people or data mining
Just because it has a code doesn't mean you can bill for it. Just because you can bill for it doesn't mean you can get paid for it. Just because you've been paid doesn't mean you can keep the money
Chris Acevedo is a credible practitioner with 23 years of hands-on compliance work, a six-year operator stint as COO of a multi-state practice and VP of physician services for a large hospice, and active DOJ case work - genuine credentials rather than a thought-leader circuit guest; he is, however, a regional expert rather than a nationally prominent figure, and the longtime personal friendship with the host softens the interview dynamic.
I had about a six-year hiatus from consulting, where I went and was the COO of uh multi-state medical practice and uh vice president of physician services for the largest privately held hospice
we do a ton of work with the Department of Justice when it when they present a case to us, we look at the merits of the case
The episode delivers concrete, named specifics: Humana demanding 65% of Medicare allowable, Aetna yielding an effective 68% rate, United Healthcare's 60-day timely filing window vs. CMS's 365 days, Florida's 2.5-year-old vendor data-storage attestation requirement, and the host naming Cigna NetNow when the guest demurred - these are actionable data points; other claims (physician burnout scale, system-level arguments) are asserted without supporting evidence.
After I spent three years negotiating that contract, they came back 18 months later and wanted to reduce my reimbursement literally to 65% of Medicare allowable
when I did the math, we were getting paid at about 68% of Medicare allowable
The host contributes real practitioner knowledge from running her own rheumatology practice - naming Cigna NetNow when the guest wouldn't, inserting the Humana/Aetna data points, and pushing back on the risk-model framing - but the deep personal friendship produces more mutual validation than genuine challenge; questions are reasonable but rarely follow-up hard on mechanisms or press for evidence behind claims.
I'll say it for you, it's Cigna NetNow. So what can practices do to fight against that?
Can I edit that a little bit? And say sometimes the final rules are not even enforced or implemented or known until after the first of the year
Computed from the transcript - who did the talking, and the words that came up most.
Most people think a doctor’s visit ends when they walk out of the exam room. It doesn’t. That visit triggers a maze of prior authorizations, coverage rules, coding decisions and payer tactics that can make or break a medical practice months or even years later. On this episode of Working Healthcare, host Meredith Hirsh sits down with Chris Acevedo, CEO of Acevedo Consulting, who grew up watching his mom run practices and now helps physicians across the country navigate the business side of medicine. Chris walks through what really happens before and after a visit - from front-desk data entry and benefit checks to denials, timely filing traps and surprise takebacks on claims that payers already processed and paid. He explains why one technical error can cost a practice both the drug it infused and the reimbursement it thought was safe, creating what he calls a double whammy.
Transcribed and scored by The B2B Podcast Index.
1 - > SPEAKER_01: If you're getting value from working healthcare, I 2 - > have a quick ask. 3 - > Follow the podcast and leave a five-star review on Apple 4 - > Podcasts, Spotify, or wherever you listen to the podcast. 5 - > That simple action helps more physicians and leaders find 6 - > these conversations and better understand how our healthcare 7 - > system actually works. 8 - > And that matters because we can't fix what we don't 9 - > understand.
10 - > You gotta run it, gotta run it. 11 - > Most people think that when they walk out of an exam room, the 12 - > visit's over. 13 - > It isn't. 14 - > There's so much.
15 - > You have the policies, the compliance, the players, the 16 - > coding, the auditing, the edits, the PBMs, the vertical 17 - > integration is extensive. 18 - > And having the right people behind you to support you and 19 - > have your back is so vital. 20 - > I just interviewed Chris Acevedo. 21 - > He and I have known each other for about 25 years.
22 - > And he is, even though he doesn't say he's a king, he's a 23 - > pawn, I will tell you, he's the king of compliance. 24 - > You will not want to miss this episode. 25 - > Chris Acevedo, welcome to Working Healthcare. 26 - > SPEAKER_00: Happy to be here.
27 - > Thanks for having me. 28 - > SPEAKER_01: It's like interviewing my brother, a 29 - > brother from another mother, right? 30 - > Your mom is one of my mentors. 31 - > She was one of my first podcast episodes, I think episode 11, 32 - > Gene Acevedo.
33 - > And uh I I adore your entire family. 34 - > Even Marcus, who's Benjamin's age. 35 - > SPEAKER_00: Absolutely. 36 - > I think we're going on almost 25 years of friendship.
37 - > So it is absolutely a pleasure to be here and share this uh 38 - > experience with you. 39 - > SPEAKER_01: I wanted you here because you and I teach together 40 - > at FAU, although I just had my last class last week, and I 41 - > think you're on it as well. 42 - > SPEAKER_00: June will be my last class after on and off the last 43 - > two decades of teaching with the executive education there. 44 - > Yeah.
45 - > SPEAKER_01: You definitely did more than me. 46 - > I gave eight years. 47 - > So I gave eight years, and you and I have presented together at 48 - > the Palm Beach County Medical Society, and we run in the same 49 - > circles because I do the administrative side. 50 - > You are very much focused on compliance, billing, coding, 51 - > regulations, like that's your jam.
52 - > What do people not understand about the whole process? 53 - > Because the doctor's visit doesn't end after the patient 54 - > leaves the exam room. 55 - > SPEAKER_00: Yeah, well, the, you know, oftentimes patients don't 56 - > think about the business of healthcare. 57 - > They think about the what I would call clinical transaction 58 - > between themselves and the doctor, right?
59 - > And maybe some of the staff members in the practice. 60 - > Uh, but the overwhelming majority of the time spent in 61 - > the business of healthcare is outside of the room between the 62 - > patient and the doctor. 63 - > Right? 64 - > If you put your, if you put your mind in the body of a patient 65 - > who's having a visit today with whatever their specialty doctor 66 - > is, well, stay rheumatology, since that's where I know your 67 - > husband practices.
68 - > Uh that patient doesn't even realize before they walk in the 69 - > door that that practice has spent minutes to perhaps 70 - > fractions of an hour getting all of their pre-approval work done. 71 - > If they're on some type of uh drug-based procedure, there 72 - > might be financial assistance that practice is working with, 73 - > right? 74 - > So you have all of that before they walk in the door. 75 - > Then they walk in the door and the front desk staff have to 76 - > make sure that all of the information is correct, because 77 - > if it's not correct, there could be a reason that the doctor at 78 - > the end of the day isn't able to get uh paid for the work they 79 - > did, right?
80 - > Which would shut down the system. 81 - > SPEAKER_01: And I don't even think people realize if 82 - > information is incorrect in the system and it gets sent out to 83 - > the payer, if the administrative team, the billing team, are not 84 - > reviewing the denied claims, you could hit a timely filing issue 85 - > where, oh, I found it 61 days later. 86 - > And United Healthcare is a really big uh player in only 87 - > allowing you to bill within 60 days. 88 - > I always tell people when you negotiate contracts, follow 89 - > CMS's rules.
90 - > So you have 365 days, but then it's a denied claim because of 91 - > timely filing. 92 - > SPEAKER_00: Yeah, so you you have you run the risk of A not 93 - > even being able to have your claim considered for payment, 94 - > right? 95 - > Because you didn't get the information, the all of the 96 - > accurate information in timely. 97 - > But on the flip side of that, depending on who the payer is, 98 - > right?
99 - > And here in Florida, uh we have a number of practices and 100 - > physician offices that deal with Medicare as their primary payer, 101 - > right? 102 - > And um those payers, again, depending on who they are, can 103 - > go back years later and say, oh, by the way, there was this 104 - > technical error you had, and we want the money back that we paid 105 - > you for that visit. 106 - > Um, and so you're out clearly the money for that visit if you 107 - > don't have a leg to stand on with that technical denial 108 - > reason.
