We have a really great CFO that we share with our surgery center, so he's half-time for our practice and that each practice I know, especially me, we all different sizes of practices from one, two physician practices up to practices that are double, triple the size of what we are. And so I know that not every practice can afford to have the scale of leadership members is what we have, but having a CFO that is strong certainly helps a CEO, revenue cycle director, and our entire leadership team that may not be financially versed. So as I was putting this PowerPoint together, I thought, well, you know, being humble is important to me. I think most members of our leadership team are very humble here. And so I thought back on my career. So I've actually been in healthcare for 20 years now, which is a little crazy to think about myself, but, you know, there was, I can still remember the days of my first professional level job when I literally asked my leader, you know, what does it mean to par with an insurance company? I think that word par had me confused. What is an RVU and how do you achieve RVUs and all of the acronyms that come along with healthcare and those that are finance related. And I call that out to say, we've all started somewhere and none of us jumped into our roles or the industry knowing everything that we know today. A lot of those things are things, you know, you learn once, which I understand an RVU is, and I've known that right from day, from that day on. And so financial acumen very much in my opinion is the same. So I really liked the picture there of, you know, how much we learn from theory, from practice and from mistakes. So the fact that myself, Lisa and others, you know, don't have, and maybe many on the phone, a formal finance degree or not a CPA or come from a formal finance background by no means does that mean that you can't understand or can't, you know, know enough about finance to be successful and help run your organization. And so I always just pull it back to, you know, we are constantly learning, constantly investing in ourselves. And that was a piece that I took seriously probably five or so years ago. And I wanted to know more about the finance side. And then I sought out some certifications. Mine particularly were through Healthcare Financial Management Association, HFMA, and achieved the certified healthcare finance professional certification, as well as the revenue cycle certification, because I wanted to know more about the healthcare finance arena, because I know it would help me in my future career as well. So obtaining those certifications was important. Investing in myself to learn more about finance was important. And as I mentioned, at that time, I was at a large health system and the thought I really knew the ropes of the healthcare finance arena. And then jumping into a private practice, you're really put on top of your head. And it's, you know, very different and much more complex at times, it feels like than working for a large system. So Lisa and I were actually joking before the webinar that the finances of a, you know, 20,000 plus employee system actually sometimes felt easier than a 26 position practice, just with how complex we can make ourselves at times. So when Jessica from AOE first talked to me, she kind of said, go through just our tactics, the things I do, the things I track in the how I keep finance front of mind for me. So expenses, of course, expenses and revenue are our top two topics and tactics that I personally use at OEM are really I have tried to embed myself into our practices, financials as much as I possibly can. Likely to the point of nauseam for some of my team members and for my controller, but again, I am first year for my revenue cycle director. So I'm year one into my the CEO position here. So I need to know intimately where all of our money is going, because ultimately, who are the physicians going to come to and ask those questions and who do they expect to have the answer is me. So I look at all of our outgoing expenses. I sign all of our invoice checks. They by the time they get to me, luckily, I have a great team of leaders who have reviewed and approved those. But it's very important and has been quite telling to even understand, you know, working here for a couple of years before being in this position of not even understanding sometimes how the financials add up and how much we're spending on certain things. So really just embedding yourself at all levels of your organization's expenses is really important and consistently reviewing them regularly and again and again and again. Another tactic that I've liked is really benchmarking to prior years. So working with my finance folks here, how much should we spend on marketing in 2022 and 2021 and 2020? How much should we spend on community engagement resources of sponsoring local teams and whatnot in the past five years really to see how are we trending? Are we trending at the pace that our organizations are growing? Are we going trending too quickly? Are we overspending in areas? And so really benchmarking internally has been helpful and then also benchmarking externally, which I'll talk on here in a moment. Understanding your spend is critical and really I think of a non-finance leader of how do you break it down in ways that you can understand? And so our reports very much call out salary and wages are a bucket, depreciation is a bucket, our equipment, IT supplies. In one piece, and I made this a little bit bolder, is really your vendors. So, you know, we all have contracts with vendors. Our vendors are very important to us and they help us get a lot of our work done. But understanding what your contract actually is and when you have changes that may impact that