YEAR TWO, Q2
SUBJECTIVE:
In the midst of Covid-19 and reflecting on the impact as of early April, I lamented on the office lease price. Such a futile exercise. THE BOSS reminded me once again that it was the right choice at that time and with original plans to pursue ECT, nothing would have been different. Reassurance was nice.
First wave of GT modifier with 02 point of service (POS) codes coming back. So far so good, but my main payer for above medicare rates were ~74% of their usual. That stirred up a strong emotional reaction, could my practice survive with this hit? Took a pause, eventually called the insurance, they said they hadn’t got their act together yet and to resubmit the codes with POS 11 and GT modifier. Frustrating there will be a pay delay, but at least its back to full rate. The state I’m in passed a law for parity for telemedicine services. But I guess it only enforces some insurance, but not others, so unclear if telemedicine is viable. I hope to continue Telepsych service line post Covid, but if it means reduction in service contracted rates, can I really do this? This then has downstream effects on if I opt in for the paid service of Doxy.me and even further invest in more quality tech or even increased bandwidth from the telecom company. Have had a few encounters fail with tech that prompted them as phone encounters. So this spurred the use of 99441-3 codes. These telephone encounters are abysmal for pay, almost not even worth submitting the claim.
One of my lower-than-medicare insurance companies doesn’t reimburse for 99406 smoking cessation. Just wow, insert long winded clinical, epidemiological, social, etc soap box [here].
Kept myself involved with 1-2 medical schools over the years. Little bit of a pause for past year due to low clinical volume that just isn’t worth a student’s time. One of them recently reached out to offer a small quick teaching stint for a few days (their students are off service and potentially doing nothing?) that normally wouldn’t be worth a Psychiatrist’s time purely on financial remuneration, but considering my current schedule gaps it actually worked out and will be a Win-Win. However, this is also a state school, so it will be months before I get this paycheck.
Needing to spend more time chasing down PHQ-9, GAD-7 questionnaires with patients to further facilitate billing for 96127. Back when seeing patients in the office, easier to just hand a clip board with these on it.
Slowdown in new consults has cast an element of unease. My website Google analytics reflects a marked down turn in traffic with Covid-19, too. I have been negatively impacted from Covid-19 for sure. Applied for the EIDL and PPP loans to the truest bare minimum sense for my employee, and in part because I don’t trust the government. Wouldn’t be surprised if I get stuck with an actual unforgiven loan. With EIDL and PPP, I’m looking to reduce overhead before employee hours.
Part of my goals to not reduce employee hours, are reviewing overhead and cutting. Currently paying $20/month for 500 pages with fax service. Going to change to another service, SRFax which will be $9-10/month for 500 pages. And the key to this process, is they will port over my existing fax number from that online service to theirs so thankfully no need to change my number – took several weeks, but they did it! This fax even allows a cover sheet to have your logo, pretty cool. The bigger overhead reduction is the 3rd party billing service which is $500-700/month, depending on monthly billings lately, and will transition to the integrated Luminello feature with ApexEDI which is $65/month for my current number of fixed claims submitted. Even at full projection, their tiered rates would be at most $134/month for me. The billing company was trying to do everything they could to keep me as a client, and practically offering free services. But the seamless integration of Luminello, they just can’t compete.
Personal finances just took a massive hit on home front, things are now much tighter, and Covid-19 is truly far reaching. I will now be needing health insurance, and will purchase directly from the insurance company. I did briefly explore the state exchange. Great to get some tax deductions from this. Great to be able to choose a better insurance company. Having now worked with almost all the flavors in the area, I know I’ll be getting a good one, and I’ll be looking to rock the tax benefits of the high deductible plan with the HSA. I really like HSAs.
So far, the transition to ApexEDI (the integrated clearing house with Luminello) has been fair to good process. One question and hiccup with using the ApexEDI system is Box 6, of the CMS 1500 form. If the patient is the insured, but a spouse or dependent you check ‘spouse’ or ‘dependent.’ That then prompts the need for the whole address of the primary insured person and their date of birth. This isn’t always available. So, I’m sampling some without this, and seeing if insurance will process anyways. A few of these sample claims have come back just fine. I’m not going to sweat that anymore, the little things you learn along the way. Receptionist loves their customer service regarding complexities of submitting to secondaries or atypical denials. It’s been a bit of slow roll out to get the ERA statements to show up in ApexEDI and in turn be automatically uploaded into Luminello. You have to fill out a bunch of applications for the different insurance companies which is called ERA/EFT enrollment. Since I’m wide paneled and doing this all at once it was quite the admin time suck for a while there. But now that some of them are coming thru and connecting. I LOVE IT. Say it again, I LOVE IT. The seamless nature of these claims submission and insurance processing is so easy. It’s like the practice set ups a few other posters on SDN have, and I wish I did it earlier. This is also going to drastically reduce the work load for my assistant.
