Thank you for joining us for the financial impact of injections in your practice webinar. If you ask me knows to get started, all attendees are in listen only mode. We will be using the Q&A function today to gather questions for our speakers. We will not be using the raise hand function. Please submit questions through the Q&A and interact with other attendees by posting comments to the chat. When using the chat function, just be sure to select all panelists and attendees from the drop down above the message box before submitting your chat so everyone can see it. This webinar is being recorded. Please know we will be sending all registrants to webinar recording via email in the next couple of days. Our speakers for today are Joseph Matthews, Practice Administrator with Advanced Orthopedics and Sports Medicine located in Houston, Texas, and Andrea Allen, Clinic and Sports Medicine Director with Heartland Orthopedic Specialists located in Alexandria, Minnesota. Now I'll turn it over to Joseph to get us started. Thank you everyone for coming. As you saw, it's Joseph. I am in Houston and Andrea is all the way in the north. I'm in a private practice and Andrea is in a hospital setting. I was hoping that we can provide you different perspectives on the same topic. And I apologize in advance that this is a little more information than you probably need. But my gut reaction when this rule came out was anger, denial, all those stages that how can they force us to go into a loss. And as I started researching, I realized why we got into this pickle. And I thought it might also help you with your therapy when you understand how these decisions are made. So without further delay, let me start. This will take a little more than 30 minutes. So I hope that you have the time to stick around with us. So let me start with the average wholesale price and the This was what was used before 2005 for reimbursements. And this is what happens between the wholesaler and the retailers, what the wholesalers get for is the WAC pricing, which even today exists for the wholesalers, but what Medicare found out that this cost Medicare a lot of money. And between 2001 and 2004, Medicare Part B spending increased from $6.5 billion to $6.5 billion, which is a lot of money for the wholesalers and the retailers. Increased from $6.5 billion to $10.9 billion. And you think we are possibly not spending this much money on orthopedics. What I found in my reading is seven out of 10 drugs that are affected are cancer drugs. Unfortunately, they fall in the same rulemaking as in orthopedic drugs. And what the government accountability office found that private purchases received discounts ranging from 13 to 34%. So this model was definitely getting out of favor. So we went into the average sales price starting 2005 which was the drugs plus 6% Now, according to the Let's cue share the PowerPoint. I don't think they can Oh, I am not in share mode. I'm so sorry. There we go. I am so sorry that I kept talking. Thank you, Andrea. So this is what we were I was showing initially and this is the next one. Thank you. I was wondering why the thing was not moving forward when I kept clicking on it. This is the average sales price and what I put in red. It's, this is the dirty Underbelly of the of this beast that we will explain a little more. This is that is net of discounts rebates chargebacks and credits. So what was a good intention that it's cost plus 6% because they don't want you to make a lot of money on this boxes actually results in losses for a lot of people So this was how the game started AWP ASP and then several manufacturers figure out a way to cheat the system again. So what they did is they got the FDA to approve this go supplementation as a device and some of you who were part of this game, including me. Figured out how to jump from one medication choice to another. Because if you're a device, you did not have to report your cost and the margins on those drugs were much higher. So this created an unlevel playing field between drugs that reported pricing and devices that did not have to And unfortunately, what happened is one of this big manufacturers that was playing this game, which I don't want to mention names. Got their hands slapped because their CEO wrote a letter where they put their pricing net profits, everything in a letter to everybody and CMS lapped down on them and the same manufacturer realized that, you know what, if I can make money on this because they had to become a drug now. They realized that if I'm not going to make money on this, then nobody should. So starting 2019 they spent more than $5 million on the legislation that just passed making us all have to go to the drugs, not devices. So this is where advocacy comes in. I'm hoping that we all participate in advocacy and realize that some of these things that are happening on the back end are done by players that are much bigger than us and that we all need to voice our opinion. Otherwise, we will just be on the menu. So the level playing field started because of this Consolidated Appropriations Act that was going to be effective January 1, delayed until July 1. Because the Medicare, the MedPAC provided the report in 2017 saying that the lack of competition incentivized providers to use higher priced drugs, including, you know, I was also part of that whole crowdfunding campaign. So that was the whole process. What Medicare, again, Medicare is so big that the right hand does not sometimes realize what the left hand is doing. CMMI that does a lot of these cost saving measures does not know what the main Medicare does. The other concern that I have is PAYGO looks like it's going to take effect in January, and they also are under the same sequestration law. So now you will start with a 6% reduction on the payment when they're only going to give me a 6% bump on the cost. And, you know, even though we are not MBAs or big time financial officers, we can understand that that would always start off in a lost situation for us. And then there are the dirty secrets of rebates discounts where you truly will not get what the ASB says, because you're having to pay much higher than the ASB, and you will see in my chart that I won't name the drugs but some of these drugs start off at $100-$200 loss fee. I'm also going to put some upcoming changes because I don't know how this is going to affect us. There was another law that was passed. It was probably August that it was signed, the Inflation Reduction Act, where the federal government can negotiate prices for some covered drugs in Part B. I don't know how it will affect us yet. The other thing that it requires is the drug companies pays Medicare rebates. No one's talking about paying me rebates. So I, as a provider, I'm forced to buy and bill in Medicare. So Medicare forces the providers to buy and bill patients that said that they can go as a provider to do this injection. But if Medicare gets the rebates, do I have to pay higher prices? I don't know yet. And I, you know, I tried to put all the references on the bottom so that you could go and check these out on your own. So this