contract, it may impact your spend for that vendor. And an example I'll use that actually recently I was looking at an invoice from a company that charges us by a physician that we have. And so, as I mentioned, we have 26 physicians. And on this invoice, we were getting billed for 26 physicians, but it was actually for MIBS. And so I looked at that and thought of our 26 physicians, there are seven of them that we don't do any MIBS reporting on. They are either contracted out to another organization or they're anesthesiologists. And so had I not, you know, combed through that invoice and gone, OK, I understand our contract is that they charge us by physician and I'm mirroring that of the contract. And now I see the invoice and knowing that the product is for MIBS, I was able to push back on that vendor easily enough and say, hey, this is too high. We don't submit MIBS for 26 physicians. And they were able to change that. And so that's one small example, but it's an example of how you have to manage your expenses and how in the weeds at times you really have to be if you feel you don't understand them today. And I put on here kind of back to the humble piece, you may be uncomfortable. There are days I am super uncomfortable with some of our practices, financials and having to look at them and having to pull some layers back. And you may learn things you don't want to learn, but it's all relevant and important. So knowing your expenses is key. Oh, and I thought this was a great image because this is truly, I think, what my physicians think I do and when I'm back in my office and in my spare time is they think I just, you know, either throw the money out the window or burn the money or what have you. So that was a good picture. Revenue, I will talk about a couple of highlights here and then leave some of this for Lisa, you know, we really have to understand your revenue cycle functions and where your revenue is coming from, looking at your payer contracts, remembering underpayments and when a payer tracking on when a payer is not paying you to the contract happens more frequently than you think, looking at your ancillary revenue sources and by ancillary, you know, we've had a mindset change here. You know, of course, that's DME, PTOT, urgent care. But then what other ancillary revenue sources are out there that may not even be in house? So looking at, you know, third party vendors that may have a fitness or health program that you just refer patients to, but you can still make revenue on. Looking at real estate ventures, I'm sure many of your physicians and practices that are practices are involved in, you know, what real estate do you have and how that can be ancillary revenue to the physicians. Looking at your quality programs and especially preparing for more value based care and kind of making sure you're projecting of how much, you know, of our spend and revenue is going to become value based in years to come and really understanding, you know, the impacts of BPCI, the impacts of MIPS and how that can drive your revenue or unfortunately sometimes not drive your revenue. How how your operations impact revenue, this is a big bullet point for me being an operations minded individual of how all of the activities that go on at your practice really impact your revenue from the injections or, you know, special things the providers may be doing that they don't know we can build for or that we don't even know they're doing, all the way down to how the staff and leadership think that we can become more efficient or capture more revenue. We have an example of that. We have a very strong DME coordinator here at OAM who revenue, bless her, and expenses are always a very front of mind for her. And she's always analyzing every product and the reimbursement we get on each of those. And so I can confidently say in my position that I know in our DME space, we are maximizing our revenue. And so getting your leadership team involved and figuring out how each facet of your organization touches your revenue is important. And to the point of, you know, having your leaders engaged on staff and revenue opportunities, and then really if you're able to having focus and accountability in all areas for revenue. So I'd mentioned really being embedded in your financials, and it's an ongoing, constant focus. So as an individual, I'd mentioned at the beginning, you know, inquiring financial acumen isn't always as easy as what some may want it to be. So looking out there of what educational opportunities are out there for you to understand health care finance more, different types of certifications or mentorship from someone, even through AOE of someone that is highly skilled in finance and someone you want to learn more from. And then always utilizing external resources, you know, CPAs, your financial firms, anyone tax skilled. I actually was having a conversation with my CFO last week. I mentioned it's a very great CFO, but there's so much about these tax laws that will almost break your brain. We are expanding our surgery center. Just a quick example, we talked through and we talked about physician parking spots. And so right now we have a parking nightmare here. But once the surgery center expands, it's open a lot more parking. And some of the physicians said, are we going to have those set spots set aside, you know, that we had prior to the construction? And my CFO actually said, you know, I was talking and I will say I don't understand the details of this, but he was talking to one of our external firms who said, well, if you actually label the spots as physician designated parking, there's some financial and tax impact on the backside because we did that given how much space we're allocating to our building. And so there is so