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    Christian Green
    Christian Green, MA

    Serving the digestive health needs of the City of Palms and beyond



    Gastroenterology Associates of Southwest Florida has been serving patients in the greater Fort Myers, Fla., area for more than three decades, opening its first office in Fort Myers in 1990, followed by a four-room, 12-bed surgery center in 1993. Later, offices in Cape Coral and Bonita Springs were opened.

    According to Kerri Gantt, MHA, LHRM, FACMPE, administrative director, the practice has 11 physicians, 10 advanced practice providers (APPs) and 44 staff who help in providing general gastroenterology services, including colonoscopy, upper endoscopy, endoscopic retrograde cholangiopancreatography, endoscopic ultrasound, capsule endoscopy, peg tube placement/replacement, and Bravo esophageal pH studies. The practice also treats several hepatitis and inflammatory bowel disease patients. 

    The majority of patients are 41 to 64 years old (47.5%) and 65 and older (37.9%), with the remainder age 22 to 40 (12.6%) and 18 to 21 (2%). The payer mix is 29% commercial, 26% traditional Medicare, 16% commercial HMO, 13% Medicare Advantage, 10% Medicare HMO, 2.5% CHAMPVA, 2% self-pay and 1.5% Medicaid.

    About Gastroenterology Associates of Southwest Florida, Fort Myers, Fla.:

    • Founded in 1990 by Nick Sharma, MD, as a solo practice, GIASWFL “provides leading-edge gastrointestinal health treatment in a safe, minimally invasive, and compassionate setting.”
    • 21 FTE providers and 44 staff across three offices (Fort Myers, Cape Coral and Bonita Springs) and a surgery center in southwestern Florida
    • In addition to Gantt, leadership team composed of Office Manager Michele Peters, CMPE; Site Manager Nicole Roland; HIS Supervisor Heather Lewis; CBO Supervisor Jessica Scott, CMM; and Endoscopy Manager Kim Lopez, RN.
    • MGMA Better Performer in operations, profitability and value

    Profitability*

    As a Better Performer in profitability, GIASWFL surpassed MGMA’s criteria in the following areas:

    • Less than the median for total operating cost per work RVU (GIASWFL: $37.20; NSSP**: $40.31).
    • Less than the median for total cost per total RVU (GIASWFL: $39.19; GI: $44.97).
    • Less than the median for total operating cost as a percent of total medical revenue (GIASWFL: 45.47%; GI: 56.85%).
    • Greater than the median for total medical revenue after operating cost per FTE physician (GIASWFL: $627,123.26; GI: $352,567).


    *Data from 2020 MGMA DataDive Practice Operations (based on 2019 data)
    ** NSSP = nonsurgical single-specialty practices

    Managing costs

    In focusing on managing costs, GIASWFL has primarily targeted three areas: monitoring recurring expenses, reviewing support and service contracts, and pursuing better pricing with vendors.

    As Gantt points out, the practice regularly reviews recurring expenses, which identifies potential savings from services and/or equipment no longer being used or serving its purpose.

    GIASWFL also conducts an annual review of its support and service contracts to ensure spending is in line with the contracts. For example, Gantt said routine vendor fees are negotiated into a single, annual fee rather than being charged ongoing fees or markups.

    The practice also compiles an annual list of supplies and meets with its vendors to seek out the best pricing for items. Similarly, the practice has used MGMA BestPrice to help negotiate better pricing with its vendors.

    In addition, GIASWFL implemented a cost containment strategy in January 2020, focusing on its patient intake system. Shifting away from printing new patient packets, Gantt says more than 90% of patients now check in electronically, which significantly reduces resources for printed packets and eliminates staff effort in scanning documents, not to mention freeing up storage space and mitigating the risk of misplaced files. 
      
    Beyond these factors, according to Gantt, the practice management (PM) system has allowed GIASWFL to collect copayments electronically, and with the help of its application programing interface (API), the practice can review past-due balances. When returning patients attempt to schedule an appointment, GIASWFL automatically notifies them if they have past-due balances, which must be paid before they can be seen.

    Another way GIASWFL has been able to manage costs is by outsourcing the legal review of payer contracts. “We work with a company more on a consulting basis … in a collaborative fashion to review the fee schedules to make sure that we’re still going to remain profitable,” maintains Gantt. “That was a huge savings for us, because otherwise we would be having internal staff really paying attention to that, or we may have had to hire outside legal counsel to review the terms.”

    The practice also uses revenue cycle management software that incorporates HL7 standards with patient data to handle eligibility verifications, provide price estimators and supply payer alerts, which has helped the practice reduce FTE hours.

    As a privately held company, GIASWFL has never gone through a formal auditing process, though the practice reviews its financials with its CPA annually. Beyond participating in MGMA surveys to benchmark provider and staff salaries, GIASWFL works with a professional employer organization (PEO), which has a human resources division. “When we’re looking for specific local information or regional information specific to a job description, we can send them our job description, and they’ll go out and do a full survey for that particular job and send data back to us,” says Gantt.  