109 - > But God forbid you had some expenditure for that visit. 110 - > So maybe you had uh a drug or biologic that the practice paid 111 - > for that they got reimbursed. 112 - > Well, that's having to be refunded too, right? 113 - > So you're hit with what I would call a double whammy there, 114 - > where you're out the expense of the product that you provided a 115 - > patient, your staff time, and then you're out the 116 - > reimbursement that you've already spent because it was 117 - > given to you two years ago.
118 - > SPEAKER_01: How did you even get into healthcare? 119 - > SPEAKER_00: Oh, wow, we're gonna hit nepotism early on. 120 - > So, so um, I've been doing this for uh since 2002. 121 - > Uh, luckily for me, very luckily for me, uh, my mother Jean 122 - > started our firm, Acevedo Consulting, uh, in 2000.
123 - > And um, by that time, she was already a pretty well-recognized 124 - > expert in uh coding, billing, reimbursement, and compliance. 125 - > So the the practice itself uh took off pretty quickly from 126 - > 2000. 127 - > I joined in 2002, um, when after, you know, as a young, 128 - > young man realizing I don't want to be in wireless communications 129 - > uh as a career, right? 130 - > I had this job and um and I was working for Verizon Wireless.
131 - > They were a great company, nothing against them, and they 132 - > were having corporate layoffs. 133 - > Uh and um it was good timing. 134 - > So um I was really in the midst of what do I want to do with my 135 - > life? 136 - > I I don't want just to go from job to job, right?
137 - > Uh study communications in college and some criminology, 138 - > wasn't really sure. 139 - > You know, as young adults, they kind of push you into making a 140 - > decision really quickly. 141 - > Uh and thought to myself, you know, this is a a really cool 142 - > thing that my mom has a business with our family name on it. 143 - > Um, and what would I have to do to be serious about that?
144 - > I I was always intrigued by what she did for work. 145 - > Um, I have a strong relationship uh with my mother, who was a 146 - > single mother. 147 - > And um, and so I would work the switchboard at the medical 148 - > practices she ran at eight years old, right, over the summers. 149 - > So uh it never turned me off to what she did, right?
150 - > Some kids, they come home, they don't want to talk about their 151 - > parents' jobs. 152 - > It's so disinteresting. 153 - > I I always found it intriguing. 154 - > So um I really thought to myself, what a waste it would be 155 - > if when she was done practicing, if this business just went away.
156 - > Um, little did I know that she would still be uh uh by my side 157 - > as a partner now uh and working with the firm as we try to uh 158 - > coerce her into enjoying her. 159 - > Yeah, which she will never do. 160 - > I I love G. 161 - > But but so got into it in 2002, and it was a unique opportunity 162 - > because the national law that deals with uh patient privacy 163 - > called HIPAA, right?
164 - > The Health Insurance Portability and Accountability Act, uh went 165 - > into enforcement in 2003. 166 - > So um we both sat down. 167 - > Um I'll say Gene and I, because it's taken me long enough to get 168 - > out from her uh um wings and spread my own. 169 - > So um, for work purposes, we call Mom Jean.
170 - > But um, we sat down and we said, you know, this would be a really 171 - > unique opportunity. 172 - > There are no experts in HIPAA because the law isn't enforced 173 - > yet. 174 - > Um, and so I spent the first about year and a half just 175 - > reading the law and was charged with developing um our privacy 176 - > program manuals and policies and procedures all around HIPAA. 177 - > Um, and that's what I did, just sat there back to back with 178 - > somebody who was a consummate professional in the industry and 179 - > learned every day.
180 - > Almost I had a what I would call like a true apprenticeship, 181 - > right? 182 - > Um, and so cut my teeth there, um, was was working as kind of 183 - > her personal assistant when it came to the coding and billing 184 - > reimbursement stuff, realized I could do that too, um, and got 185 - > certified in in coding. 186 - > Um, had a small stint as a coder for what was at the time Hospice 187 - > of Palm Beach County. 188 - > Um, we do a lot of work in hospice and palliative medicine.
189 - > And so um I needed some more experience. 190 - > They needed a coder, worked out great. 191 - > I'm, you know, it's a small, small world and timing is 192 - > everything, right? 193 - > Um, and so slowly but surely uh gained the confidence to uh to 194 - > and the knowledge to be able to be provide trusted guidance to 195 - > clients.
196 - > And um at the end of the day, I think luckily because I have a 197 - > fairly outgoing personality and I'm not scared to talk, started 198 - > lecturing fairly young in my career, uh became a respected uh 199 - > and sought-after speaker with respect to HIPAA, coding 200 - > building and reimbursement. 201 - > Um, and you know, 23 years later, have the uh pleasure and 202 - > honor of serving some of the country's finest physicians and 203 - > helping them navigate this absolutely tricky maze of 204 - > reimbursement.
205 - > SPEAKER_01: Oh, way more than a tricky maze. 206 - > I mean, it's utter chaos. 207 - > Your son Marcus is Benjamin's age and just finished his second 208 - > year in college, and he is going to apprentice for you again this 209 - > summer. 210 - > Does he want to take over the family business?
211 - > When you I know you're not working as long as your mom. 212 - > We already know that. 213 - > When you decide to separate, that's I think yet to be 214 - > determined. 215 - > SPEAKER_00: Uh, it was funny.
216 - > Last year uh he did a uh what we would call apprenticeship summer 217 - > internship, and um it was a lot of busy work, and there were 218 - > there were some complaints about how, you know, I feel like I'm 219 - > not learning anything, but you gotta cut your teeth somewhere. 220 - > Or so had to remind him. 221 - > You know, your grandmother and I were the ones who empty the 222 - > trash, wash the towels, oh yeah, clean the sink, do everything 223 - > from invoicing to scheduling to learning all the little things 224 - > that you're doing.
225 - > It didn't come out of nowhere, right? 226 - > So um just stick with it, right? 227 - > And this year he actually came back and said, you know, rather 228 - > than interning somewhere else, he really wanted to learn more 229 - > about the business and um, you know, sit in on as many calls as 230 - > he could and and really gain some more experience. 231 - > So I think we'll have a good, a better barometer of that after 232 - > this summer when he gets a feel for less of the administrative 233 - > work that we had him doing and more of uh learning about the 234 - > ins and outs of what we do for our clients to um help ensure 235 - > their financial wellness.
236 - > SPEAKER_01: I love that. 237 - > Your mom, as I've said so many times, is one of my mentors and 238 - > I adore her. 239 - > I love her. 240 - > I don't even say that that often how I feel about people, but 241 - > that's why I think you're my brother.
242 - > Don't tell Brian that. 243 - > I will not. 244 - > So what has your mom, because she's taught me a lot, what has 245 - > Gene taught you that still resonates every day when you 246 - > work with clients? 247 - > SPEAKER_00: Oh wow.
248 - > I mean, the first was a really simple life lesson, not 249 - > necessarily a business lesson. 250 - > Um, and and it really boils down to us all being different pieces 251 - > on a chessboard at any given time, right? 252 - > Healthcare is such a small community, and you know, we 253 - > service clients all across the country, from Puerto Rico to 254 - > Portland and and uh South California through Maine, right? 255 - > So we've really and Hawaii, we've had clients.
256 - > So um, but at the end of the day, while while I may be a rook 257 - > sometimes or a bishop, um, every once in a while I get to play 258 - > the queen. 259 - > SPEAKER_01: You don't get to be a king ever? 260 - > SPEAKER_00: Never, never get to be the king. 261 - > Uh at the end of the day, the majority of us, right, in the in 262 - > the in the dynamic of healthcare are pawns on the chessboard.