much and it's so ever changing that you really need it. No one will ever know all of it. Right. So you really need to use your external resources when you can and when you need to, because there are people out there that keep up on these things. There are tax experts or, you know, financial gurus that this is what gets them up in the morning. Again, I'm an operations person at heart, so it's not necessary that we get me up in the morning, but those resources are necessary to help us be successful. And again, I mentioned a little bit of understanding your practice operations impacts on your financials. So again, being operations, I feel, you know, I sometimes know or can identify ways that we can be more efficient in the practice. Right. So how can I add value? Well, some of that could be through understanding which physicians need to go to which locations we have or how do we make the workflow in the clinic more efficient to see potentially a couple more patients or how do we market and shift our payer mix in a different direction so that we're obtaining more commercial payers? So. Every piece, you know, every individual in the practice from the staff level to your leadership team has an impact on your financials and getting them engaged is only going to help you. Reporting is a critical piece of actually understanding your financials. So when I was talking to Jessica, you know, I was thinking about, you know, what are the financial reports that I look at and how often are those looked at? Something to ask yourself, you know, who else is reviewing or analyzing your reports? Are they actionable reports that you can take action on or is a report just informational, something you should review? Really want to make sure you're not getting report fatigue is that, you know, as I get I can't tell you how many when I come to work, how many emails I have in my inbox that are automated reports from either a phone system or a finance system or you name it. And so sifting through those to see which of these have a nugget of information that I can actually act on is important. And also when you build a report, who's the who's the audience for the report? So who needs to be getting this report? One and non-finance reports, but a report that we have or have at OAM is a discharge report from our hospital of the patients that were inpatient the day prior and when they were discharged. Well, coming to find out recently, we were sending that to scheduler so they could schedule the patients in to come in, but we were not sending it some of our revenue cycle staff. So always looking at a report to say who's the audience and who needs to be getting a report is important. For myself, I look at a weekly snapshot of our financials, and so that's an Excel sheet that has all of our financials broken down that I review weekly. We have a weekly snapshot of our revenue cycle that I review. Of course, I review monthly physician financials and monthly revenue cycle scorecards. When it comes to month end, it's ad nauseum, you know, that last week of the month we're reviewing. I'm even getting into the detail, which Lisa hates, but in our EHR of looking at what all is left in the EHR and what needs to go out. So that's always a big push. And I'll also say in this presentation, please know we have a ton of room for improvement still at OAM. So I'm talking on these, you know, these reports and, you know, the things that we do, and we still have lots and lots of room for financial improvement, as I think most all practices do. And so by no means is any of this, you know, the perfect way to run financials for non finance individuals at your organization, but really just a framework on what we do and how we're trying to get improve as much as we can. And then benchmarking, right? So AOE obviously has benchmarking tools. You're likely are members of other organizations that we frequently are that have benchmarking to see your salaries and wages compared to other organizations, your position compensation, your rent and facilities. And so using those benchmarking tools to understand where you're at geographically, you know, within your state, within your region, so obviously Midwest for us. And then looking at those against other like orthopedic practices is important. And those are important for kind of on two sides, A, for me to understand how we're doing, but then B, when I bring data to the physicians to say, hey, we're actually outperforming other areas in this, outperforming other practices in this area, or hey, you know, we have some room to grow here in this area compared to our peers in the industry. So external benchmarking is always really good to help drive decisions as well. I wanted to give a shout out to some of my team under leader and staff engagement. So honestly, I can only know so much. I can only do so much in a week and in a day. But I know that my team likely knows more about my practices spend in certain areas than I certainly do. So getting your team involved is really important. I actually sat down with all supervisors and up earlier in 2023 and said, hey, you guys, we really need to look at some cost measures to make sure that we're managing our spend as best we can. And from that one meeting in my one ask, I had emails in my inbox by the time we got back to my office from supervisors who I don't even interact with on an overly frequent basis with their ideas on how to reduce spend. And so I thought, well, this is great. You know, I just had to ask the question. And my leaders had ideas. And so we ended up having over $500,000 in erroneous spend reduced or by attrition of certain employees that we realized we didn't need after they had departed. And that was just from simply asking the question and saying, hey, you