Finally emailed the BlueFin folks connected with Luminello who do the credit card processing (nod to SDN poster here, thank you for the tip). They got back to me and were like, “nope.” Credit card processing fees are unchanged. The convenience factor of integrated billing is too nice and I’m not going to change that workflow to save $5-30/month.
A Sleep Medicine doc I know got laid off by the person’s Big Box Shop job due to Covid-19 stuff. Sad really, considering they could have done part time, or furlough, or a whole bunch of other things first. The person suspects they will be replaced by an ARNP once the pandemic eases up more. The remaining doc at that location is now getting slammed – but if you haven’t paid attention to SDN posts – Big Box Shops don’t care. As a result, this doc is going to be subleasing from me which will raise income. Interestingly, sublease income
is income, and not a reduction in my lease overhead, which took me a bit to process, a minor pain, when thinking about tax optimization and where to place it in QuickBooks accounting. I’m also guiding this person some on how to start up a practice, and so far, the trajectory is so much faster and cleaner than mine. Took some time, but finally got a contract for sublease approved by everyone. Entry in August, free for August, collecting rent in September. Month-to-month contract. Person isn’t planning on doing a sleep lab at this time but only HST and get their footings in the community before further expansion. Also, nice to be able to cross refer, too. WIN – WIN.
Psychology Today has been a much better advertisement service than Google. Cost neutral to cheaper change with Psychology Today. Deferred on doing a small local newspaper online add. Trying to line up some lunchtime meetings with local independent PCPs, and going to cater them lunch. Will tag team this with the Sleep Medicine doc and sort of do a ‘twofer’ to reduce costs. MISTAKE: doing Google ads before Psychology today.
Sleep doc has been looking into a lot of EMRs. Fascinating to hear about their billing, features, and rates for their services and some are eye popping expensive, like 7% of total collections! Makes me appreciate Luminello more despite not having all the extra bells and whistles. Tried to keep an open mind for possibly switching myself, but with the ApexEDI and Invoice Tracker (see below), I’ll be sticking with Luminello. For a sleep medicine clinic some of these expanded services make more sense. Of which some supposedly have interoperability with the beast known as Epic. Which got me searching, and supposedly there is a way to get a remote access link as small entity like myself, so I have been reaching out to the local Epic Big Box shops the Epic person put me in touch with to see about actually getting this access. Would be nice to skip the record acquisition by fax and weeks delays, and simply be able to just log in and review. See how this unfolds – update this next quarter.
Did get the EIDL and PPP for about ~6.3K in total. A blessing really, considering my personal finances just went to Scat, and will also need to buy my own health/dental insurance for family to tune of ~20K/year. So, this money originally meant to stave off cutting hours for assistant, now has a greater value to it, and I’m counting down the days before I have to pick up a side gig. So, so want to avoid this. I loathe the thought of Big Box Shops tickling my NPI number again. The “never again” mantra will be tested…
Covid-19 patient impacts have been trickling in, too. Two patients dropped out due to job loss and getting Medicaid insurance. A few others have been losing jobs, but being buffered by their spouses. A few patient balances are starting to climb, too.
Out of the blue, Luminello goes and does another update. This time an ‘invoice tracker’ feature has so simplified billing even more and really made bill analysis for patients so much easier. I and my assistant can’t stop talking about this – and we are both telecommuting. That’s how great this addition is with the internal claim submission/clearing house with ApexEDI. I’m now playing devil’s advocate to the Sleep Doc and trying to convince this person to use Luminello. These billing changes with ApexEDI integration and now Invoice Tracker feature, nervously/joking have assistant pointing out her duties will be so reduced she is questioning why she’s needed and even willing to consider hours reduction. Reminded her the phones are primary (during non-Covid time) and that there will always be billing tasks and other things that pop up where she is needed. Sleep Doc finally selected Charmhealth.com for the EMR.
Discovered a new ARNP in community, and another new one who replaced one who retired. Also discovered a psychiatrist in the Metro area, just outside my draw area, hired an ARNP. This doc opened their practice +/- the same time I did, but was definitely doing other side gigs this whole time. MISTAKE: as others pointed out, side gigs can be solid means to keep the income flowing, and also siphon patients to your practice – I have chosen not to.
Big Box Shop radiation is improving with natural decay. I used to encourage people from Orange Box or Blue Box to seek their specialist care from the same color box. Now as an independent and ruminating on the greater forces of the health care system, I am instead referring when available to other independent practices. The enculturation I (we?) endured with our training and even working at a Big Box, it closes your mind that it’s THE WAY. Feels so good to not drink that kool-aid anymore. One Big Box shop has 0 mental health and yet, I don’t get any referrals from them. They sent me a handful of their most complex patients who were Medicare back when I was still open to Medicare, but now, I get none. There is one doctor at another Big Box shop who routinely sends patients to me, as their several Psychiatrists are all full – in part because I took the time to meet that person face to face. But not a single one of the numerous other PCPs there do… In summary, my PCP lacking patients, I now point only to the small independent practices. Sleep medicine only to independent practices. I wish we had a private Cardiology group in the area to do the same. Big Box Shops keep track of their “external” referrals with Epic EMR, well, I’m keeping track of my non-independent referrals.