comes to rebates, I had calls with several big manufacturers, distributors about how this works, because in my mind, I thought it was illegal. Because my understanding, which was verified, is that some of these drug companies are paying up to 80% rebates to private carriers to be on the tiered preferred list. So then my thought was, okay, as the patient, he's the patient is paying copays, the employer is having the cost. And the insurance company has a fiduciary responsibility of making sure that they adjudicate the claim properly. But if they are going to force me to use a higher price drugs, and getting, in my opinion, a kickback on the back, back end, I'm sure there's legalese for all of this. But if that does not trickle down to the patient or the person paying the money, I thought that was wrong. But that is how rebates apparently work. And when I researched more, I found that the FTC has actually a policy that they just released in June. And here are all the laws that could be violated. But I wondered, I'm wondering why someone is not taking action on it, because a lot of these drugs that are being forced upon the people are higher price drugs, because they are the ones that want to pay the rebates. So if you can, like these, these are all these will all be available for you. So these are all the acts that I think are getting violated. But these are things that I'm sure advocacy council or legislation is looking at, because the FTC, all of these people are starting to look at this, because they are seeing costs going out of hand. I found this really good graphic on how the money flows between people. As you can see, the plan sponsor keeps paying, the employers keep paying, but they don't get anything in return. The beneficiary might get something as a copy assistance from the manufacturer through coupons. But if you can see that all the money is going, it is going to the pharmacy benefit and the health plan. I'm sure the wholesaler manufacturer gets a part of it too, but the people paying the money are the ones that are not getting anything in return for all the rebates. What I thought was sad too is the pharmacy benefit managers, which were created out of the thought process that, oh, you know what, the manufacturers are going crazy, they're raising the prices. Of course, these were in relation to lifesaving drugs like insulin, that pharmacy benefit managers would try and reduce the cost. But unfortunately, they have found how much money that is in the system that can be made, that they have also joined in becoming part of the problem. And as you can see, the number of drugs that are excluded have risen so rapidly, because only it's a pay to play for the drugs that are willing to pay the pharmacy benefit managers and health insurance companies the rebates. So where does it leave us as providers? You know, the manufacturers and their reps that come into our offices, these are some of the arguments that they give me when they say why I should use their high priced drugs. And I don't know if anyone has heard this, but the only time I've actually kicked a vendor out of my office is because they made the one statement that says negotiate with your billing company to waive their fees, because it was so blatant to me that they wanted to keep the money, but they wanted me to tell my billing company, which I had no control over, to waive their fees for doing work for me, which I thought was unreasonable. But these are some of the other arguments that I've seen. So this is what you were waiting for. And this is my process. So when any drug company manufacturer, when rep comes to me and says, hey, you will make so much money, here is what Medicare pays you. So I tell them I have a spreadsheet, which on the right side, as you can see, there is the actual spreadsheet, but there's formulas in there. I calculate the actual payment, and I tell them I don't control, and this is all based on Medicare initially, because in Houston, I don't know about the other cities and states, a lot of the payments are based on Medicare. So I actually have one insurance company that pays me less than Medicare. So you can guess how much I'm making on those. So I try and figure out what the actual payment is, which is, I look at sequestration, I'm going to look at pay-go as my actual payment, but I also look at many, many losses. And I don't know if you're looking at this, but a qualified Medicare beneficiary is someone who has Medicare and Medicaid. And maybe it depends on your state Medicaid, but at least in Texas, the Medicaid states, oh, you've got paid enough from Medicare, we're not going to pay you anything. So technically, those patients, I get nothing for the 20%, and I can't collect from the patient. So what I do, as you can see on the right side, is Medicare, 85% of the volume on Medicare, I get what is less on sequestration. And this is an imaginary drug, I won't tell you the name of the drug, but I'm sure you can find out based on the cost. The many, many, 15% of my patients, I calculate what I actually get. And then I get a blended reimbursement that I calculate for the 100% of my population. And I add the billing cost, for example, you might have an EMR, for example, Athena, that is going to take its pound of flesh before you even see the money. You might have a billing company that you have to pay before you even see anything. So then I calculate the actual net, and I look at what is the boxes to recover. Which means that if I lose one box, which is going to happen, expiry dates, denials, how many boxes do I do for free before I can get it? Get back to zero. The closer to zero boxes to recover, of course, that's what I'm going to do. Then I also look at what are my fixed costs. I check the costs, but I also look at the reimbursements every quarter because those change every quarter. Some of them lag a quarter to what Medicare changes. I also look at shipping costs because you might have a vendor that taxing shipping cost of it. Again, you don't control that. But that, in my opinion, should be added. It's not a cost of doing business. Then I try to figure out, are there any ways for me to drop the cost? Can I get a prom pay discount? If I pay with a check rather than a credit card. So credit cards, I might get 1% back, but they charge me 3%. So I'm not going to do credit card on that one. So I'm going to try and figure out where can I get the best cash back to my company? I'll see if the tier pricing is reasonable because sometimes the tier pricing is so high, that I'll have to buy a whole amount of boxes to even break even. I'm not going to even try the product. As a company, then you need to decide, do you even want to control or include the cost of the employees? The collection fees, credit card fees, if a patient is paying for the box, if he's undeductible or paying 20% of the cost, then you need to decide whether you want to do that or not. that box and you're going to get charged 3%, 4%. That's again added to the cost that you have no control over. If you're having to pay statement fees for each of these, do you want to include that in your actual