guys, I'm, you know, trying to be humble here. I need everyone's help with managing the financials of the organization. And the lead, the staff and leaders felt engaged with that. They were following it with me of, hey, did we change this vendor? Did we switch to this, you know, different water bottle even? Did we switch over to, you know, this, the standard form for ordering office supplies? And so I think you'll find that a lot of leaders in your practice have great ideas. And sometimes it just takes asking them, what's your idea? And you can actually get a lot from that. Our physician financials are distributed monthly to the physicians. And so knowing what they want to see, of course, is important. And this is a quick snapshot of what all we report on the physician's financials. So we start with their revenue, which includes their billings, their adjustments, refunds, and then also a section for their other revenue, which is their call revenue, BPCI, teaching revenue, to bring them to their total revenue. We then have their expenses, which, you know, hollows out usually our bigger buckets are transcription, malpractice, drugs and medications, their collection expenses, and then allocated expenses of salaries and wages, payroll benefits, what have you, to get to their net practice income. So we take the revenue, obviously subtract the expenses. And I, we attempt to get these on one page, they're about a page and a half, because we want these to be digestible for the physicians. And then I'm sure you all have them in your practice, the ones that will come find you after these are distributed to talk them through further. Then we of course have ancillary income, and we do the revenue expenses in this category, of course, for their APPs, x-ray, DME, PTOT, and urgent care, which then brings us to our net income for their physician expenses, as well as their overhead percentage. I didn't think I would, I originally thought I'd like to get through this presentation without saying the word overhead, but I had to put it on this slide because I know we all hear it way too often. And then we have the individual physician expenses of, you know, their salary, their payroll tax, their insurance, pensions, and dues, which comes to their net income, hopefully, or their net loss. So I actually put the slide together this morning because I thought, well, this is something to show you the things that we distribute to our physicians on their core financials monthly, because I don't think sometimes we compare those enough, but these are the categories that we report on and our physicians are engaged in seeing. And now I'm going to hand it over to Lisa to talk a little bit on that revenue side of the bucket, which is obviously just as important as our expenses. Hi, good morning. Revenue cycle for me and our practice consists of coding AR, both insurance and patient authorizations, credentialing, payment, we do have payment posting. I don't have front desk, but I do collaborate and partner very closely with our operations director. I will say, and I always say this revenue cycle is a team sport. I can't do it by myself. I rely on provider engagement, operations, the CEO engagement, which be careful, which teacher CEO do I see uses at the end of the month, which actually I joke about that, but it really is great. Our system is really terrible. We're going to Athena in April and we have three different systems we're working on right now for PT, orthopedics, billing, and it's a nightmare. I think the importance of pair relationships is, needs to be focused on as well. Knowing people we work in a small enough community where everybody knows everybody eventually, especially when you've been doing this for 25 years, having those contacts, helping you resolve issues. It's interesting. We recently had an issue with Blue Cross here locally, Blue Cross of Michigan, and they didn't have a way to calculate interest, even though it's a law that they have to do that, but we got $15,000 just on interest from claims they had not paid correctly. So that's important. Like I said, our systems are terrible. So when it comes to the end of the month, my billing manager, who is phenomenal, thank goodness, and Jeff are checking probably five or six different ways to make sure we've not missed charges and that the physicians are where they need to be. Transparency is incredibly important. Even if it's something you don't want to be transparent about, you do not want your CEO, your CFO, or your providers to have surprises at the end of the month. We focus on high dollar, especially at the end of the month, getting all the high dollar stuff in. We focus on any missed surgeries, which I'll get to that in a minute, and especially with authorizations, patient communication, and the estimates that you can give them, and transparency is incredibly important. They'll be very forgiving if you've communicated with them throughout the process. So we brought together, when I first started four years ago, our office scheduling team was doing authorizations, and we realized through reporting that there was a lot of denied authorizations and surgery still happening and writing off of those surgeries. So we brought a group of four people at that time together to do the authorizations, and I have seven now doing authorizations. I run weekly reports and partner with the hospital to make sure that if it's an inpatient surgery, it's authorized as an inpatient surgery. Otherwise, they don't get paid, and we want to have a really great relationship with our hospital. This is all manual at this point, and it takes a lot of time, but well worth it to avoid any missed surgery authorization, so you don't get paid. And we often, though we don't like to do this, we'll