    Value

    To qualify as a Better Performer in value, practices must attain Better Performer status in at least one of the other three categories — operations, productivity or profitability. Additionally, practices must report quality metrics. In that respect, GIASWFL has just started to take part in a clinically integrated network (CIN) with a local hospital system.

    “They are just getting a GI bundle for the upcoming year,” Gantt relays. “At some point, there will be a value-based agreement with that bundled package, and we would have risk associated with that.” In turn, the practice has begun to ramp up its review of key performance indicators (KPIs) to help ensure organizational success.

    KPIs

    In terms of KPIs, GIASWFL reviews them monthly, quarterly and annually, notes Gantt. For its GI surgical center, the practice is focusing on KPIs related to procedures. “We might look at clinical staff per room, encounters per room, procedures per room, device costs per encounter, scope repair cost as a percentage of total costs,” explains Gantt. GIASWFL also looks at various financial indicators, such as revenue per encounter and expense per encounter.

    Beyond the aforementioned MGMA surveys, GIASWFL also reviews specialty-specific society surveys and participates in a Qualified Clinical Data Registry (QCDR) to help improve quality. “We’re looking at those on a monthly basis and trying to provide feedback to the physicians,” states Gantt. “We’re hoping at some point to be able to leverage those quality indicators as part of our financial package from the insurance companies.”

    Gantt notes that beyond financial-related KPIs, the practice’s providers are most interested in metrics directly related to endoscopic procedures. It’s important for the providers to assess how they compare to their peers in terms of quality of procedures, because as Gantt points out, that could have an impact on referrals. It also provides peace of mind knowing that they are doing comparable work to their peers and making proper diagnoses.

    This also ties back to primary care physicians, who are increasingly entering value-based care and working to improve patient access. Gantt asserts that providers need to determine whether they are asking patients to come in too soon after a visit or procedure, which may increase costs. Conversely, she adds that GIASWFL wants to make certain it won’t be held liable for missing something as a result of putting off patient care too long.

    “It’s really a delicate balance to try to find that information,” Gantt says. “We feel that those KPIs are really important to monitor and ensure that we’re within the industry standard.”

    In sharing KPIs with staff, there is an emphasis on access and how quickly the practice is getting patients in for visits. GIASWFL also shares copay collection rates and how those rates compare to the national average in an effort to prompt conversation about ways to improve.

    As Gantt notes, it’s important for the practice to determine how often providers request that patients go to the ER rather than asking them to come back to the office. “Once they get to the hospital, there’s a good chance that they’ll be readmitted, and then that’s going to have an impact on the bundles,” adds Gantt of the need to make an accurate diagnosis.

    Related to hospital readmissions, Gantt says the practice is also focusing on adverse events after procedures and how those can be tied to access to care. “After they’ve had something done, how quickly can you get them in?” asks Gantt about improving access for timely visits. “Because if you’re not getting them in, they’re going to go somewhere else for care, and most of the time it’s the emergency room.”

    Risk stratification

    During the past year, GIASWFL has begun focusing on two different risk stratification groups: cirrhotic patients (those with liver disease who have hospitalizations) and inflammatory bowel disease patients. “A lot of times those patients with Crohn’s disease or ulcerative colitis end up having frequent hospitalizations, and they’ll have flares,” says Gantt regarding the latter group. “So we’re trying to rate those patients on a scale of one to five.” Once patients are selected to participate in the program, providers can easily identify their level when they log in to the patient’s chart.

    If the patient’s conditions are well controlled and symptoms have been reduced, Gantt maintains that he or she will be classified on the lower end of the scale. Conversely, if the patient has Crohn’s disease, for example, and may require a procedure such as a bowel resection and/or requires frequent hospitalization, that individual would rank higher on the scale. According to Gantt, the scale helps determine how aggressive providers will be in responding to patients and requesting that they visit the office. Moreover, the scale is a good benchmark for determining how frequently the practice needs to check in with patients, rather than simply waiting for them to call their physician when they are experiencing issues.

    Operations

    As a Better Performer in operations, GIASWFL surpassed MGMA’s criteria in the following areas:

    • Less than the median for percentage of total A/R over 120 days (GIASWFL: 7.94%; GI: 26.87%).
    • Less than the median for days adjusted FFS charges in A/R (GIASWFL: 53.65 days; GI: 140.61 days).
    • Greater than the median for adjusted FFS collection percent (GIASWFL: 99.00%; GI: 95.01%).

    Patient eligibility

    One of the first steps with new and returning patients is checking insurance eligibility.

    GIASWFL has a three-tiered process:

    1. The PM system includes eligibility verification.
    2. When a patient schedules a visit, staff checks eligibility.
    3. It has an automated patient intake system that can determine eligibility, which is displayed on the patient dashboard.