calculations? You can put that in your actual additional cost if you want. You can make another line to see what your actual net is and what your box is to recover it. And then never forget to go back and audit what your actual profit and losses. Because you might think this is what you're doing. You know insurance companies can pay you a different because of a glitch in their system. You might not be getting paid the rate that you're supposed to. Or of course there are denials. They might tell you you don't need off and then 50 injections later you realize, which I'm saying 50 because that actually happened, with an insurance company that forced us to use a certain product and said you don't need injection, pre-op. And then we had to involve the state societies to get paid a year later. So those are things that you need to always go back and check every quarter unfortunately, if you want to do this, if you're getting paid, if you're profitable. We built this grid which is posted in all the parts. We call the insurance companies every quarter to figure out what your primary injection is. We go back and we do the math and say, will we make money on this? If not, push it out of pharmacy. Some of these companies say, okay, fine, we'll give you this. We'll open it, leave it open. But the first time you have to do something else. So we will say, okay, first time we will send it out to pharmacy. If it doesn't work, then we'll do it in-house. We will only do this one drug now. This is what was done last month. I can tell you that certain medications went up in price, but the reimbursements decreased. So you have to be careful. This changes every quarter and margins might be lower now. And you have to do this every quarter, unfortunately. And I always put the date on the bottom. So my doctors, if they see that it is not updated in the quarter, they will ask me, what is it for this quarter? And what they will do is my pre-authorization department also knows this. So when they are asking for a certain med that is not on this grid, my pre-auth department has the authority to say, FII, you sure you're going off the grid on this one? Just a warning session to the doctor. And I'll let Andrea pitch in now. All right. So hopefully, as Joseph said, I'm coming from Minnesota. So I think what we've noticed the most was that regional settings seem to vary the most by your payers and your payers' requirements, more so than maybe the fact that I'm hospital versus private practice. And so you'll see my med list here is completely different than Joseph's. And that is driven right off of what our top payers are allowing. So we started this, I believe, back around 2017 is when we started seeing restriction of our big payers, only allowing the CINVASC-1 as it came available. And then we were able to use ZUFlexa if they had a rooster comb contraindication. So we've really bounced between those meds for the most part. Gel-1 came into the market, we had a payer that was paying or covering that, one of our bigger payers. Then on the flip of a dime, I believe it was actually this year, they no longer allowed that med. And so again, it was one thing where we were watching our inventory levels. Luckily, I don't keep a lot of inventory on hand. I think that's one thing that we would advise you to is watch your inventory levels. You really only need about a month's inventory at most on hand. So that way, as these changes can fly at you pretty quickly, you're not stuck with that overhead that now you do not have payers that are paying for it. Another reason to watch all of that is watching any contracts you have with the pricing on these meds. Because again, quarterly or annually, January is a common time, but July has also become a very common time. Those can just switch up on you. And so again, the meds we've selected or that we carry, I can't get it down to one here, but we typically have kept it always to basically three. I do have one payer that actually forces us to use a med that we know we're losing money on. That was a decision we made because that's a population we need to serve. I'm in a rural setting. And so again, all of this is payer driven. Next slide. So I'm going to take you through some of the other sides of getting paid besides just absolutely you got to know your margins on all of these meds. But the next trick that obviously has trickled into our lives in many different ways is that whole pre-authorization process. The documentation that's going to be required, it must be crystal clear. Know that medical policies can change, let's say one payer, depending on a Medicare product versus a true commercial. So you really just have to really know the different medical policies and who's giving that prior authorization. Know the difference of meeting medical policy when they may tell you no prior authorization is needed. Some will say yes it is, some may say no, no prior auth is needed. Don't take that as the woohoo pass go and keep going. Go back to make sure, see if they have a medical policy in place. That'll come into play that if you have a billing audit, you are by performing the injection, you are stating that you have met medical policy, whatever that may be, and then billing it out. So dollars can actually get taken back in that example. And then something a bit newer to this, at least in our market, is that those repeat injections, they're really starting to dive into some extra details, of course, of when we can and can't proceed with a repeat injection. Six months actually is a pretty standard time frame out there so far. But also make sure you have to have documentation that they had really from the last one. They don't just get to call in, show up, and say, hey, I'm here for my repeat. And so really know what their insurance company requires on that repeat, what kind of relief they need to have had for how long, in what ways they want that documented, increased activity, decreased use of NSAIDs. So again, it's reading those medical policies, unfortunately, to dive into all of this. The meds can change. Patients may have had a med last year that they really liked, and now that insurance company no longer allows that med. So having the conversations around, I know you had this one last time, but this year they're only covering this med. And so being aware of that also, not just repeating what they had last time. Patients changing insurances can quickly change the meds available to them. So again, having to just really, there's a lot of details that one has to really keep track of to try to make sure you're getting paid. In the frustrations of patients wanting that med they had last year or two years ago that's no longer paid, patients have said, I just want to pay for it. And so that's another piece to be ready for. And what processes do you have in place to offer that cash payment, making sure you get an estimate out to them, and making sure you're quoting the cost of that injection accurately. So next slide. So as I dove into some of the medical policies here, I'm not going to spend a lot of time on all of these, but I really just wanted to use them as