263 - > And we have to remember how we take a piece, when we take that 264 - > piece, it is going to be reciprocated somewhere down the 265 - > line, right? 266 - > So that was probably the biggest lesson uh that I learned from a 267 - > from a business perspective. 268 - > Um, I mean, Gene's a shark, but really about putting our 269 - > clients' needs first, and that begins with ensuring we know 270 - > what we don't know and really staying in our niche. 271 - > I mean, we at one point we thought about having a billing 272 - > company because our clients all struggle with having good 273 - > quality billing companies.
274 - > Um, and we've thought about dabbling in other areas of 275 - > professional healthcare compliance. 276 - > Um, but what we do, we do really well because it's all all that 277 - > we do. 278 - > And I think that's been a wonderful lesson is you know, 279 - > really without keeping blinders on, staying in a lane. 280 - > Oh, stay in your lane.
281 - > That is what I had to learn this year. 282 - > Stay in my lane. 283 - > And and every time, you know, I go to step out of it, I'm 284 - > reminded quickly with one of those, you know, jockey whips to 285 - > my horse hips that get back in the lane. 286 - > Right.
287 - > SPEAKER_01: So tell me, tell me what was so difficult for you to 288 - > learn. 289 - > Like, what did you have to learn on your own that nepotism 290 - > couldn't give you? 291 - > SPEAKER_00: Oh, wow. 292 - > So um there is from a I think from a physician and office 293 - > manager perspective, right?
294 - > Which are really who we deal with. 295 - > Some C some practices are large enough to have C-suites, right? 296 - > But at the end of the day, it's the administrative leadership 297 - > team and the doctors, the providers, some some advanced 298 - > practitioners and doctors. 299 - > Um and I think the hardest thing to learn was to ensure my 300 - > approach is a talk with them approach.
301 - > Because I've I've found over the course of these last two decades 302 - > that a lot of the work we do is counterintuitive to their 303 - > thought process for what makes sense. 304 - > Um and they don't they don't like that they're questioned by 305 - > a nurse in a reviewer station at a payer, right? 306 - > So they don't like that. 307 - > They don't like that their thought process is being 308 - > questioned because they didn't necessarily use the word a nurse 309 - > reviewer wanted to see on a piece of paper, right?
310 - > Um, and so I've I've really had to, and I don't think it took me 311 - > long to learn this because I had a good teacher, but I did learn 312 - > that I have to take the approach of talking with that team, 313 - > right? 314 - > Um, and and trying to find the yes in a sea of no's because 315 - > everyone else is looking for the no, you can't do that, right? 316 - > And that's really where I think I've been the most helpful to my 317 - > clients is sitting down and really providing a practical 318 - > approach to some of these ridiculous rules or some of the 319 - > audit findings that you look at and you're scratching your head 320 - > to find out how could this nurse not recognize that GNR sepsis 321 - > and bacteremia in a patient in the ICU is a complex patient?
322 - > SPEAKER_01: Oh, I I will tell you, I don't even know what 323 - > those terms are, but I will tell you, oftentimes I'm scratching 324 - > my head and I'm like, bring it down, Meredith, bring it down. 325 - > Like I'm like, how could you not have figured that out? 326 - > And you've worked with so many different entities, physicians, 327 - > nurses, practice administrators, hospitals, hospice 328 - > organizations, attorneys, regulators, you're all over the 329 - > board.
330 - > What has that taught you about how healthcare really works in 331 - > America? 332 - > SPEAKER_00: It works in the trenches. 333 - > It really does, right? 334 - > You've got to strategize.
335 - > I mean, it's almost like I don't want to minimize, especially in 336 - > today, with what's going on in today's society. 337 - > I don't want to minimize military strategy, right? 338 - > But it is a battlefield for the providers with payers. 339 - > They are constantly looking for ways to, in their minds and 340 - > perhaps in their shareholders' minds, uh, ensure that they're 341 - > spending the least amount for the most return.
342 - > SPEAKER_01: Yeah. 343 - > SPEAKER_00: Right. 344 - > And oftentimes that means the doctors and practices are caught 345 - > in the crosshairs. 346 - > So that it takes, it takes thinking through a strategy.
347 - > It takes really sitting down and, you know, we did it once at 348 - > your house, right? 349 - > Hey, we want to expand our practice. 350 - > We don't know where the heck to start because we don't 351 - > necessarily know what the landscape looks like from a 352 - > reimbursement perspective regulatorily. 353 - > Do we open a physical therapy wing or not?
354 - > Think about if you would have done that and they just cut 355 - > physical therapy assistance reimbursement over the last few 356 - > years, right? 357 - > You would have been three years into still paying off the debt 358 - > that you use to expand the practice to now have a loss 359 - > leader. 360 - > SPEAKER_01: But I think what you bring up is so important and 361 - > crucial. 362 - > It's strategy.
363 - > Yes. 364 - > You have to be strategic. 365 - > You have to be business minded. 366 - > When I teach the business of medicine, because you also teach 367 - > the business of medicine, what is the goal of any business?
368 - > SPEAKER_00: To make money. 369 - > Exactly. 370 - > Even if you're a non-for-profit, we work for a ton with a ton of 371 - > hospice not-for-profit entities. 372 - > We work with physician practice not-for-profit entities, right?
373 - > Um, and some some wonderful ones that do amazing work for sickle 374 - > cell patients or AIDS patients. 375 - > But at the end of the day, if they're not making enough money 376 - > to keep the lights on, those grant dollars dry up, right? 377 - > So, so yes, it's not enough today to just be a provider who 378 - > wants to just see patients, right? 379 - > If you want to do that, you need to be a hospitalist.
380 - > And I'm not taking anything away from the hospitalists, right? 381 - > But you go and you see your patient, when you're done, you 382 - > have your week off after your week on, and you have an 383 - > administrative team dealing with everything else. 384 - > If you're gonna run a practice, you have to, as a physician, 385 - > rely on the folks who can run that small business the way it 386 - > needs to be run. 387 - > SPEAKER_01: What is most difficult right now for those 388 - > who are trying to run these businesses in healthcare?
389 - > What's making the American healthcare system so difficult 390 - > right now? 391 - > SPEAKER_00: I think it's a combination of factors, right? 392 - > I mean, clearly with the overwhelming number of 393 - > commercial payers that have policies that at the end of the 394 - > day reduce reimbursement. 395 - > SPEAKER_01: It's not even that they reduce reimbursement.
396 - > Every insurance company has different guidelines. 397 - > Right. 398 - > SPEAKER_00: So that's what I'm saying. 399 - > So so let's so so let's start with the notion that um every 400 - > year the commercial payers are trying to find a way to at the 401 - > at minimum reduce reimbursement.
402 - > On top of that, right, they all have their own guidelines and 403 - > ways they want things done. 404 - > On top of that, they create little policies that make it 405 - > harder to even get to the reimbursement level you're 406 - > trying to get to, right? 407 - > So a good example this year, there are a number of payers, 408 - > you can name them, I won't, that um have have policies in place 409 - > that automatically downcode services if they're billed at a 410 - > certain level, right?
411 - > And so they look at the claim that's submitted and they say, 412 - > oh, this claim doesn't look to us from a from a pure bird's eye 413 - > perspective, whether you they're using AI or people or data 414 - > mining, doesn't look to us like it would support the type of 415 - > visit you've billed for. 416 - > How the heck do they know that? 417 - > SPEAKER_01: So what is the fight or what is the pushback that 418 - > practices can do for that? 419 - > And by the way, I'll say it for you, it's Cigna NetNow.
420 - > So what can practices do to fight against that? 421 - > SPEAKER_00: So the first thing you have to do is ensure you're 422 - > knowledgeable. 423 - > So you have to have folks, you have to have a pipeline of 424 - > information, right? 425 - > If you don't know this is happening, and and then you 426 - > don't even know to ask your staff if you're in leadership or 427 - > a doctor, you don't even know to ask your staff, is this 428 - > happening to us?
