Hi everybody. We've got a great conversation keyed up today. I'm Dr. Michael Redler. I'm an orthopedic surgeon at Connecticut Orthopedics. I specialize in sports medicine and upper extremity surgery, but I've got additional interests in medical mission work. I've got an additional interest in teaching, but I've also got a fine interest in the business of running orthopedic practices and ambulatory surgical centers. And we are so lucky today to have Angie Van Utrecht with us today to tell us a little bit. So Angie, introduce yourself. Hi, Dr. Redler. Thank you very much. My name is Angie Van Utrecht. I'm the director of operations at Bone & Joint Institute of Tennessee in Franklin, Tennessee. I've been doing operations in private practices for, gosh, I'm starting my 26th year and have spent over half of that time in orthopedics. Well that sounds like a great background. Angie, I know that you came into a challenging but perhaps not unique situation at the Bone & Joint Institute of Tennessee, and I think that's a great place to start. Tell us a little bit about that. Yes, absolutely. So I joined their practice in November of 2022. Like I said previously, have an extensive background in operational aspects of clinics, orthopedics in particular, and we're a very large group. We've got multiple locations, 40 plus providers. That includes surgeons, non-surgeons. We do procedures. We have a surgery center. We've got physical therapy. So a lot of different arms to this group. And so when I started with them, they were a group that grew very quickly. They left a hospital system that was a teaching institute here locally and joined a not-for-profit entity here in Franklin. And so with that rapid growth, they tried billing in-house, then they outsourced it, then they brought it back. And unfortunately, some of the management of the entire revenue cycle just wasn't done very well, which resulted in some cleanup that had to be done to put it loosely. And so we're to a point now almost two years later where we're starting to see the light at the end of the tunnel. But having that strong background in management of the revenue cycle, along with the appropriate staff doing the appropriate jobs, really is key to making sure that you don't end up in a situation like I walked into. So that really sounds challenging. And we know when you've got such a large group, you've got a variety of individuals that you're working with, you have practices that have been done for years, and yet some things have to be changed. So how did you attack this problem? What did you do to start to get you headed in the right direction? That's a great question. Like with anything, we attacked it, I in particular attacked it from the standpoint of just really looking, starting at the very granular level and looking at the processes that we currently had in place, looking at, did we have the right people doing the right jobs? We may have had the right people, but maybe that just, they weren't in the right seat on the bus, as I like to say. So we did a full evaluation of not only the processes, but everything, we weren't doing everything that poorly. And just looking at, okay, what are the keys to success here? So what are we doing well? I'm a big proponent of no need to rock a boat if it's working. And let's start with the things that we're doing well and see how we can do this better. And then looking at the other items where and processes that we need to tweak a little bit to make things more efficient. So our biggest hurdle, I think, after kind of looking at everything was really, it did start with having the right people in the right seat on the bus and doing the right job. So we had to do a full evaluation of, do we want somebody, for example, to be a data entry person or do we want somebody that is a true charge entry person that has a coding background that can do more than just do input numbers? So, and this is, nobody likes change. And this was an organization that had been going down this path for about five years. So really just had to start with that whole process aspect and, you know, make changes from within as needed and, and kind of go from there. Yeah. So I think evaluating people in any role is always challenging. It's easy to tell people when they've done well, it's more challenging when you have to tell someone, hey, this isn't really cutting the mustard. This is not really up to snub. What can you do to make it better? How do you do that? And what, what approach do you use to really, you know, start to talk about current practices and what's better behavior and frankly, better practices? Yeah. And one of the biggest struggles was, you know, nobody likes change as I'd mentioned earlier and really having, you know, it starts from, you know, the top. And so really having the right person in that manager position that was reporting to me to make sure that everybody was rowing in the, in the same direction. And so getting their buy-in was, was huge. And we struggled a little bit with, because you have some expectations I think weren't set probably properly in the beginning. And so it really was a period where we, it was really just kind of a, like kind of starting from scratch and trying to lead positively and, you know, not talk about all the negatives and all the things that weren't being done right. But starting with some of the good things and saying, okay, we're doing this really