an example of the wide variety that's out there. So this is just a CMS. Again, knowing that I'm out of the Minnesota area, there's a lot of meds they cover. They're pretty easy and just saying that the treatment must clearly establish or medical records should contain documentation that fully supports the medical necessity of this injection. So that one's not too bad. Their repeat is also pretty simple in that six months, that they continue to meet indications that they had significant improvement. And that the, again, making sure we don't do within six months. Next slide. So when you get to the commercial payers, you can have huge variability. And so another item is a commercial's actual medical policy versus a, let's call it prior authorization company that you may go through that has their own set of policies. Those can differ. So you really just have to be clear, you know, which policy you are standing to. But this is an example of one where watch your ANs and your BOLs. Patients are required. Some require therapy. Patients, there's a lot of education that goes into sharing with the patients that this isn't our standard for you. But for us to be able to get your injection paid for, your insurance company is telling you, you need to do PT. And PT is one that we get. Patients don't have time for it. They may, that's an increased cost just there for them going to four weeks of physical therapy. And then also, you know, again, which meds you can and can't use. Doesn't matter which ones they've had in the past. So go to the next one. Keeping an eye on what is needed for a physical exam is another piece that I would just highlight. Again, it varies. You know, I just had one the other day that said you have to actually got a denial on it and said you have to document bony enlargement. And right now, I don't know how we're going to document that in regards to OA. But that is exactly what it says. And that is their denial reason. So you just have to really read the medical policies to understand the denials. And again, repeat, know exactly where the repeat requirements are. Next one. And some of them are very complicated. I just threw this one on there as a, it's kind of an if, they're an and based on the meds. So they may or may not cover the requirements could look a bit different depending on what meds you're using. So it's, you really have to just read and look at each one of these as you go. Next slide. So when you're dealing with meds covered, not covered, you'll also have insurance companies that may state you have to use a specialty pharmacy, they will not allow you to buy and bill. So now we come into the terms of white begging and brown begging. This is another tie back to advocacy. As these, both these terms are at many state but also national levels on the radar of associations to just have awareness of and know that this is not ideal for us as providers. So white begging is when that specialty pharmacy is sending the med to the provider. Brown begging is when the specialty pharmacy will only send the med to the patient. Obviously, with both models, there's risks and concerns. And so what happens here is that they require the specialty pharmacy to submit the claim for reimbursement and to collect a copayment. And insurance companies will are mandating this in certain instances. And so then at that point, you can't bill up the med because you did you'd not buy it. And you're just billing out the injection code at that point. So really, you'll you're going to have payers that try to force this on you. And so knowing your risks is the biggest thing. Um, risks of the the med integrity, where's it been? Did it know depending on what part of the country and did it get too hot? Did it get too cold? The length of time it's it's been in any of those conditions, maybe it's okay for certain meds to to be in a certain temperature for a period of time, but not extended amount of time. You just don't know where this med has honestly been. Um, and then just the reality of the med on that med, that specific med with the patient's name on it actually being at the right place in the right time for it to be injected on that patient is just an operational headache to nightmare for you to keep track of. And again, who's going to be that responsible party? We had an example where we do not allow this. But we tried to make that one exception for the patient. And of course, that patient got scheduled not outreach location while the med was sitting on the surgeon's desk. And so again, it's a waste and is another piece of it. And that then, you know, does that patient have to come back for another day, you know, now you're left trying to explain all this to the patient and the patient experience. Another piece on white bagging and brown bagging is know the rules. Medicare states the healthcare provider who administers the injections is the one who purchases the medication. And so Medicare basically says you can't white or brown bag. And so that is the why behind a lot of I think you'll see a lot of practices or systems or hospitals have said they just don't allow it, they're not going to do it. Because one, there is the risks of that integrity of the medication. But also Medicare comes straight out to say that they don't they don't allow it for Medicare patients. Right. So into some details on the billing, billing is very confusing. Also, you've got to know that J code, you've got to know the units per J code. They're not all just one syringe equals one unit, that could be 16 units, 48 units, 36 units, you really have to watch the actual drug that J code and how it's built out. And then you're billing the J code plus the injection code without ultrasound or with ultrasound, you'll notice on one of one or two of the medical policies I showed, they actually consider ultrasound guided injection experimental and investigative, so they will not pay for that. So that's another thing to be watching on. I know a lot of providers like using the ultrasound guided. And that's fine. It's just you may not always get paid for it. So knowing that ahead of time, is good. If you're doing a right and left knee, know that that modifier 50 is going to come into play. And so you would see a reduction on that second J code. If doing two injections on the same day, also always including the left or right if just doing unilateral. And then there's a lot of why's I would say these days as to why you don't bill an E&M code the same day as the injection one, you're doing that E&M code on the probably your first visit with the patient, figuring out what they've got going on, what treatment options you have for them. And so that that is the appropriate time for that E&M code, you have to get that prior authorization. So most prior auth teams don't work within minutes, as we all know, these days. And so bringing them back for an injection only visit serves many purposes. But also, just knowing that if you ever tie an injection code up with the E&M code, you do have to use that modifier 25, which reduces your there's also the complexity that some insurance companies had automatically denied or