429 - > Is this automatic down coding happening in a way that we 430 - > weren't even aware of because nobody's reconciling, right, the 431 - > claim we submitted with the dollars we submitted to what we 432 - > got paid, right? 433 - > Because there's no, there's a reason code for that down code, 434 - > but there's no denial it was paid, right? 435 - > So if all you're doing at the end of the day is submitting 436 - > claims and checking a box that those claims got paid, you're 437 - > not doing enough.
438 - > You've got to know that those claims got paid at the amount 439 - > they were supposed to get paid because you've loaded that fee 440 - > schedule and there's checks and balances. 441 - > And that's where we started the show off, right? 442 - > At where we talked about the bulk of the work not happening. 443 - > In the doctor-patient transaction, right?
444 - > That's the real nitty-gritty work that has to be done is the 445 - > checks and balances, inspecting what you expect. 446 - > Know when a new rule is starting, right? 447 - > So another silly, not silly, but another example, right? 448 - > Medicare, CMS just changed their ABNs, advanced beneficiary 449 - > notices, right?
450 - > I'm not going to go into all of the details, but when you're 451 - > putting a patient on notice that they might be financially 452 - > responsible, they change the ABN. 453 - > Effective this week, the new ones have to be used. 454 - > What is the difference between the old ones and the new ones? 455 - > Let's just for argument's sake, say semantics, one line.
456 - > There's something different in a box here versus the box over 457 - > here. 458 - > But if you're not using the new one, guess what could be a 459 - > technical denial reason to go back and get money back, or say 460 - > that you didn't properly notify a patient to get paid and you 461 - > need to refund patients, right? 462 - > So, but if you didn't have someone pushing that information 463 - > to you that this changed, do you have someone on your team 464 - > looking for something like that?
465 - > The overwhelming majority of doctor practices don't have 466 - > that. 467 - > SPEAKER_01: Even insurance companies say it is the 468 - > practice's responsibility to know the rules. 469 - > To know the rules and to seek them out, even though they're 470 - > changed and uncovered and covered up and uncovered and 471 - > covered up and then buried very deep in the minutiae. 472 - > SPEAKER_00: So I'll revisit your question about what did I learn?
473 - > Because that made me think of something else. 474 - > Is I I had to learn where to find as much of the information 475 - > as possible and not be scared to have it pushed to me and have 476 - > information overload, right? 477 - > It's my job to have more information than you, right? 478 - > And so if you're getting all of the same listserv publications 479 - > and notifications that I'm getting, well, you have the 480 - > information at your fingertips.
481 - > You might want some help interpreting things, right? 482 - > Or practically coming up with a solution. 483 - > But my real value to the clients on top of those things is 484 - > heading off that information first, notifying you first. 485 - > Hey, Meredith, Mark, here's something that you have to be 486 - > aware of that you didn't necessarily know so that you're 487 - > not financially at risk down the line.
488 - > SPEAKER_01: And even if we had access to all of the information 489 - > that you have, who has the time? 490 - > SPEAKER_00: Sure. 491 - > No, understood. 492 - > SPEAKER_01: Yeah, that's the biggest challenge.
493 - > And I'm looking at all of the players and all of the parts 494 - > within our system and everything that you oversee at Acevedo 495 - > Consulting. 496 - > So from your vantage point, where does the system break 497 - > first? 498 - > Because you have coverage, you have reimbursement, regulation, 499 - > documentation, coding, compliance, and then payer 500 - > behavior. 501 - > Can you even choose one?
502 - > SPEAKER_00: Where where the breakdown lies first? 503 - > Yeah. 504 - > Oof. 505 - > They're so layered and interconnected.
506 - > That's that's a difficult question to answer, right? 507 - > Because you'd think it'd be as easy as doctors are fed up, they 508 - > can just stop. 509 - > Right. 510 - > Well, we won't just we just won't take any more United 511 - > Healthcare.
512 - > We won't take any more Florida blue, right? 513 - > It's not that easy. 514 - > That's what happened to us. 515 - > And you can't abandon your patients, first of all, right?
516 - > You're you're yes, you can make the business decision, the hard 517 - > decision to say, you know what, Maddie Smith, she's just not 518 - > going to be seen. 519 - > SPEAKER_01: It's difficult. 520 - > And going back to the business side of medicine, we had to step 521 - > away from Humana. 522 - > After I spent three years negotiating that contract, they 523 - > came back 18 months later and wanted to reduce my 524 - > reimbursement literally to 65% of Medicare allowable.
525 - > How do you run a practice on 65% of Medicare? 526 - > SPEAKER_00: It's a Medicare practice at that point. 527 - > SPEAKER_01: Yeah. 528 - > Right.
529 - > And we're not set up for that. 530 - > They almost yelled at me and thought I was such a terrible 531 - > person that we would not provide care to their patients at 65% of 532 - > Medicare allowable. 533 - > Then we had to step away from Aetna because there were so many 534 - > denials and coding changes and non-coverage guidelines that 535 - > when I did the math, we were getting paid at about 68% of 536 - > Medicare allowable. 537 - > SPEAKER_00: Yeah, and unfortunately, the insurance 538 - > companies have that leverage, right?
539 - > Because they they the we're in a third-party payer system, 540 - > whether you like it or not, right? 541 - > So you can go to concierge medicine or a direct pay model, 542 - > right? 543 - > If you have the luxury to do that, if you're in the right 544 - > specialty with the right patient population, a population that 545 - > can afford it. 546 - > You know, we we do a lot of work with concierge medicine 547 - > practices.
548 - > They they're um do amazing work for their patients because they 549 - > can dedicate more time and things like that, right? 550 - > But you have to have the right population to do that. 551 - > So the the insurance, the payers have the leverage, right? 552 - > Medicare is by far the largest payer.
553 - > They have the leverage. 554 - > You can't negotiate your rates with them, right? 555 - > Um and and and then on top of that, they have the leverage of 556 - > if you change your mind later. 557 - > So you go back to Humana and say, you know what?
558 - > We'll come, we we do want to see these patients. 559 - > It hurt our business, and we want to come back and see them. 560 - > Tail between your legs, right? 561 - > Not only could they say, well, the deal that was on the table 562 - > is no longer on the table, they could say, sorry, our panel's 563 - > closed.
564 - > SPEAKER_01: We don't want you at all. 565 - > Which actually brings me to something very important that I 566 - > spoke to our students about last week. 567 - > When you're in negotiations and you want to hang your own 568 - > shingle, you have to make sure that there are payer panels 569 - > available to you. 570 - > Now, with Medicare, yes, but then you have to look at DME.
571 - > Durable medical equipment right now, on hold. 572 - > It's been on hold for I think two months, maybe longer, but 573 - > it's on a six-month hold. 574 - > So if you are thinking you're going to dispense DME, uh, think 575 - > again. 576 - > SPEAKER_00: Yeah, you and and and again, how do you know that 577 - > going in that there's a moratorium on something, right?
578 - > That you're thinking about doing, right? 579 - > Or maybe there's a practice in another state that's doing 580 - > something really innovative, and you say, Oh, I want to do that 581 - > too. 582 - > I want to do in-office dispensing, but you have no idea 583 - > about all the little nuances, right? 584 - > So I do think, well, while I'm not trying to make a plug for 585 - > vendors, I do think there's a place for professionals who have 586 - > the knowledge base to get you through something, right?
587 - > You took over that class of mine. 588 - > Yes, yeah, outsource, right? 589 - > When to outsource. 590 - > And um, and you know, I I watched a recent comment from uh 591 - > Kevin O'Leary, the Shark Tank, uh, Mr.