Discovered that a big payer just ended their acceptance of GT modifier. So with medicare already wanting 95 modifier for telemedicine and my low level sleuthing that most insurance will accept 95 or GT, I’m going to simply switch over to 100% 95 modifier. Sort of like Ford vs Chevy, doesn’t really matter, but I was personally rooting for GT.
In grand summary, due to Covid-19, I did not expect any positives. But there was PPP/EIDL, tiny patient growth, tiny payer mix improvement, and I was able to pay myself something. Life is good.
OBJECTIVE:
| Total Active Patients: | 102 | | |
| Insurance Payer Mix: | 34 < Medicare | 7 Medicare | 61 > Medicare (59.8%) |
| Follow Ups: | 169 | 13.0 (weekly mean) | range of 8-22 per week |
| Consults: | 24 | 1.8 (weekly mean) | range of 0-5 per week |
| Weekly Clinical Hours: | 8.3 (quarterly mean) | | |
| Blended Payer Mix: | $139.77 per follow up | <----Secret sauce formula | |
| Overhead Percentage: | 57.0% | | |
| Days Off: | 2.5 | | |
| Apr-20 | May-20 | Jun-20 | TOTAL |
GROSS PROFIT | $9,278.38 | $17,241.64 | $12,588.97 | $39,108.99 |
| Expenses | | | | |
Advertising & Marketing | 123.52 | 88.95 | 88.95 | $301.42 |
| Credit Card Processing Fees | 129.15 | 93.52 | 135.24 | $357.91 |
| Liability Insurance | 0 | 2,487.00 | 0 | $2,487.00 |
| Medical Billing Services | 495 | 610.42 | 560 | $1,665.42 |
| Medical Society Membership Dues | 0 | 0 | 205 | $205.00 |
| Office Supplies & Software | 72.94 | 481.06 | 601.97 | $1,155.97 |
| Payroll Expenses | 1,524.78 | 1,414.15 | 1,380.48 | $4,319.41 |
| Payroll Taxes | 0 | 0 | 866.82 | $866.82 |
| Rent & Lease | 3,301.42 | 3,301.42 | 3,301.42 | $9,904.26 |
| Taxes & Licenses | 0 | 0 | 60 | $60.00 |
| Utilities | 129.83 | 129.61 | 129.67 | $389.11 |
| State Tax | 0 | 0 | 586.63 | $586.63 |
Total Expenses | $5,776.64 | $8,606.13 | $7,916.18 | $22,298.95 |
| NET INCOME | $3,501.74 | $8,635.51 | $4,672.79 | $16,810.04 |
ASSESSMENT:
1) Professional Dissatisfaction
2) Slow practice growth rate
3) Optimization Deficiency
4) Infrastructure Deficits
5) Retirement Exposure
PLAN:
1) In Remission, continue this private practice. Never again policy, may face the reality of life circumstances and a side gig of some sort may be necessary. I am now more in line with the other independents and point my patients to PCPs and specialists who aren’t Big Box Shop affiliated.
2) Growth rate has just taken a beat down from Covid-19. Overall a cost neutral change by opting for Psychology Today over Google Ads. So far appears to have better traction. Next level marketing is going to be doing lunches with Independent/private PCPs in tandem with Sleep Doc in Q3.
3) Not yet time to drop Medicare, nor lower payor insurance until about 20 clinical hours per week achieved. Successfully transitioned billing away from a 3rd party entity and entirely with the Luminello integration – money and time saver. So efficient. Next quarter overhead will start to reflect this ~$440/month savings. Successfully transitioned to a cheaper better fax service. In process of finalizing a sublease with Sleep Doc. Failed at reducing credit card processing fees.
4) Still debating on buying a blood pressure cuff, defer until after Covid. Next quarter the topic of land/construction loan for an office will be more real. I have until the end of Q4 to make this happen, as such a project will take year to complete, and coincide with lease end. Lease or build? Considering porting phone numbers over to Google Voice with G-Suite.
5) Very low risk of conversion to retirement at this time. Will continue to treat with high dose of bills for suppression, and monitor with these quarterly assessments. Covid-19 hasn’t helped. Pay for this quarter will be ~$16.8K, and 20% of that will be put aside for SEP-IRA contribution, and then 20% of that 0.8 put aside for taxes, leaving ~$10.8K to pay personal bills.