put software into deny the 25 modifier. So then you will end up having to appeal those cases. But at the same time, some of my doctors right now are questioning the wisdom of the three series because they feel like they can fit in more regular patients and the second and third the time spent on the second and third injection with a visit that they could actually get more on. So as you're dealing with the prior authorizations, or the billing, one thing I guess I've just I've learned honestly, from our own experience here is just first or second level can be written appeals most of the time when you know, you've got an outlier, you've you didn't have a x ray that within the past six months, or the PT didn't happen within the past six months, which they require, you can do a first or second level written appeal, a letter from the ordering provider showing that additional information that's needed, maybe do a follow up phone call to the patient to better document, I need to know more about your relief from that last injection. I just encourage those as options as they're quicker. They don't take as much time, you don't have to fight with the phone systems. The worst fight is maybe just getting the letter to to the whether that's fighting the fax machine or they're uploading on their portals. But it's relatively quick. And the peer to peers, I guess we've found these are our last, last, supposed to be last chance, kind of your third strike. And so just use those wisely, as we've been seeing more and more that if you jump to that, and the peer to peer is upheld, the patient actually can be locked out for 60 to 90 days on that CPT code request. And so if that denial is upheld, you're, you're stuck, and the patient's really stuck. So just encouraging, not jumping to that peer to peer, I don't know about your guys's physicians, but mine don't love doing them. So again, we, we only do them when we know we have a case and we know the patient's meeting the policy. Otherwise, we kind of tread lightly on that. When dealing with appeals and prior authorizations, I just encourage everyone to know your state statutes, many states have local criteria out there for how these processes work. In an attempt to hold the payers and physician offices accountable or on a level playing field. So knowing that can be of help too, as you're, I get it, you're fighting your way through these. They're not fun, but they are the reality of getting paid. So just taking you through, I put HOS there, but for Heartland, what our patient experience looks like, because there's a lot, obviously, that we've shared with you now that you're trying to sort through. And in the meantime, the patient's like, I just want my injection. And so again, trying to present this in a way that is the patient, what does this look like to the patient and how can you ensure they're having a good experience? So again, we'll do that eval, we'll determine that VSCOs may be an option for them. We're able to enter requests within our EHR, that kicks to the prior auth team, because they are the experts at knowing that patient's insurance, who's processing it. The approval gets, it either gets approved and meets medical policy, and then it pushes straight to the PAR team for scheduling. PAR team is going to schedule with the ordering provider, surgeon. If ordered, patient chooses, otherwise, honestly, our PAs normally have the most access. So they do, a lot of them do end up on the PA schedule to perform the injection. And again, trying to make sure that that office visit is that second, it is a second visit, but that is for the injection only. There's, as we explained earlier, reasons for that. Next slide. So again, let me start by saying that in the first part, if I was nervous and I went really fast, for those who cannot understand my accent, I apologize. I'll stay as long as you want after to ask any questions on the first slides. But I wanted to go over some of the tidbits, almost like a summary of what we have been talking around till now is limit yourself to two to three main medications. Don't keep a lot of medications on hand. Inventory control, centralize your purchasing, which I have a funny story. One of my doctors had this really cute vendor come in and sell him a hundred boxes of Efluxa. And you know, he was not going to be able to use all of it in time because he, she promised him that he would be on this tier thing, but he bought it for himself. And the rest of the doctors decided not to join in on that deal. So it ended up being on his dime. So try and centralize your purchasing. And we will try and give you some handouts on how we keep our inventory logs. We make the doctor sign out the medication. So once they sign them out, it's their cost. We keep monthly logs. The manager who counts them has an incentive to make sure nothing is going to expire. And every quarter before the quarter, a month before the quarter, your vendors, your distributors actually are good. You can make good use of them. CuraScript, you know, I have a contact in there who is really good. I reach out to him and say, Hey, do you have any insider information for me? I reach out to my reps and say, any changes in pricing? And so me having to do a lot of the work, they start supplying me the information I've put into my grid, make it easier for me. Try to make friends of these vendors and distributors. Personally, I limit three series injections. Of course, my doctors don't like the fact that patients come in and it's not an office visit. But at the same time, if there is a company that has multiple injections in one box, if the patient does not come out for every injection, then because of the way my doctors do it, it ends up being a loss for them. If you can track the individual injections separately, then it's fine. It might not matter to you. Can I add one thing there just to maybe share another piece where we don't do sign out logs here, but we do limit. Meds are only stored in one place. Everybody within each site goes to that one place for the meds. Again, we limit our inventory control. We have on and off done sign outs for the meds that we keep on hand that we know are low volume and we're only bringing them on because a certain insurance company has it. So like that meds not even necessarily just a quick grab out of the cabinet. They have to go somewhere else to find that specific one because we know we have a loss there. So there's some different things you can do there. But I think the biggest thing is just don't buy into the sales pitch of getting that hundred. A lot of times you may say, because these meds typically do ship pretty fast, you only need probably two weeks of inventory. Two weeks of inventory can go really quickly. So maybe you keep a month. But these meds typically have six months expiration on them. So it's just once you limit your inventory, you've basically taken care of that expiration issue. Every group is different. Some groups are more socialized in that it doesn't matter if there's a profit or loss. It gets shared by everyone. So it might not matter. But in our practice, we have tried to keep