cancel a surgery to make sure that we don't have a surgery happen that's not authorized. I don't have a good reporting system with authorizations. I don't have a good reporting system with authorizations. I cannot track how many they do unless they do it manually. I am very much looking forward to Athena when we can track that. They work, I'm very thankful of all of my teams, and probably most importantly, authorizations that work very closely together and communicate and help each other. If somebody's a little behind or somebody's out, they are jumping in to help each other, and pretty much most of them are all cross-trained on all of that, which is very helpful as well. We have, when I first started, we started some career ladder planning, and I think that our team, especially Revenue Cycle from the front desk, even though my operations manager wants to kill me most days, they transition over to authorizations or they transition to AR, and we're very thankful for that. We're thankful and think that people actually stay because we have career ladders. They learn from each other. They provide incredible insight, and we think it's really important to our employees to invest in them and provide that. I do hire from the outside and have hired new AR people recently, and having strong AR people has really shown in the money that comes in at the end of the day. I have hired some people that weren't strong, just to be clear, and it makes a huge difference. So, I've talked about transparency and how important transparency is, and I started these physician scorecards, which are on another slide, and I keep adding to them as we go each month, and we started very basic with just charges, AR, and payments, and it's just simple. It's only from a revenue cycle perspective. It doesn't include all the stuff that Jeff was talking about on his slides, and really got our physicians engaged in the process, and I'm always happy when they're emailing me every month and saying, okay, this doesn't look right, and because it's a manual process, it takes me a week to do them. I may forget to include an office, which I did last month, and Dr. Hawkins said, my EMGs don't look right, and I'm like, oh, my gosh, it took me about 20 minutes to figure out I hadn't included the other satellite office he goes to. So, I'm always thankful when they're talking to me, engage with me, asking me about them. They will now ask if I'm late, where they are, which is very nice. We never had this before. I don't know if it's ever happened before. I believe they have gained trust, although I will say it was a very rocky start. So, when I first started sending the scorecards out, I had a physician that said, these numbers don't look right. My surgeries don't look right, and sure enough, they weren't right. What had happened was when they were on call, and they were at one of our other hospitals, they were, he was faxing in his sheets showing who he had seen while he was on call, but they were going to people that were no longer here, and so those surgeries were missed. We were able to audit, which was a huge undertaking, and I don't even remember at this point how many surgeries we found, but found the surgeries, improved our processes, and as hard as that was, and as terrible as it was, it made us better, and we would have not gotten there had we not started with the transparency. I then started adding detail to their scorecards. I tell them if they want, some of them do, and some of them don't. I tell them exactly what surgery we coded, what the CPT code was. I tell them the number of EMGs, the number of injections, because these are the big things to them, and then I just give them their other, the office E&M coding, and x-ray, and DME, as they, and they can see this month over month over month, which helps us a lot, so I know now very well where I think one doctor should be, and one isn't, and so at the end of the month, if they're not where they're supposed to be, on top of Jeff emailing me five times a day, we're really tracking on those physicians, and we can go to the coder and say, focus on this doctor, or focus on that doctor. They really need it, so that's been very nice, and I'm very proud of those, especially given the type of system we have, and the type of reporting we have. We basically had to build those from scratch. I'll say Lisa's revenue cycle scorecards have helped out on the finance side as well. We had, our financials were a little delayed about a month or so ago. Our CFO was on a much-needed vacation, and I said to our executive committee, I said, you know, financials will be coming out next week. They're a little bit, a couple days late compared to prior months, and they, the response I got back was, oh, well, that's fine. You know, Lisa gets hers out in the first week of the month, and so we know where we're essentially going to be, and so it made the core financial statements not as surprising, of course, but it also made it so that, while they're still very important, that the physicians are much more comfortable knowing immediately, you know, between the first and fifth of the following month where their charges and payments landed, and put them immediately at ease, or engage in some of those discussions, instead of waiting until the 20th of the month when we're looking at other financials, and we have already lost a month, so they've been a really good win for Lisa and her team. I will say also, you guys, and I don't know if my email's out there or not, I love talking to other revenue cycle leaders. I would love watching the AAOE board in questions. I learn a lot from you guys, and I'm happy to share whatever I know. Our practice management system is from the Flintstones, and most people don't even know what it