well. Here are some things we need to work on and really trying to get the staff's input from that. Because I'm a firm believer that, you know, if you empower the staff and they feel they have some say in it and they have some input, it's most likely going to go better on the backend. And if they can buy into it and not necessarily think that it's just upper management dictating what, you know, what has to be done because we're not, you know, in the trenches per se. I think that's a great approach. And look, we know that human nature is people respond well to praise. Hey, you're doing this well, but here are the things we can do better. Some of the things that you were hoping they could do better. What were some of the biggest issues that you felt like you had to tackle first? We really struggled with our EMR system. So I'm very well-versed. I've done, I can't remember how many EMR systems and dealt with them over my career. And we currently use Athena and because of the way in which this whole transition from they were at Vanderbilt, part of Vanderbilt, and then moved to Williamson Medical Center, it was a pretty quick turnaround. And so the setup of the system, I don't think was set up probably the most efficiently on the front end. And so now five years plus have passed and people get into the routines. I think a lot of the staff after the evaluation process, just in my opinion, I don't know that a lot of the staff fully understood the EMR system and where that was the billing side, where that was the clinical side, it obviously ties together. And so that was a huge challenge. And then I was learning a new system, so it could have been the perfect storm. So it was trying to evaluate the system, look at the processes, learn the new practice. You know, I don't do anything easily, that's kind of a running joke in my household. And I'm always up for the challenge. I think that's probably where I shine the most. And so I really had to reteach the manager, like this is what you have to look for. And just understanding the basics of the revenue cycle, it's more than just entering the charges and hoping that they get paid, like statusing the claim. A couple of our staff, they were like, we don't do that. We just enter in the charges. I'm like, oh gosh, no, it's a continuing process. So some people decided this probably wasn't the place for them. And that's okay. I mean, we've always said, we want you to be here because we think you're a valuable employee, but there's going to be some changes. And if you don't think that this is the place for you when we may have to change your job around a little bit, we'll be your biggest supporter in finding that right position for you. So we've had to do, there's been some major overhaul in staffing and processes, lot of re-education. Our current revenue cycle manager has a lot, 20 plus years of experience in revenue cycle. She's a super user with our current system. So she came into the situation and was really like a plug and play, which was great from my standpoint and from our CEO, John's standpoint. So it's, I keep trying to remind her that Rome wasn't built in a day. And I know that this didn't get to the state in six months. So it may take a year to get things fully, to get your team where your team needs to be and kind of re-educated. And it's the physicians too. I mean, physicians, I'm pretty lucky. We have a really good group of providers and they, I can say this to you as a physician, the goal is right to maximize revenue, but you want to do it ethically and legally in the correct way because nobody looks good in stripes or orange. And so they want to do it right. They thrive on the feedback. We do an audit once a year with an outside company that's part of our billing compliance plan. And they like wait for the results, you know, excited to see how well they're doing and they want ongoing education. So we've just, we really just revamped our really kind of everything from A to Z. So you've given us a lot of really important points. You talked about one, having the foundation of where you want to do, two, identifying good people. And I think that just as important as identifying good people is identifying people that probably aren't able to do the job that you're asking them to do. And that sounds tremendously important, but you brought up something really important because look, in any big practice you talked about, you guys have over 40 providers, that's 40 different physicians and providers that have different ways of doing things. You know, and I think that that is sometimes as just as big a challenge as working with the billing department. What have you done and how have you worked with these different providers and these different physicians to get them on board? Because the lifeblood of any practice is the finance. You've got to have your accounts receivable taken care of. You've got to be able to bring the money into the practice. So tell us some great secrets that we can all learn about. Yeah, that's a great question. So with our group, the physician salaries are RVU based. So the first meeting we have every year with our physician council is an education and it's based on the previous year's outside audit that we do with a third party company. And we have a set target in our billing compliance plan. And if a physician doesn't meet that, then they're required to do monthly ongoing training. And then we do a kind of