accountability. So if they sign off the medication, they make a bad choice, it is their problem. And I tell them that if it is on the grid, I will do my best to protect you. But if it's not on the grid, it's your decision, not mine. Collect the patient portion at the time of service, especially with higher deductibles. If these are going under deductible, make sure that you collect at the time of service because this was a hard cost that you had to pay. Then we try our best not to do same-day injections. We try to make sure we check, go through the checkboxes of does it need pre-op, does it not? We document all of that. But at the same time, we watch the patient messaging. We don't try and say that, hey, we're going to lose money. We try and inform the patient that we don't want you to be stuck with the bill. That's why we are doing these processes because these patients, like Andrea said, hey, I just need the injection, just give it to me. So we go through, we try to see, here are the policies, here's what we need to make, so that you don't get stuck in the room. As I reminded earlier, monitor the prices and reimbursements every quarter and review the actual payments every quarter, or at least once in six months, but six months makes it too far behind, in my opinion. Document the current diagnosis. I can't tell you how many times these doctors are giving injections and they don't have osteoarthritis in their notes. And I think that's the number one diagnosis you need in your note for injections. And submit a clean claim the first time. What we are finding now is, and I'll share what we are doing to avoid this is, like we said, in milligrams, units, there's so many different caveats that if you put, for example, Synvisc is 48. If you put one and send it in, of course, you're getting one 48th of what you're supposed to get. And then when you say, oh, I caught this mistake. Let me send it the first time. Let me redo, send a corrected claim. They will start saying it's a duplicate claim and you have to fight a lot more to get the same claim paid. So try your best on the injections, especially to check before you send it out. Here is our VSCO injection log template. So of course these are our injections. You can pick what you want. Again, we don't use a lot of those now, but these might flip and come back to these next quarter. So I leave them on. We have our top one, two, three that we use. And as you can see, there's expiring 90 days. If anything hits that, then my supervisor loses a part of the incentives. So what sometimes you forget is as the boxes come, the new boxes come, you can stuff them in the front. The back stays the same. So my staff now know, you do that, you know, stick it in the back so that the ones that are older stay in the front. It's almost like grocery store ideas, right? Again, I made sure that I removed all the medications names and the dosages. But as you can see, my spreadsheet actually has automatic calculations in there. The Medicare pricing is in the second column, but the actual paid includes the sequestrations. You can add whatever cost you want and the automatic formula in there. They say, you want to add your billing cost. If you know what your fixed cost is, you can add in this to say, what is your actual paid? And then the cost to get your net. And as you can see, there are some injections that you're going to lose 50 and $70. This is where that ASP model comes into being is if some drugs are paying 70, 80% rebates, that gets calculated into your ASP. And there's no way that you would make it up because your cost is going to be way higher than the ASP. This is what we do every three months and we do it by doctor and by insurance. And of course, again, as you see, I have removed the name of the drug, but we actually see, and we put it into two. On the fourth column, we can say the payment is expected. We don't put that into our loss calculation because there seems to be a reasonable movement that these claims are going to be paid. But as you can see, there are some that we know, we tried our efforts and it's not working. Those costs of the boxes get added into the loss and then it gets calculated in the profit per box. So as you can see, there is an injection, there is a company that always pays me less than Medicare. And you can see where it is. So there's some losses that come because my doctors don't put the diagnosis and we've educated them, please don't bill these medications not allowed. And they go ahead anyways, or they give it in the same day is their prerogative because it's their friend, whoever, or they do not put osteoarthritis diagnosis. That's the issue we try to educate them now. Can you be a backup to them? Sure, we try our best to be backups like sometime before you forget. And then we write the notes on the side so that the doctors know how and why they lost money. Hopefully that they will learn from it. And so I just threw in what I use as a spreadsheet. Joseph has a very detailed spreadsheets. If any of you know him, he goes into every little detail. On our spreadsheet, I've kept it a little bit more basic. Again, just looking at my cost, looking at those units, you really got to track those units. If they are a pack of three, look at what each patient's going to complete a pack of three. So look at that financial picture across the three or what happens when they maybe only show up for the one. And so I just threw this in there as another FYI on how your spreadsheet can look, whatever seems to make the most sense for you and your practice. And we are more than happy to stay as long as you want for questions. Andrea, let's pull up the questions there. The first one. Oh, sorry. I'll maybe grab this first one I see here that asks, how are you managing the patient experience satisfaction when this process can take a long time? That's a very fair question. It's probably been one of the harder pieces. And really it's just been setting the expectations up front for the patients. And that this is what we have to do. This is what we have to do to ensure that you don't have any surprise bills. And really tried to, as Joseph had mentioned earlier, it's not about us getting paid. It's also, it's about the bill you could end up with. And so just managing that and just here in the state of Minnesota we do have a state statute that states loan of time for a prior off loan of time that they must respond to those types of things. And so the payers for the most part align with that. So we just saw upfront that it's typically at least 14 days. Cause we know we have 14 days once we submit that initial prior off. The biggest pieces is knowing what you're dealing with upfront. You really can't take, I can't express the importance of taking that pause when you know you want to proceed with a VSCO and really take the time to figure out what does this patient's insurance require? What med do they allow? Is a prior off needed? What's the medical policy? Having those facts earliest in the process allows you to get a clean approval of the prior authorization. It allows you to get the patient scheduled sooner. There