592 - > Wonderful, right? 593 - > And he's he despises consultants, right? 594 - > I I think I don't want to speak for him and and I don't want to, 595 - > you know, say whether I whether I'm siding with him or not, but 596 - > I think what he despises is somebody who just tells you like 597 - > all these things you need to change without any real 598 - > practical solutions. 599 - > SPEAKER_01: Oh yeah, like it kills me when I have vendors who 600 - > come in and teach me how to run my practice or want to tell me 601 - > how to run my practice.
602 - > I'm like, have you ever been a practice administrator? 603 - > Have you ever run a medical practice? 604 - > Have you actually even worked inside of a medical practice? 605 - > But they all like to share information.
606 - > But what I thought was really interesting, and I had not known 607 - > this about your mom until I interviewed her, she actually 608 - > ran a medical practice. 609 - > SPEAKER_00: So she ran her first practice back in the 70s. 610 - > Yeah. 611 - > Yeah.
612 - > She ran a uh practice up in New York and really cut her teeth 613 - > there. 614 - > And I'll say to that point, you know, I had about a six-year 615 - > hiatus from consulting, where I went and was the COO of uh 616 - > multi-state medical practice and uh vice president of physician 617 - > services for the largest privately held hospice. 618 - > So I was in the provider hot seat, right, and had to deal 619 - > with these problems. 620 - > That was a great experience to really get me to understand the 621 - > pain points at the end user, right?
622 - > Rather than just sitting in an ivory tower in a consulting 623 - > office. 624 - > Um, and I do think I brought that approach when I came back 625 - > to the firm as a as a positive for our clients. 626 - > SPEAKER_01: It's always great when you can learn all aspects. 627 - > It is so difficult to be able to run a medical practice right 628 - > now, and there's so many different entities.
629 - > And doctors want to provide the best care that they can to their 630 - > patients. 631 - > Do you think the system rewards them for providing exemplary 632 - > care, or do you think the system rewards them for playing the 633 - > game? 634 - > SPEAKER_00: I think that there are relationships that a 635 - > practice can have with certain bundled care networks, if you 636 - > will, right? 637 - > ACOs, um, some value-based options.
638 - > Even Medicare has some unique payment alternatives, right? 639 - > Alternative payment methodologies that you can get 640 - > into where you are rewarded for quality medicine at minimum for 641 - > keeping costs down. 642 - > SPEAKER_01: Yeah, but the way they attribute that, Chris, is 643 - > so insane. 644 - > We don't even need to get into that, but it's crazy.
645 - > SPEAKER_00: I think the problem with our system, the third-party 646 - > system, and I may take heat for this or not, I think the biggest 647 - > problem is the fact that there is assignment of responsibility. 648 - > I think that um whether you like it or not, as a patient, you 649 - > have to own some responsibility in the maintenance of your care. 650 - > And far too many patients don't want to own any of their own 651 - > responsibility. 652 - > SPEAKER_01: We've talked about that on previous podcasts, and I 653 - > don't think you should take heat for it.
654 - > You're not just sitting there idly by. 655 - > This is your body, this is your life. 656 - > You have to take responsibility. 657 - > You can't just go blame a provider.
658 - > It always shocks me when I don't know if this is a great example, 659 - > but the surgeon cuts off the wrong limb, but it was marked 660 - > when the patient was alive, like and they are totally coherent. 661 - > And you're thinking, hmm, maybe this was a problem as a patient, 662 - > and I should have been aware of it. 663 - > I mean, that is a stark, crazy example. 664 - > SPEAKER_00: I understand where you're where you're going with 665 - > that, but you have to take responsibility.
666 - > Yeah, I mean, I so I do I think, you know, if if the model was 667 - > better, I think that if you were a doctor and you demonstrated 668 - > you got a patient to quit smoking, you should get paid 669 - > more for caring for that patient, right? 670 - > Which is which is where the risk model really plays to with with 671 - > Medicare, right? 672 - > If you can, you're given this bucket of money to care for the 673 - > patients. 674 - > And if you can keep their utilization down, which to the 675 - > payer means they're paying less and conceptually they're 676 - > healthier, that's why they're paying less.
677 - > SPEAKER_01: Yeah, but that doesn't happen because again, I 678 - > go back to it's a game. 679 - > So when somebody has that risk model, the doctor, they get a 680 - > lump sum of money to take care of the patient. 681 - > If the doctor refers that patient out to a specialist, 682 - > they've now lost the money. 683 - > SPEAKER_00: Well, so that's where I think it's if the doctor 684 - > refers the patient out, they're doing so.
685 - > They know what's going on. 686 - > That's part of the risk reward game, if you will. 687 - > What's not fair is that the patient gets to just go 688 - > somewhere else on their own. 689 - > The patient gets to decide, I'm gonna go get this CT scan.
690 - > SPEAKER_01: But does that really happen? 691 - > SPEAKER_00: Oh, absolutely. 692 - > They'll well, maybe not in that way, right? 693 - > Because they can't bypass if it's a if it's an HMO, they 694 - > can't bypass the primary care physician, but they can make it 695 - > to the point where that physician finally just says, 696 - > here's the script, go get the darn CT scan.
697 - > SPEAKER_01: But so many doctors do that. 698 - > We have patients who watch commercials on TV and they see 699 - > that one of these pharmaceutical drugs is the best and the 700 - > brightest. 701 - > And they went and played mahjong, and their friend is 702 - > also on that drug. 703 - > And so they go to the doctor and they're like, This is the drug I 704 - > want.
705 - > And doctors are just tired of fighting against patients. 706 - > It's similar, I think, to teachers. 707 - > When I was a teacher, it wasn't quite as bad, but my best friend 708 - > is a teacher. 709 - > She's like, I am so tired of fighting with parents.
710 - > Right. 711 - > Just give the kid an A. 712 - > SPEAKER_00: No, I I hear you. 713 - > You know, that's that's uh any medical advice given on a 714 - > pickleball court, right?
715 - > They come back to the to the doctor and say, Well, you know, 716 - > Maggie told me I should be on this. 717 - > Right. 718 - > Um I think that that to a large extent because of lack of tort 719 - > reform. 720 - > I mean, there are again, there are so many, there are so many 721 - > influences here, right?
722 - > Because of a lot, because of a lack of tort reform, right? 723 - > You have doctors who are scared to get sued. 724 - > So they write the script, they write the order, right? 725 - > They know that there's a litigious society out there that 726 - > um the moment something happens that they it was impossible for 727 - > them to foresee as a physician, but it happens and they didn't 728 - > write an order.
729 - > And even if that had nothing to do with, they're getting sued. 730 - > Right. 731 - > So um there are there's this confluence of outside influences 732 - > on that doctor-patient relationship, right? 733 - > Um, would it, wouldn't it be nice if the doctors could have 734 - > their lifestyle income subsidized, right?
735 - > Um, and they didn't have to worry about it, right? 736 - > It would be, I I actually think it would be a good thing if 737 - > there was a, and I don't know how you would calculate it, but 738 - > by specialist, right? 739 - > They were, they were our tax dollars paid for the care we 740 - > get, similar to Germany's structure where there's also a 741 - > private, robust uh uh commercial system, right? 742 - > If you can afford more healthcare, you buy it, but 743 - > there's nationalized healthcare.
744 - > And the doctors, based on their training and specialty and board 745 - > certifications, they get an income. 746 - > And they can do outside work. 747 - > They could be medical directors somewhere else, they could do 748 - > work for pharma or or uh device companies, they can lecture, 749 - > they can do all kinds of work. 750 - > So their income isn't capped, right?