a mini audit after three months of that. And then if they meet that threshold, then they're considered good again and they don't have to do the monthly education. But our coders, our charge entry are all certified coders. One is not, but she's been doing it for a really long time and she's working on her certification. So we provide, I'm a big proponent, whether it's with physicians or with my staff, that if something's being done incorrectly, let's correct it now. Let's not wait until we did the audit in 12 months. Let's not wait until we do your evaluation in a year, because the best way to change habits is to address it immediately and let them know they're doing something wrong or something needs to be tweaked so they don't keep continuing to do it incorrectly down the line. I suspect that one of the things that you deal with is a big challenge is inertia. People have done things the same way for a very long time. You've got over 40 different providers, which means 40 different personalities. They've all got medical assistants that are working with them as well. Do you have any great secrets? How do you deal with it? Because everybody thinks that their way of doing it is the right way, but you know that that doesn't always contribute equally to the bottom line. It's definitely a challenge. This group of providers, I'm very lucky. We're very lucky to have them in this community. They will have their moments, of course, but they're probably more receptive to education and to, I mean, criticism is probably a harsh word, but advice, constructive criticism, more so than any group that I've worked with over the last 20 plus years. We tend to do a lot of our education in a group setting. I jokingly say there's the whole group shaming and nobody wants to be the one that's on the position. You don't want to be the one that's got the lowest score. They're very active in their organizations. They will sometimes bring things to my revenue cycle manager or billing department and say, hey, I was just at this conference and they talked about this. Are we doing it like this? While they might be part of the problem, sometimes they really are also a part of the solution more so than they are the problem. Well, that certainly is a refreshing response. There are different practices that have to go through all different types of challenges. what is unique to coding for a large orthopedic practice? Gosh, orthopedics, as you personally know, there's so many changes, then the bundling, and it's not a straight, it's like a primary care practice or even like I managed GI, that's my other background. So, GI, they do procedures, but there's a handful of procedures. With orthopedics, you've got multiple modifiers, multiple CPT codes, you could have one procedure with eight or nine different codes. So, making sure that you have, that's where we really struggled the most was having someone who had internally that had the knowledge base to code our surgeries. And some of them were easier, some of the totals, that wasn't, I'm joking with you, I could probably code those and get them right. And, but finding that knowledge base from a surgical standpoint that we trusted. And unfortunately, when I took over the operations of this practice, they were using an outsourced company and it was not a good situation at all. And within the first like six months, I would find like massive amounts of claims that hadn't been, or surges that hadn't been billed or 400 claims that were billed without the assistant modifier. So, these are things that we find, and so they didn't have any sort of quality check in place. And so it got to the point where we sought out, okay, we're like, we have to make some changes here. We didn't necessarily wanna bring it back in house because again, we face that same challenge. And that in itself has to be a really big challenge because there are an awful lot of companies who if you read what they have to say, all will do a fantastic job. And yet you have to have some criteria. How do you end up choosing a company that you think is gonna be best to assist you, one that assists you, one that will really sort of match what you're trying to do with the practice? Because that in itself has to be a big challenge. Yeah, you're absolutely correct. And especially coming off of the experience, the previous experience. So it was just kind of the hesitation of like, well, how do you know they're gonna be better? They cost more money. How do you know they're gonna be worth it? And I just kind of knew, I mean, not really kind of knew, but I mean, we talked to several current clients they were using that were large practices. And then we internally have a checks and balances system. So people are human, they're gonna make mistakes. But so we've got somebody internally that makes, we have a report that we run out of our EMR system and it will say, okay, these were done, were they billed, you're missing a couple. And we're working through some interface things, which I think we finally have gotten corrected after starting with them a few months ago. So for me, it was really, I vetted them versus where I walked into a situation that, and so really making sure you have a checks and balances system for everything really to make sure this charge was done, this procedure was done, this E&M was done. Did we have a charge for that? And if not, then how do we rectify that moving forward? So it sounds