aren't surprises along the way of you schedule them cause you think you've got it. And then somebody goes, oh, but there's a medical policy on this one. I know you got to, now they need PT. And so I guess those are, there's no great way. It isn't what we'd like to do if we had our choice but it's doing the best with whatever your payers and your areas are throwing at you. So there's three questions that seem to be related to specialty pharmacies, brown bagging, which is BarberSec. As if we know a percentage of patients that are non-medicare that you use this for. I don't have it, Barb, but I know that this last quarter we did a lot more specialty than we did before. We don't like specialty pharmacies either. Like Suzanne asked if there's any tips and tricks because it takes forever and it's free work that we're doing for the patient because the specialty pharmacy takes its time. And what's more annoying is that a lot of the specialty pharmacies are owned by the same insurance companies or VPNs. And they are the ones that are charging. Sometimes you see what the specialty pharmacy actually charges and you're like, how the hell can you even justify this? Because you're owned by the same insurance company that is getting a rebate on the backend for the same medication. But we've not found any tips or tricks. We just keep calling. And sometimes it is when the patients call us all annoyed. We say, here, we document the efforts we've called them and nothing else we can do. And Cassandra, we do participate with specialty pharmacies. And so that might have been Andrea. Yeah, so we most commonly do not. Like I said, I've tried once or twice, let's say to do the white bag where they send it to us and either the patient just decides to never show up or stuck with med patient shows up at the wrong location. It just, it gets tricky. And then also making sure that that's not a Medicare. So we don't have a high percentage of payers requiring that right now in our area. So I think that's something that could be very regional because we really, I don't run into a lot of issues and saying we're not gonna offer that option. So I guess I'll consider myself lucky there. But Darren, I'm tagging on to Andrea's answer. You asked if anyone's going to not do J-Codes. You said negotiate them out. We just are, we are a private practice. We cannot subsidize these injections because they don't pay us enough for the surgeries. Some, like if you're a hospital based groups and the hospital is taking the cost of these meds and they get the surgery, it may be okay. So it's your choice if you want to do the J-Codes but my doctors are getting more and more strict and saying, no, we will not do them in the office. And we try to do our best to educate the patient saying we cannot do this because we are going to run into loss. And at that time, unfortunately, the patient messaging is, we can't sugar coat it any better than that. But what sometimes we do is we do PRP and there is enough research now on PRP and osteoarthritis. We say, hey, it's a toss up. Look at AOS articles on injections. It says anything is good and it is better than placebo. And PRP says it's good. So we try and go that route as cash pay. At least we have something that gets paid but you cannot do a J-Code if you have a contract with an insurance company and get self pay out unless you get the patient to sign the documentation that says, I don't want you to bill insurance and they sign and do all the paperwork for it. There were some, Andrea, anything to add on that one? No, I think one thing I would just add is when you do hit one of these, they require a special pharmacy and maybe your organization has just said we're not gonna do that. Or you hit the barrier of they need PT, those different barriers that are out there. They haven't met the three months conservative treatment. I've just learned the quicker you can get the provider looped back in and have a conversation with them around it just to say, hey, should we really push for this in your mind frame and or in what the patient's wanting? Because there may be absolutely, I'm not doing surgery. Just the sooner you can start that conversation with your provider to know the patient and to really kind of figure out what direction can we get the patient going? Again, helps with that experience. And again, just, it's a lot of education, educating the providers of this is why we are where we are, looping them in to say, what do you think would be best for the patient? Are we doing, I see someone had asked, are we doing less viscose? I would say yes and no. Are there patients where for whatever reason, it's not, they just don't, they don't wanna throw that extra feather towards postponing the surgery when they hear what could be required and they are in that borderline of being appropriate. You know, yeah, I think there are patients that maybe are going to surgery ahead of time. We also have a ton of patients that this one injection gets them an annual or a yearly relief. And so if they're getting that relief, it's hard to not do what we can to, if they really don't want surgery. And so it's really kind of knowing what that patient's looking for. An anonymous attendee asked if we are putting in signatures or vet signatures. And I think that might be specific to your state carriers or your primary, like we are able to send our notes and digitally signed and they are approving it. Of course, Medicare requires, if you're doing a paper chart, it probably requires a vet signature, but they are accepting, even Medicare will accept a digital signature, does not need a vet signature on a note, in my understanding. Andrea, you have any different thoughts? Yeah, I think that it's the pre-op work, whether you wanna term it pre-op, the review of medical policies, knowing they all are required. It's that pause before we do the injection that really sets the tone for what do we need. And so that is when a specialty pharmacy gets flagged, an extra form has to be signed. I have some payer that we just have to sign off on, which they have to sign off on which med they're gonna do. So I've seen a couple of different things, but it's taking that pause that allows you to really know the details for that patient and that patient's insurance, what's going to be required. Before, I know that we had 173 when we started and there's some people are dropping off. So I just want to make sure that I put a plug for AAOE, because they looked at what was happening on Collaborate and try to arrange this at short notice. So if there are topics that you truly, truly need help on, which I will need a lot of help on on several topics, as more people ask for it, AAOE reaches out to those subject matter experts to try and get them to help everyone. So please feel free to use Collaborate to ask those questions and say, hey, can we have a webinar on this? Because according to AAOE, we had a lot of people asking for this and we were able to provide something. So please make sure that you make your questions known on Collaborate, advocate for orthopedics, please, and your patients, because your patients are the