751 - > But for the care they provide Monday through Friday in a 752 - > clinic, this is what the going rate is. 753 - > And there's no negotiating with insurance payers for that 754 - > baseline rate, right? 755 - > Now, you also work with, I'm just like Florida Blue happens 756 - > to be one of the commercial payers in this made-up market, 757 - > right? 758 - > And you're a five-star provider with them, and so they pay you a 759 - > certain rate and you're happy with it.
760 - > Great. 761 - > Right. 762 - > So, yes, doctors can still have the uh uh financial, the 763 - > financial reward of all the schooling they put in, right? 764 - > And it's still a profession that makes sense to put the amount of 765 - > training and the liability that you have, or there has to be 766 - > that reward for it.
767 - > It can't just all be because I want to serve, right? 768 - > Um, but but in today's capitalistic society, it just 769 - > has to be reward for that. 770 - > SPEAKER_01: Not only that, it's delayed gratification for 771 - > doctors. 772 - > Most of them, the average amount that most doctors graduate in 773 - > debt is about$300,000.
774 - > So how do they continue to pay that off? 775 - > How do they have their families? 776 - > How do they take care of patients if they're constantly 777 - > worried about putting food on their own tables? 778 - > Who wants to start going into medicine at the age of 33?
779 - > SPEAKER_00: Right. 780 - > And they can't all go work in a mockly and get their debt wiped 781 - > out, right? 782 - > It just doesn't work, right? 783 - > So you need metropolitan, urban, urban area trained physicians to 784 - > work in those areas.
785 - > But I do think if you took assignment out of the mix and 786 - > there was more responsibility on the patient just having to do 787 - > what they had to do and less responsibility on a third-party 788 - > payers profit line, right? 789 - > Um, I do think there's some answer in that equation, right? 790 - > Um you know, I know that that um I'm not an expert in socializing 791 - > medicine, or uh, but there there definitely has to be a better 792 - > way. 793 - > I'm tired of seeing seeing my friend physicians burn out.
794 - > My best friend's a primary care physician. 795 - > He's in the process of fire selling his practice because he 796 - > doesn't want to deal with it anymore. 797 - > SPEAKER_01: And how old is he? 798 - > SPEAKER_00: My age, 50.
799 - > SPEAKER_01: Yeah, that's the problem. 800 - > Yeah. 801 - > You know, we we talked about this because our moms are baby 802 - > boomers, and your mom is continuing to work. 803 - > My mom worked until the end, and you and I are looking at them 804 - > saying, that's not the life we want.
805 - > We do not want to only identify with our job, our profession, 806 - > and what we're doing for everyone else. 807 - > What about our families? 808 - > What about our time? 809 - > What about our sanctity?
810 - > And so you and I are about the same age, and we're going, okay, 811 - > uh, we might end up leaving before our parents. 812 - > I mean, not in our situation. 813 - > I know what you mean. 814 - > But it's it's difficult because you do.
815 - > It's yin or yang, it's all or nothing. 816 - > There, we have to have a middle ground. 817 - > And a lot of this and a lot of what comes at us is because we, 818 - > I believe, are constantly playing whack-a-mole. 819 - > And you work a lot, I know, in the fraud, waste, and abuse 820 - > area, or at least Acevedo Consulting does.
821 - > Your mom loves to tell me stories about how she testified 822 - > or how she had to deal with the DOJ. 823 - > How does that impact the good players, which are probably, 824 - > I've gotta believe, are 98% of doctors. 825 - > How does that impact us? 826 - > SPEAKER_00: The bad players, how do they impact?
827 - > Yeah. 828 - > I So one of the things that in my in in one of my um compliance 829 - > courses that I teach, I talk about the dollars that are spent 830 - > with Medicare contractors just to ensure the$1 that they paid 831 - > you is paid correctly, right? 832 - > So you've got a cert contractor, uh fraud contractor, the general 833 - > contractor, the Mac who's paying you. 834 - > You have a recovery audit contractor, right?
835 - > Then there's the commercials have those same types of in uh 836 - > uh uh contractors, and Medicaid has them. 837 - > And then there's the OIG doing their audits, right? 838 - > So um, so they're spending all this money just to ensure that 839 - > first line dollar was paid correctly. 840 - > And and yeah, they recover exponentially more money than 841 - > they spend, right?
842 - > Some of that's on the backs of providers who just made innocent 843 - > mistakes, weren't committing fraud, didn't realize what they 844 - > were doing wasn't allowed, right? 845 - > Whether they should have or not, but they weren't committing 846 - > fraud. 847 - > There was no malicious intent, no deliberate disregard or or uh 848 - > deliberate ignorance, right? 849 - > Um and and it's because of the bad providers that they find, 850 - > right?
851 - > The doctors who are diluting chemotherapy drugs and billing 852 - > for them, the doctors who are um and and and licensed physicians, 853 - > right? 854 - > Not just, you know, not just immigrants from another country 855 - > who are criminals, right? 856 - > These are licensed physicians, some some foreign, some 857 - > American, right? 858 - > Um, and they are they are out there having patients provide 859 - > their provider numbers, giving them$20 in a sandwich, and then 860 - > billing for infusion that never happened, right?
861 - > Or they're taking kickbacks for home health or uh whatever the 862 - > other referral might be, right? 863 - > So because there are so many of those that keep getting caught, 864 - > the government keeps looking, right? 865 - > Um, and and then the good providers get caught up in that 866 - > in that fishing net, right? 867 - > It's almost like commercial fishing.
868 - > You get caught up in that fishing net like a dolphin, and 869 - > um, and because you perhaps had an EMR that didn't sign your 870 - > orders when you ordered infusion, and there's no way to 871 - > print out a signed order, you owe all that money back for 872 - > those infusions, right? 873 - > You just get caught in the trap. 874 - > So it absolutely makes it more difficult, the the bad 875 - > providers, um, which is why we don't feel bad with the work we 876 - > do with the DOJ, right?
877 - > We do a ton of work with the Department of Justice when it 878 - > when they present a case to us, we look at the merits of the 879 - > case. 880 - > And if it's a bad provider, yeah, let's go get them. 881 - > Let us help you, Department of Justice, go get them. 882 - > SPEAKER_01: It reminds me of one of the pearls Gene taught me.
883 - > And it is just because you don't know something doesn't mean 884 - > you're innocent. 885 - > SPEAKER_00: Yeah, absolutely. 886 - > So there's this for for since I've been with the firm, uh, 887 - > there is a slide that both Gene and I use when we do education. 888 - > It's from an attorney, Larry O'Day, and we give it 889 - > attribution, right?
890 - > So all for plagiarism with attribution, right? 891 - > But it's the iron laws of Medicare. 892 - > It's and it's meant to bring a little bit of levity to what 893 - > we're gonna discuss, because it's not always positive, the 894 - > things we're talking about, right? 895 - > Sometimes it's payment cuts or changes that you have to prepare 896 - > for.
897 - > Um, but it's, you know, just because it has, I'll I'll I know 898 - > some of them by heart, right? 899 - > Because I've been doing this so long. 900 - > Just because it has a code doesn't mean you can bill for 901 - > it. 902 - > Just because you can bill for it doesn't mean you can get paid 903 - > for it.
904 - > Just because you've been paid doesn't mean you can keep the 905 - > money, right? 906 - > Um, and it goes on and so forth. 907 - > And the last two lines. 908 - > Are basically there's always some uh I believe they're both 909 - > Yiddish terms, right?
910 - > There's always some Schlamiel who knows who did who uh who who 911 - > knows uh who who didn't know, right, that they should have 912 - > known. 913 - > And there's always some Schmendrick who knew and did it 914 - > anyways, right? 915 - > Uh and so um that's the world we live in, right? 916 - > Uh it's unfortunate.