like what you were saying is that when you're looking for a company, you talk to an awful lot of people, you get an awful lot of stories, you find out what they've done, see if it matches what you're doing, but then there's ongoing checks and balances. So it's active, it's not a passive relationship, it's active on both sides. That sounds like a really important point. And it has to be, because, I mean, like I said, humans, if there's a human involved, there's going to be an error. I mean, I make mistakes daily, as I'm sure you do. So just making sure that we're comparing apples to apples and making sure that they have what they need to succeed and making sure that we have what we need to succeed. And we do that even internally, we have a quality check program with our internal coding staff. Because again, we see on average between all of our urgent cares, our physical therapy, surgery, and our main clinic, we're on average billing out probably 10,000 plus encounters a month. So it's a lot. So, you know, something's going to get missed probably. Well, that sounds like a prime example for checks and balances. Angie, we've talked a lot about coding. You know, one of the things that becomes challenging for us as physicians, we as physicians, is if we're putting in a code, there's all these modifiers that we've got to use. Any great secrets, things that we should let all of our listeners know. How do you make those modifiers work so that you get the absolute best benefit from the coding you've done? Yeah, that's a great question. And I would say modifiers are probably the one thing that really trips up, especially our newbies, you know, when we're doing our kind of onboarding, you know, with our new staff or providers. You know, I think that for what we have done, which seems to have worked, and I think most systems have that ability. And ironically, one of the things we kind of uncovered during this whole, you know, evaluation process recently was that our system wasn't set up correctly for the 50 modifier, which is a bilateral. So the way it was set up, it was requiring that the coding staff or the charge entry staff was remembering to go in and change the fee to 1.5 times. Well, when you're in 10,000 plus, like that's going to not occur, you know, all the time. And so we went in, reset everything up. So for example, 20610 for an injection. So we entered into our fee schedule, 20610 comma 50. So the charge went in with the modifier at the 1.5 amount versus relying on the clinical staff or the provider or the coders to remember to change that. So it's really, there's a couple of common ones you're going to use, but just the education. And that's really where we strive is to educate because I had yesterday, I had a PA reach out and say, I can't, the modifier is not taking it. I said, well, it's because you're putting it on the E&M code. It's not going to go on the E&M code. Oh, okay. And this is somebody that had been there for, in practice for five years. So it's just a constant education. Like it, you know, and just kind of reminding them. And so that's why we provide feedback on a monthly basis. We do an audit internally and say, okay, you're, I'm having to correct Dr. So-and-so's modifier every single time. It's probably time to sit down and have a little bit of re-education with Dr. So-and-so to make sure that doesn't happen again. I think as providers and physicians, we can all have ongoing learning regarding that, the dash 24, the dash 50, where you put the code. Those are all really important. And I've got to tell you, I'll speak as an orthopedic surgeon. I can talk for hours about the most complex orthopedic procedure. You start talking about modifiers, I start to get glassy-eyed and I need to have guidance and we need people like you in order to make that happen. And that's a great story, but all right. So we've now learned about dash 50. That's awesome. That's awesome. Well, and I think they really, I think it's probably getting a little better, but they just, in my opinion, I don't think that enough time is spent even in like, you know, whether it's residency or like just during the training with physicians and even PAs and MPs, you know, that's maybe like a half a week or a week of a training. That's a big part of your practice, whether you're in private practice or not. And knowing how to document, knowing how to, you know, code correctly. It feels like it should be a little higher up in the, you know. You know, one of the things that I've always thought about is that, you know, surgeons will do a surgery or, and they'll put in certain codes. How often in that situation to you on the business side, the billing side, have to look at that and say, hey, is what you are coding or asking to code for in the operative note? How often does that have to change and how do you approach that? Now that we are with this new company, we actually get feedback immediately to the extent where they, because they know that the surgeons most likely gonna say, well, how do you know that that's right? This is, I think it's right. So they will go to the extent of putting a red box, typing in in red, in order for you to be able to build this, you would have had to have done this. You may have done that, but you didn't put it in your note. So if you did that, then add it and we can actually code what you had on your, so for the ones that do their own coding in the OR and put