Securing Anesthesiology’s Future, and Safeguarding its Present: Thoughts From the Advanced Institute for Anesthesia Practice Management

While we are all trying to understand how the landscape is evolving for anesthesiologists, nurse anesthetists and anesthesia groups, keeping our eyes on traditional practice management issues such as compliance remains as important as ever.  Similarly, we must maintain a dual focus on the big picture of system and organizational changes, on the one hand, and on the day-to-day requirements of providing and being paid for anesthesia and pain medicine services, on the other.  Our field of vision has to be both longitudinal and latitudinal.

One of the frankest talks on system evolution at this past weekend’s Advanced Institute for Anesthesia Practice Management (AIAPM) in Las Vegas was that of Howard Greenfield, MD of Enhance Healthcare.  Dr. Greenfield, discussing The Anesthesia Workforce of the Future, quoted Kaplan’s and Porter’s observations that “some facilities that serve patients with unpredictable and rare medical needs … carry extra [personnel] capacity” and that “Much excess resource capacity … is due not to [a uniformly high prevalence of] rare conditions … but to the tendency to provide [that level of] care for … every type of medical problem.”  Current workforce models in our specialty illustrate the problem, according to Dr. Greenfield, “when we inflexibly assign fixed low supervision ratios without regard to patient acuity or surgical complexity.”  We were reminded that none other than Mark Lema, MD, PhD, then president of ASA, told us at the 2007 Practice Management Conference that anesthesiologists will need to prepare both medically and financially to expand supervision to an ICU-type medical direction (10:1) using conscious sedation nurses along with CRNAs.   Leaping back to the present and to the near future, Dr. Greenfield drew the connection between telemedicine and new staffing models, stating that “Like the tele-ICUs, someday tele-ORs may have anesthesiologists rotating through tele-control room assignments, with two-way video and audio connectivity to each OR or procedure suite” and that “The tele-anesthesiologist could oversee and advise in the care of multiple rooms in a cost-effective manner.  He or she could instantaneously respond to a query, even switch attention from room to room on a minute-by-minute basis.”

It is worth noting that tele-OR surveillance is already here.  The AlertWatch system  integrates inputs from the physiologic monitor, the lab, the AIMS and the patient’s history and physical and displays the information as icons of the organs being monitored. “Just as the multifunction monitor in modern aircraft uses multiple sources of data to feed algorithms continuously searching for potential problems, AlertWatch does the same with the patient’s medical data being updated every 10 seconds,” according to Kevin K. Tremper, MD, PhD, FRCA, chair of the Department of Anesthesiology at the University of Michigan, who states further that “The algorithms are based on the latest literature and reported standards, e.g., SCIP measures.  In the future, systems like this may allow tele-OR as a continuous electronic consult. Preliminary results of the use of this system, developed at the University of Michigan [with support from ABC], were reported at January 2014 meeting of the Society of Technology in Anesthesia.”

Organizational strategies—joining an Accountable Care Organization, merging with another group, selling the practice to a national company or to a private equity firm—were the focus of multiple lectures at the AIAPM.  The stronger the group, the more options it is likely to have, including the option of remaining independent.  Potential partners are looking for the same things, starting with solid leadership, high quality and value, productive relationships with hospitals and surgeons and sustainable case-mix and payer mix.

William Britton, MBA of Cross Keys Capital, speaking on Anesthesiology Acquisitions: Is Your Practice a Candidate for Acquisition by a National Firm or Private Equity Group, presented an outline for “Making Your Group More Attractive to Potential Buyers” that would apply to any practice seeking to thrive and grow:

Focus on:

• Strengthening / improving leadership roles
• Implementing the proper governance for “your group”
• Solidifying Contracts
• Building a cohesive culture within the group
• An Internal Audit of Coding and Compliance
• Evaluating the merits of partnership-track vs. employed physicians

“An internal audit of coding and compliance,” the fifth of the six elements on the list above, does not figure in every summary of strategies for success, but the importance of compliance cannot be overlooked, or indeed overstated.  The Affordable Care Act increased the government’s auditing capability, expanded fraud and abuse laws, increased resources to combat fraud and provided for the mandatory return of overpayments, as noted by Neda Ryan, Esq. of Clark Hill in her talk on Government Audit and Investigations:  How to Protect Your Practice When the Government Comes Knocking.”  In 2013, the government recovered $4.3 billion and opened 1,013 new criminal and 1,083 new civil healthcare fraud investigations.

The AIAPM offered multiple presentations on coding and billing, on documentation and on other compliance issues including EHR cloning.  Kelly Dennis, MBA of Perfect Office Solutions offered a complete checklist for conducting an internal practice audit in her discussion Auditing for Compliance and has graciously given us permission to reproduce the checklist here:

Auditing Checklist

1. Information necessary:
   • Copy of surgery schedule (don’t forget add-on cases, i.e. obstetrics)
   • Copy of anesthesia record(s)
     • Review pre and post operative for medically directing and/or teaching physicians
   • Copy of operative report (if used by coders)
   • Copy of claim form
   • Insurance information and contracted rates with carriers
   • Explanation of benefits and/or patient notes.
2. Sort charges (full day’s worth if checking concurrency)
   • [One method] is to separate by provider and time for each date reviewed.
3. Hand key information (change spreadsheet to reflect YOUR practice or the scope of review)
4. Make clear notes regarding errors found.
   • Wrong patient – CORRECT
   • Date of service – CORRECT
   • Place of service – CORRECT, IF NECESSARY
     • Did error affect payment of claim?
   • Provider – CORRECT, IF NECESSARY
     • Was incorrect name on claim?
   • Diagnosis code – CORRECT, IF NECESSARY
     • Did error affect patient’s medical history or payment?
     • Review error made with coder
   • Procedure code - CORRECT, IF NECESSARY
     • Was ASA or CPT code filed?? Was crosswalk correct?
     • Review error made with coder
   • Modifier – CORRECT, IF NECESSARY
     • i. Did error affect patient’s medical history or payment?
     • ii. Review error made with coder
   • Anesthesia time – CORRECT, IF NECESSARY
     • If under billed, correct if benefit outweighs cost of correction. ….
     • If over-billed, correct according to compliance plan.
   • Were applicable medical direction steps documented?
   • Are signature and documentation legible?
   • Pre and post anesthesia documentation as required by Conditions of Participation? (Typically reviewed during joint commission audits)
   • Was payment made as expected?
     • Underpayment – handled correctly?
     • Overpayment – refunded as applicable to patient, insurance, other party or to state “unclaimed funds” or documented as below threshold?
     • Is there a pattern of problems by carrier?
     • Are adjustments taken when insurance is not contracted? If so, is the physician group aware?
     • If paid by insurance, was patient billed timely?
     • If not paid by insurance, was there sufficient account follow up?
     • Was account noted if adjusted for financial hardship or turned over to a collection agency?

Watch for patterns

Watch how long it takes to enter charge from date of service (using business days)

Watch computer notes for account activity (i.e. Claim filing date, patient bill dates, follow up activity)

Recognize excellent documentation, coding or account follow up!

The more than 300 attendees at the AIAPM received much additional valuable information during the three days of plenary and breakout sessions.  Next year’s conference will be held on April 17-19.  We hope you will mark your calendars and consider the benefit of participating.