917 - > Um but because of the constant rule changes, I mean, if I if 918 - > you were, I'll take a step back for a second. 919 - > If you were opening a business today, and I were to tell you 920 - > it's gonna be uh a multi-million dollar small business, right? 921 - > Small in the terms of the number of people it's gonna employ, 922 - > right? 923 - > And that business is going to generate uh gross revenue in 924 - > excess of ten million dollars, um, and you're gonna have a good 925 - > profit margin.
926 - > But every November, somewhere around the first week of 927 - > November, you're going to be told what the rules are that you 928 - > have to play by in this business for selling your widgets, 929 - > documenting how you sold those widgets, and what you have to 930 - > pay for those widgets. 931 - > I'm gonna tell you by the 15th of November, and you're gonna 932 - > have till January 1st, December 31st, to make those changes for 933 - > next year. 934 - > SPEAKER_01: Can I edit that a little bit?
935 - > Absolutely. 936 - > And say sometimes the final rules are not even enforced or 937 - > implemented or known until after the first of the year. 938 - > SPEAKER_00: Sure. 939 - > And and and right, so there there might be some 940 - > interpretations that come later, right?
941 - > And and Medicare, they haven't done so in uh recently, but they 942 - > were notorious for publishing guidance today, May 15th, with 943 - > an effective date of February 15th. 944 - > Yeah, right. 945 - > So, hey, this is the guidance we're publishing today, but it 946 - > was effective 60 days ago, right? 947 - > If you were to start a business, and I said you could that's a 948 - > business you could start, or you could start any other business 949 - > where you don't have this problem, and you can't pay 950 - > people to get patients for you, right?
951 - > To get widgets, to get buyers for you. 952 - > You can't pay people to thank them for getting you those 953 - > widgets, right? 954 - > You'd say, well, let me start a different business, right? 955 - > And so most physicians don't go into this thinking any of that, 956 - > right?
957 - > When we talk about the business of medicine. 958 - > They just, I want to serve patients, and and and yes, it's 959 - > going to be a good career dollar-wise down the line, but 960 - > none of this stuff has gone over in medical school, right? 961 - > Uh, we there are some medical schools here in South Florida 962 - > that we do some education for their graduating third and 963 - > fourth year residents or their graduating classes, the the some 964 - > of the doctor of NP programs.
965 - > And these folks are going to have the business of medicine 966 - > affect their lives for the rest of their lives. 967 - > And they're in a four or six-year program, and they get 968 - > maybe two hours worth of lectures on this. 969 - > SPEAKER_01: I read some statistics that actually said 970 - > medical students only get about five hours in rheumatology. 971 - > So think of the burden that we have.
972 - > They get two hours of business training and five hours of 973 - > rheumatology training, and then they go into their residency 974 - > program. 975 - > SPEAKER_00: Absolutely. 976 - > I mean, you're you're stuck with the burden as a practice owner 977 - > if you if you say, all right, I'm going to expand my clinic, 978 - > my medical workforce by bringing on a physician assistant or an 979 - > advanced practice RN, right? 980 - > So they've got whatever their two years of advanced practice 981 - > training is, but there's no real fellowship for them.
982 - > Your practice is their fellowship, right? 983 - > But you have to absorb that. 984 - > There's no extra pay for that. 985 - > You've got to absorb a two to four year learning period, 986 - > paying them full salary.
987 - > Now they come out wanting more than almost as much as some of 988 - > the doctors make. 989 - > Right. 990 - > And I'm not saying that's a bad thing for them to want that, but 991 - > the reality is they're not worth it without the fellowship 992 - > training. 993 - > SPEAKER_01: They're not worth it.
994 - > And pure ratio, right? 995 - > SPEAKER_00: FTE to expense. 996 - > SPEAKER_01: And oftentimes they come out thinking that they can 997 - > see patients right away. 998 - > Or they worked at a minute clinic care, yeah.
999 - > Right. 1000 - > For six months, and they come out thinking they know 1001 - > everything and they want to see patients right away themselves. 1002 - > I mean, I you and I have taught about incident two billing up 1003 - > the yin-yang, and I literally should have an entire working 1004 - > healthcare podcast episode on that because I know that we bill 1005 - > properly, but I'm gonna say this is another gene tidbit. 1006 - > Who needs to know the proper way to code for incident two in any 1007 - > practice?
1008 - > SPEAKER_00: The advanced practitioners. 1009 - > SPEAKER_01: Thank you. 1010 - > See, we come from the same world. 1011 - > That's why you're my brother.
1012 - > How can practices, doctors, protect themselves? 1013 - > SPEAKER_00: So I I think one one of the things, and and I think 1014 - > it's it's reinforced in the lecture I took over for you, 1015 - > right? 1016 - > Is that doctors have to let the right people protect them. 1017 - > Right?
1018 - > They're they should know everything they need to know 1019 - > about practicing medicine. 1020 - > Um, and some of them know a lot about the business of medicine. 1021 - > I don't want to take anything away from the entrepreneurial, 1022 - > business-spirited physicians that are out there, right? 1023 - > Overwhelmingly, though, they just want to practice medicine.
1024 - > They don't want to, a, they don't have the time for all of 1025 - > the nuanced business components. 1026 - > Andor B, they don't want to do it. 1027 - > They want to see patients, right? 1028 - > Um, and they may want to do innovative things and they may 1029 - > want to dabble here and there, and good for them, but 1030 - > clinically, right?
1031 - > And they may want to do research and stay on top, and that's 1032 - > wonderful. 1033 - > Be a lifelong learner. 1034 - > Um, but but the best way to stay safe is to invest and budget, 1035 - > right? 1036 - > It should be a budgeted line item for whatever you want to 1037 - > call it, non-clinical resources, right?
1038 - > Outside, and and you might be big enough as a practice to 1039 - > bring in somebody full-time. 1040 - > Um, but I think I think doing it fractionally is an easy way to 1041 - > do that, right? 1042 - > Um and um and and even from uh from a managerial perspective, 1043 - > right? 1044 - > There are so many hats your typical practice administrator 1045 - > has to wear.
1046 - > So how do they stay on top of HR law plus compliance from a 1047 - > fraud, waste, and abuse perspective, plus just business 1048 - > compliance, right, uh issues. 1049 - > Plus, we got to know are there changes in when our doctors have 1050 - > to get licensed, what vendors we can deal with, right? 1051 - > Here in the state of Florida, now for the last, I want to say 1052 - > two and a half years, right? 1053 - > When you renew your license as a provider, you've got to attest 1054 - > to none of your vendors that you use storing information outside 1055 - > of the continental United States or Canada.
1056 - > If you didn't know that existed and you're and and what the the 1057 - > repercussions of that or the consequences are, and you have 1058 - > someone else kind of attesting for you, as doctors often will 1059 - > do, right? 1060 - > Hey, I did everything I need to go fill this out, right? 1061 - > Um God forbid the state finds out that you didn't do that 1062 - > correctly. 1063 - > SPEAKER_01: I think it's similar to accountants, right?
1064 - > We all have accountants doing our business accounting work. 1065 - > We're not going to HR block to do it once a year in the 1066 - > business world. 1067 - > We have lawyers for different entities. 1068 - > People are always like, Do you have a lawyer to recommend?
1069 - > And I'm like, What type of law? 1070 - > Because we actually brought in an employment attorney that is 1071 - > on retainer. 1072 - > He's fractional. 1073 - > And we have him because we've gotten to the size where, 1074 - > listen, I've done a really good job up until this point, but now 1075 - > I need to focus on some other things.
1076 - > And I'm not a lawyer. 1077 - > I need to have somebody who lives and breathes this. 1078 - > We've worked with you forever since literally Mark finished 1079 - > his fellowship because we wanted to make sure that we were 1080 - > following the rules, we were being compliant. 1081 - > Who has time for all of this?