it on the op note, if the company does have like a disagreement, they will provide that feedback to the physician and say, it can't be built like this because of this reason, unless you actually did that. And if you did that, I'm gonna need you to amend your note. And that was such a positive shock to the physicians because they just weren't getting that before, that it only took about one, I think there was one in particular where a surgeon was like, well, I did it. I don't wanna go back and amend it. So next time I will. And the response back was, well, unless you amend it now, I can't do that. And they did it and we haven't had an issue since. So it's kind of the show me state, right? Missouri, you gotta like show me the proof. So, but they feel much more confident in what we're doing now because they're getting that feedback and we're not running into situations six months down the road where, oh my God, 400 claims didn't have the AS modifier. So you're creating an environment that is both financially sound. Yes. And at the same time, it's an ongoing learning education experience. Ongoing, and it will never stop. To me, that's a win-win situation. Yeah, yeah, definitely. Angie, you talked about the importance of coding and looking for that outside company to help you maximize your revenue and maximize the success of your practice. Some people may think that coding is just coding, but tell me how important is it for orthopedic coding specifics when you're looking for a company and how does one stand out from another? It's extremely important. We did not wanna be in a situation like we were with our previous company that we utilized. So for me, I was looking for a company that had a long history of being in the coding business with specialists in musculoskeletal because orthopedics really is kind of a beast of its own. And we were specifically looking for a company that not only internally had the knowledge, but had the ability to relay that information and educate. And for us, we have internal certified coders, but they had no experience with surgical, great with E&M. And so we didn't feel that it was smart to try to force the hand and say, okay, well, you're a coder, so you should know how to do this. It's not the same. And you do need a lot of experience and multiple years of looking at just orthopedic surgery reports to really be able to fine tune that skill. So we looked at several companies and then once we kind of narrowed it down, reached out, like I said previously, to current clients and got nothing but positive feedback. So I think we made pretty confident in our choice. All right. So expertise in orthopedic specific coding importance and just as important is the ability to be able to educate your practice and your billers and your providers to maximize your return. Absolutely. The reason we're in healthcare practice, we want patients to have great care. We want great outcomes. The only way you can do that is if you have a financially successful practice, which brings up another, I think, important point. We know that for any episode of care, there may be multiple ways of coding it. Some of them are more efficient, some are less, some are gonna have higher reimbursement. So the big question is, how do you do coding so that it's in an honest, fast, and a cost-effective manner? Because I think that sometimes could make the big difference between a successful practice and one that is just barely getting by. I'm lucky from that standpoint, I've got some physicians that really want to do it well. But for us, we made the decision to outsource that. So to kind of remove the person that's going to get the reimbursement, kind of detaching that a little bit. So they didn't have, it wasn't quite as easy for them to, not that they, I don't think that they would, but I have been in practices where some of the surgeons have tried to intimidate the staff by saying, I'm the surgeon, this is what it has to be, I don't care. And that doesn't work, that does not work well. And so I just didn't want, with a group this large, and with this many encounters, we just felt that that worked best for our practice. But again, making sure you have the right company, vetting them, that is key, because six months ago, we were in a much different situation with the company. This is a great story, and it sounds one of success. It's one that is upwardly mobile. Yes, we're getting there. I've got to give you a great credit for helping to lead the way. And I think that coming to a situation where there are challenges is really difficult for an awful lot of people. And I think that the good support is important. I think you talked about foundation. I think you talked about finding the right people is so important. Having your surgeons and your physicians believe in you so that it's all a common effort, and that team effort. And what I think you described is great team work together to produce the best product, to produce the most financially sound organization. And this is really, really compelling. Yes, we have a few things, not quite perfect yet, or probably won't be perfect, but we're not quite where we want to be yet, but we're definitely getting there at a much quicker rate than we were. And the light is much larger now and brighter at the end of this tunnel.

orthopedic practices

revenue cycle management

orthopedic coding

financial stability

teamwork

management improvements