is. It's called CGM, so if anybody else happened, the one other person that happened to have it out there, I'm happy to talk to that, but we all learn from each other, and it takes a village to be successful at this job, so please reach out. Reach out to your counterparts. I do all the time. This is a sample of our scorecard. Again, this is the front page, and then the role labels on the bottom right are what's in the detail, and then I will add the patient detail as well, but it's a great snapshot from them. A lot of them, just like looking at the main page and not getting into the detail, it kind of tells them where they are and how they're trending, and I love when I see a physician trending higher in both charges and payments. It means we're doing our job, and I think it looks nice for them as well, and they appreciate it. I can also give them a heads up, and I can look into why they're low before they get their financials and help Jeff, and Jeff helps me with talking points, so that's very, very helpful to, again, cut off some of the anxiety that a physician may have if he has a low month. And that does bring Lisa and I to the end of our presentation. I don't know, Jessica, if there's questions in the chat or other questions individuals may have for us. Yeah, I think there was one that came in the chat that Lisa answered as a part of her presentation, but for anybody else on the call, please do feel free to drop questions in the chat while we've got Jeff and Lisa here. I can track coding pretty good. I can definitely track that. I'm not able to track authorizations. Our denial reporting is horrendous. I don't track AR staff productivity very well, just to be completely honest, and again, I'm so thankful for a new system coming in April, which I've been begging for probably at least the last three years, and we looked for one for two years for anybody out there looking, which I'm very thankful we're starting a new one. Yeah, I think Lisa made a good point earlier that AOE is a great network. You know, we probably have run into many of you at conferences and whatnot. We, our search for a new EHR and practice management system did take us around two years because we vetted a whole handful of groups, many on-site demos, and so if there's any questions on that, we'd be happy to, you know, share and talk with anybody, so don't hesitate to reach out to either of us on any of the topics that we covered today or on your EHR and PM search, or if you think there are pitfalls we may run into with Athena that we should know ahead of time, please also reach out to us to help us out from that standpoint as well. We know none of them are perfect. Somebody's asking about our third-party audits. When I first started, I had somebody audit the billing and coding team. We didn't have PT at the time. We are actually bringing in somebody to audit the PT OT for lots of reasons, not just billing and coding, but lots of it just because we are so new to it, and the faster we grow and the bigger we get, that's really important to us. Athena is only taking over a little bit of our billing, so they will take over the payment posting, and they do first-pass denials. We're still doing a majority of the lift on that, which I know is, some people think they should do all of it, and some people think they should do none of it, and I kind of, I was struggling with it at first, but I got to a happy medium knowing that they're going to do just a portion of that, which I think will greatly help us and allow us to use some of these people for other functions within the office as well. All right, any other questions from the group? The, oh, it looks like we have one. Regarding Athena, reach out to Sam Williams, CEO of MidAmerica Orthopedics. Awesome, thank you for sharing that tip. Thank you. I will say, I don't think there's any perfect EMR. We do, you know. If anything's better than what we have now, I will say that. Anything's gonna be better than what we have now, but I'm sure we all know there's nothing perfect. All right, well, as we come to the end here, just wanna thank everybody so much for coming, and especially thank Jeff and Lisa for putting together a wonderful presentation here. It was really insightful, and I think great to hear perspective from somebody who is, you know, coming in, learning the systems, and also working through challenges, because I think that that's something that's very relatable to everyone within AOE. I think everybody has, you know, challenges, and like you said, there's no perfect one solution for anything out there. So what we'll be doing now, oh, it looks like there's a couple more. Emily said, recommendations for a company for AR audit. Does anyone have something they want to recommend? AR audit recommendations. No, I don't have any, but that would be, that would be good if anybody else did. Good point on the zero payment, too. Somebody had mentioned that to me, and I'd forgotten until you just said that, so thank you. Christine. So what we're going to be doing now is just opening up a breakout room for networking. So if you're interested in continuing this conversation and talking a little bit more about this topic, feel free to join us. I am going to open it up here, so you'll be able to see room one. It is open now, so feel free to jump in. If you aren't joining us, feel free to check out this presentation on the AAOE Learning Center. The recording will be dropped in there, and we'll be sending that over to the registrants after the webinar. So thanks again for joining us, and looking forward to seeing everybody the next time around. Thank you, guys. Thank you.

financial management

healthcare practices

transparency

engagement

continuous learning

expenses tracking

revenue cycle functions