ones suffering. Last of the couple of questions that I saw in the end is, have you, have your doctors been using less VSCO and more steroid or just going for TKA sooner? This just started in October. My doctors have dropped a lot more, have usage of VSCO. We are going through the process of figuring out if we can get to TKA by doing the other conservative treatments and get to TKA. This is still a work in progress. I'm hoping that this will work. We do a lot of work for free for the pre-op and specialty pharmacy, Anonymous at Endy. And so, yes, we are doing the pre-op. Unfortunately, it is more work, but at least it is not, it's cost, but it is not like, you know, the doctors see the dollar because it is coming from their pockets and they don't want to do it. That's why we work with specialty pharmacies. Keep the questions coming. I'm willing to stay. Yeah, I think we, they will be sending out a recording of this. And I can't recall if that does or does not include the slide deck. The slide decks have been sent to AAOE, so they might be doing, posting it somewhere. Maybe it's on the web, like under education, there is webinars. I have seen my previous webinars there. So with the slide decks, it might be there. So if you need those actual handouts that I've stuck in that, and Andrea, maybe I can remove my names and just give you the formulas, just let me know. And do you use Prolia and Avenity? I can tell you personally, no. I use the same process for those medications. Actually, Prolia, Avenity, Rheumatology, we do it outsourced, but there is another medication that they keep trying to come in and get, which is a great anti-inflammatory, but I will lose $11 on every box. And they say, you need to think about the patients. And I said, yeah, you should have thought about it when you priced it this way. So I would use the same process on any drug that comes in, not just high algans. Yes, and I think if we didn't say it enough, these things are constantly changing. So even what we showed here today, it can be outdated by November 1st, typically they don't make mid-months, which is on us, but everything changes so quickly that you really just, you have to set that reminder to look at this quarterly because it is literally changing that often from all directions and they aren't going to let you know about it, which is probably where a lot of you are just feeling helpless and you just get it under control. And yep, something changes in the game. And that's just the way this has been. And I would anticipate will continue to be. And I think it will start stabilizing. Like after some time, these drugs that were devices and came in, it will stabilize, but it'll take a few quarters to do so because I spoke to a couple of manufacturers actually who of course are trying to get back and some of them are scrambling because they're firing a bunch of administrators and meaning their managers because their sales tank because people just stopped using them. So these things will, like it'll take some time for their drug pricing and the reimbursements to stabilize. So all of these are going to change rapidly for the next few quarters. And then like, I forgot which movie it is, but Life Finds A Way is a Jurassic Park. I think life will find a way. Any other questions? There's no other questions. It's an hour, but- There's one in here. Oh, another one. Sorry. I am not familiar with that med yet. I have heard it's out there. I think I would just speak to, you said that Arthrex has a prior auth hub. Most of these companies will tell you they do have a prior auth hub. So tread lightly if you use those sources. Again, a lot of them are only checking as a prior auth necessary, yes or no. So beware, just because it's no, you still have that medical policy to meet. And in my mind, not meeting medical policy and doing it is worse than failing a prior auth because you schedule it, you do it, you bill it, you get paid for it. They audit you, who knows when they take back that money. And so I just, I personally have found, and it's been working with our revenue cycle director, we do not use these programs that all of the companies have, because it really just doesn't check everything that you need to check to know that you will get paid. We do the opposite though. We actually use them. The problem of using too many hubs, unfortunately, is my verification department goes crazy. And I recommend them to use the hubs only because they have some skin in the game. If you have negotiated that, if you have negotiated that, if they said yes and they got denied and they appeal and they don't get the money that they give you a box. Otherwise, why should I use them? So they have a little more clout than me. So yes, because they have a lot of, as you can see a lot of dollars they are making in the middle of all of this, but they need to give me a box for a box if they lose it. That's where I use them. And the last part is Zylreta, which is the other drug that I was not naming. I will closely check what you're actually getting paid to the cost of the box. And I don't do Zylreta. That one falls under its own medical policy due to the J code. And it has very different restrictions. I know on that one, I've seen some payers, you get a once in a lifetime injection, which we've struggled with explaining to the patient why they had such a great relief. And yet we can't, their insurance won't pay for it again. So then you're into the potentially a self-pay area, which is always a tricky conversation. So Zylreta truly is its own med by the way, it's billed how it's reimbursement and they put them into a separate policy. And Jeremy shared his bit, which is great. Like it's not just questions, share how you do it because it'd be great for the other people to see how another group does it. They've just stopped doing buy-in bill, which is fine. My only thing is if there was any margins anywhere, I would still do them only because, if it's positive, of course, only because otherwise you're doing these pharmacies, insurance companies are making us work for free more and more. And when you do a specialty pharmacy, they're not taking the work, they're still dumping the work on me. So unfortunately, if there was a way that I can recover some of the costs, I will still do it in-house, but yes, we have also done what Jeremy has done, which is move more and more specialty pharmacy. Yeah, Andrea, I don't know what you're, sorry? There's no right or wrong answers here. Really you just have to vet out what works best for your group and it can change. And I don't know what Andrea is LOLing me for, it's either my accent or my head shaking. Anyone else wants to share their own tidbits with the group, please feel free to. Maybe Ju Young can try and get the tidbits into like a post-session summary for the people. Yeah. We have our contact info here, so go ahead and reach out to us too. That's why we gave it to you. Yes, please. Our cell numbers, email addresses, I'm more than happy to share the blank forms if you like. Thank you, Barb. We love you too. And Jeremy.

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