1082 - > SPEAKER_00: Yeah, it just it as you're laying out what practice 1083 - > expenses are, it needs to be a budgeted line item, right? 1084 - > It's the Affordable Care Act mandated compliance programs. 1085 - > That doesn't mean that it mandated you downloading 1086 - > something from compliance today and putting it on the shelf, 1087 - > right? 1088 - > Um, and and there's plenty of guidance about what an effective 1089 - > compliance program actually is.
1090 - > And the Department of Justice has a great memo that gives its 1091 - > prosecutors, right, gives its investigative arm guidelines as 1092 - > to follow as to, hey, if we're investigating Meredith because 1093 - > we think she did something bad, and this isn't specific to 1094 - > healthcare, this is corporate compliance guidance, right, for 1095 - > effective programs. 1096 - > So I'm the investigative authority. 1097 - > I'm looking into whether or not I want to charge Meredith with a 1098 - > crime.
1099 - > There's a memo that outlines all of the things I need to consider 1100 - > about your compliance program, right? 1101 - > What's the culture? 1102 - > How many dollars based on the size of your practice? 1103 - > What do you do when you find an error?
1104 - > Do you report things correctly? 1105 - > Is there evidence that you've ever reported anything ever? 1106 - > Right. 1107 - > Um, and kind of like what's the structure?
1108 - > And it hits a number of topics. 1109 - > And so, yeah, just like the practice has to account for a 1110 - > cleaning crew, accounting services, compliance services 1111 - > should be there. 1112 - > Right. 1113 - > Um, and and I I happen to take a unique approach.
1114 - > When someone asks me what I do, I generally don't say I'm a 1115 - > compliance consultant. 1116 - > Because it would bore people. 1117 - > Yeah, but I think there's more to what I do, right? 1118 - > I I usually say I help physicians optimize their 1119 - > reimbursement with a compliance focus so that in the event they 1120 - > have to defend it, the money is as safe as it can be.
1121 - > SPEAKER_01: And it's important because I get ideas all of the 1122 - > time as to what new codes are available. 1123 - > I remember sitting in on a meeting and learning all about 1124 - > principal care management. 1125 - > And then it went out the door because it was 2020, and that's 1126 - > when COVID happened. 1127 - > And then when I got my boots pulled back up a year and a half 1128 - > later, I was like, let's look at this PCM thing again.
1129 - > Let's look at chronic care management. 1130 - > So having somebody to help you develop ideas for additional 1131 - > ancillaries is so important. 1132 - > SPEAKER_00: Yeah, and I think, and I think there are folks who 1133 - > just do that, who do revenue optimization. 1134 - > And that's great too, right?
1135 - > But I do think that one of the things that physician practices, 1136 - > some healthcare entities, the larger the entity, the less it 1137 - > happens because they have all these checks and balances. 1138 - > But the small entrepreneurial practice, they don't stop at 1139 - > mile marker two or three to say, what are the compliance 1140 - > guidelines here? 1141 - > What are the what are the guardrails we need to have? 1142 - > Right.
1143 - > They get to mile marker nine on a 10 mile road and then realize 1144 - > holy expletive, we needed to make a left at mile marker 1145 - > three. 1146 - > Right. 1147 - > Um, and if you're already billing for it, sometimes that's 1148 - > too late, right? 1149 - > So um I do think compliance as a speed bump on the front end, it 1150 - > shouldn't slow you, it shouldn't slow, it shouldn't slow you to a 1151 - > halt, right?
1152 - > But absolutely, hey, we want to bring this on. 1153 - > Okay, it yes, we've gotten some performa from vendors. 1154 - > It looks like it makes money. 1155 - > Well, the vendor's always gonna tell you how good it's gonna be.
1156 - > They're selling you a product, right? 1157 - > So now it's hey, compliance professional and legal team, 1158 - > what do we need to know about this that we may not be thinking 1159 - > about? 1160 - > SPEAKER_01: I want to ask you, what is that one thing that you 1161 - > see that practices get wrong most often? 1162 - > SPEAKER_00: Can I can I use the incident two card here?
1163 - > Because that's that's probably the one thing they get wrong 1164 - > often. 1165 - > So when when a practice is committed to using that benefit 1166 - > category, and I think it's there for a reason and it's good, 1167 - > right? 1168 - > Um they don't spend the time educating the advanced 1169 - > practitioners on when they need to press the stop button, right? 1170 - > Because if I'm a patient and I'm going to see, I'm going to see 1171 - > Evan in your practice, right?
1172 - > And I'm a I I don't care sharing this, right? 1173 - > I've been seeing Mark and Evan for years. 1174 - > Luckily my gout is controlled, but every once in a while I need 1175 - > uh I have a flare-up. 1176 - > Hasn't happened in years, but uh, but let's just see, I'm 1177 - > seeing Evan in follow-up, right?
1178 - > If Evan doesn't know the rules for when we can bill that visit 1179 - > under Mark, Dr. 1180 - > Hirsch, and and I come with a new problem today because I 1181 - > pulled my shoulder playing basketball, and I bring it up, 1182 - > and Evan, your great PA, does treats me perfectly, does 1183 - > everything he needs to do, but it's a new problem which doesn't 1184 - > qualify as an incident two billing. 1185 - > And if he doesn't know that, then that bill's gonna go out 1186 - > under mark and you're gonna get 15% more reimbursement than you 1187 - > otherwise should have gotten.
1188 - > Right. 1189 - > Um, and that's gonna be, you know, the case time and time 1190 - > again. 1191 - > If I'm there for the gout and Evan says, you know what, let's 1192 - > change you from this dosage to that dosage, and there's no 1193 - > documentation by Dr. 1194 - > Hirsch that says, in the event of X, make this change.
1195 - > That's a problem, right? 1196 - > And so not enough people really take the time um to expose 1197 - > themselves to what the rules mean. 1198 - > They just think, well, the there's a patient, I have an NP, 1199 - > the doctor saw them at one point, so we're fine. 1200 - > And they need to know the rules.
1201 - > Correct. 1202 - > Yeah, that that to me is the the biggest um problem that that is 1203 - > low-hanging fruit. 1204 - > The other, from a business perspective, is people don't 1205 - > load their fee schedules and check to see are they actually 1206 - > getting paid what they were supposed to be paid? 1207 - > SPEAKER_01: Yep, a hundred percent all of the time.
1208 - > I want to wrap this up and ask you if you could fix one entity 1209 - > within our American healthcare system, you have one wish, Chris 1210 - > Acevedo, what would that be? 1211 - > These are the incentives, these are the players, these are the 1212 - > policies, anything, what would make the greatest impact? 1213 - > SPEAKER_00: I I think there definitely needs to be a push 1214 - > away from pay for the number of fee-for-service widgets the 1215 - > doctor performs.
1216 - > I don't think it's healthy for the system for a do for the for 1217 - > the overall reimbursement model to be tied to how many X, Y, or 1218 - > Z a doctor does in a day. 1219 - > SPEAKER_01: Chris Acevedo, thank you for joining me on Working 1220 - > Healthcare. 1221 - > If this conversation hit home or it made you think a little 1222 - > differently, don't keep it to yourself. 1223 - > Share the episode, tag a friend, or post about it on social 1224 - > media.
1225 - > Connect with me on LinkedIn to keep the conversation going in 1226 - > between episodes. 1227 - > If you've got a question, an episode idea, or someone you 1228 - > think I should feature, send me a note at MeredithHirsch.com. 1229 - > Thank you all for the five-star reviews.
1230 - > They help more listeners find the show. 1231 - > New episodes drop every Tuesday. 1232 - > Subscribe so you don't miss what's next. 1233 - > Tune in weekly as we explore the inner workings of healthcare 1234 - > because you can't fix what you don't understand.
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