    Although it may seem redundant, the three-tiered process has served GIASWFL well, Gantt notes. The PM system also keeps track of secondary and tertiary insurance information, which it sends to payers. Eligibility information is then sent by the payer to the practice in a work file.

    GIASWFL has a staff member in its GI office who handles all insurance verifications and authorizations and another staff member in the surgery center who handles authorizations for procedures. Thanks to this largely automated process, the practice has been able to reduce FTEs.

    Patient billing

    Charts are typically closed within 48 hours, which is streamlined by the practice’s EHR system. Providers then sign and date the patient file the same day or the next. GIASWFL does all of its billing and collections in house, because, according to Gantt, the practice felt it could do a better job than a revenue cycle management company. “There’s a lot of inherent problems if you don’t have somebody who’s really monitoring the company to make sure that things are just not getting written off,” states Gantt. “We feel like we can pay more attention to detail.”

    One of the most important patient benefits GIASWFL offers is price estimation. “If they’re having a procedure done in our office and our facility, we’ll give them an estimate for the physician cost and for the facility,” says Gantt. “If we’re having it at the hospital, we’ll give them an estimate for the physician cost.”

    As Gantt points out, one of the benefits of GIASWFL’s PM system is the price estimator, which automatically checks eligibility and determines the patient’s deductible balance — whether they have met their coinsurance and maximum out of pocket. It then applies that information to the fee schedule. If the provider determines that the patient needs more than one procedure, the price estimator will use the proper guidelines for the estimate. GIASWFL can then send that information via secure message or mail to the patient.

    Coding

    Gantt says that while providers are seeing patients in the office or via telehealth, they designate level of service based on a calculator in the practice’s EHR. Once that’s done, the coder will review it to make sure it’s coded at the right level. “If there’s an issue that needs to be addressed, she’ll either discuss it with a physician or she’ll discuss it with the CBO supervisor so that it can be addressed,” conveys Gantt. When coding a procedure, either at the hospital or surgery center, the coder can pull the operative report and code from that report.

    Conversely, at the surgery center, there’s also the option for providers to enter information in the operative report after the procedure. The software is then very proficient at determining and entering the correct code, whether procedure codes and modifiers or ICD-10 codes. This shortens the coder’s review before submission.

    Analytics

    As part of its PM system, GIASWFL has a complete practice analytics system. This allows the practice to run dashboards and reports, which includes a denials dashboard that shows the type of denials that have come in. “We use the practice analytics system for addressing claims and trying to work them and get them directly back to the insurance company so that we can get the claim paid,” says Gantt.

    The practice has a standardized chargemaster, which was set up based on GIASWFL’s RVUs. With just one staff member doing charge entry on the office side, Gantt notes that the practice doesn’t track any benchmarks per se. However, collections and claims are monitored on a daily basis. In addition, either daily or weekly, GIASWFL reviews untracked encounter forms, runs a posting lag report, and conducts an unbilled claims analysis to determine why a claim hasn’t been billed to the payer.

    Payments and collections

    Patients are able to make a secure payment by credit card or debit card through the practice’s patient portal. At present, GIASWFL does not offer payment via eChecks or mobile payment services such as PayPal or Venmo. If they don’t want to visit the portal, patients also have the option of accessing a secure link on the practice’s website that takes them to a secure bill pay site.

    If patients are not responding to payment requests, GIASWFL typically sends accounts to collections after 90 days. However, the practice offers resources for patients to make payment arrangements, particularly if they are experiencing financial hardship.

    A big part of GIASWFL’s status as an MGMA Better Performer in the profitability, value and operations categories is the practice’s collaborative culture. According to Gantt, this starts with the leadership team, all of whom have an open-door policy and empower providers and staff to strive for success, evidenced by the practice’s daily huddles, during which patient volumes, staffing, provider issues and other daily challenges are discussed and addressed.

    “Our staff are adaptive,” says Gantt. “We cross-train staff to cover shortage areas if necessary. … We embrace mentoring and encourage staff to learn new tasks and to grow within the company.”

    Returning from COVID-19

    According to Gantt, GIASWFL has returned to around 90% volume, but she expects that by April, the practice will be back to 100% volume. During COVID-19, every provider practiced telehealth, but as soon as volume returns to normal, some providers only plan to see patients in the office. That said, the majority will continue to offer telehealth services.

    “We do try to keep patients who are at a higher risk on telehealth if at all possible,” says Gantt. “Sometimes, the physician will see the patient on telehealth and say, ‘OK, you know, you really need to come in because I can’t address this particular issue without doing an actual physical exam.’ And so the patient will end up coming into the office.”

    As a small practice, GIASWFL did not permanently shift any staff to remote work and the practice did not make any significant changes to facility layout other than putting up permanent glass barriers in the check-in and check-out area to protect staff and patients. The practice also moved a desk with a computer closer to the entrance so that staff could take patients’ temperatures and assess their health before patients fully entered the office.

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    Christian Green

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