ENCORE - Revenue Radio: Biologics

Episode 12 June 01, 2023 00:29:26
ENCORE - Revenue Radio: Biologics
Kassouf Podcast Network
ENCORE - Revenue Radio: Biologics

Jun 01 2023 | 00:29:26

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Hosted By

Tara Arrington

Show Notes

Kassouf Healthcare Solutions' Revenue Radio gives practice managers the tools you need to run a successful and profitable medical practice. Your host, Kassouf Healthcare Solutions Executive Director Jeff Dance, discusses the opportunities and challenges related to the business side of medicine. 

In this episode, Jeff Dance discusses biologics, a relatively new type of treatment, and how it can affect your practice. From cancer to retina disease, biologics can offer an array of care options for your practice. This growing form of therapy is speculated to become a $720 billion industry in the next eight years. Jeff shares how biologics can affect your practice and helps you determine if biologics may be a good fit for your treatment plans. 

Founded in 1981, Kassouf Healthcare Solutions was created to handle the business side of medicine, allowing doctors to focus on their patients. The Kassouf Healthcare Solutions team is comprised of operations management and revenue cycle specialists. We enhance the business of medicine by providing value to our clients with an action-oriented and caring customer-centered focus. Learn more here. 

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Episode Transcript

Speaker 0 00:00:02 Hello and welcome again to Our Revenue Radio podcast, powered by Kause and Company, Kassouf Healthcare Solutions, where we enhance the business of medicine. Uh, today, uh, you're just gonna be listening to, to me, my name's Jeff Dance. I'm the Executive Director of Kasu Healthcare Solutions. We are, as you know, a managed services organization. We'll talk a little bit today about some thoughts on managing your practice. Uh, appreciate Russ Dorsey, our producer, being here, uh, with me. But, uh, don't have a guest, uh, today, cuz I wanna speak to you on, on an issue that we're seeing a lot in our clients and, uh, how we're managing it and how we want to, uh, be a part of the success, obviously, of the practice and the client and the business owners, uh, PR provide you some good practical guidance, uh, as you deal with, uh, a modality in your clinics. Speaker 0 00:01:02 And it may not apply to all of you, but, uh, there's a, a, a new, um, modality out there called biologics. Uh, a lot of you are still looking into it, you're still investigating it in your practices. And, um, you know, Russ, we're, we're, everything we try to do is, uh, stay on the basics as well as, uh, move, move our, our clients forward on, uh, new, new technologies, new new treatment modalities. And of course, uh, at the end of the day, we have to keep the lights on, don't we? And, uh, we've gotta gotta make sure that, uh, that we're producing, uh, good quality revenue as we manage our practices. But, um, as we, as we mentioned, biologics are a new, I say new, it's, it's, they've been out for, uh, a few years. But, uh, as, as the, as the sector develops, uh, we're seeing more and more interest by, uh, physicians and, and clinics in how do I, how do I start this? How to bring it on. And that's what we want to kind of talk about today and some of the pitfalls that you may not, uh, understand, you may not have thought about. Um, it's easy for our sales folks to come in and talk, uh, about it and the, the, the representatives from the various drug companies. And we need to kind of think through the practical side of how to deal with, um, um, biologic therapies. Speaker 0 00:02:35 Uh, I've got 30 plus years in practice management in healthcare. Um, we've seen a lot of things come and go. This is certainly a, a valid therapy for many different diagnoses from cancer all the way up to retina, uh, disease. You've got pulmonary and asthma and, um, orthopedics and such. So you want to think about your specific discipline and those biologics that will come your way. And I'm not gonna get into, uh, specific brand names today, but I do wanna let you know that there was a recent Mordor, uh, intelligence report that predicts that, uh, by in the next five years, the biologic sector's gonna grow, uh, nine and a quarter percent. Now, what does that mean in dollars? Well, by the time we, you know, this is 2022, so we'll, Russ, we're dating our podcast and we hope folks go back and listen to it and, uh, and pay attention to what we say and such. Speaker 0 00:03:40 But, uh, in the next eight years, we're looking at a 720 billion industry from what, uh, most of the reports are saying. So that's a, that's a big piece of the healthcare industry that is contained pretty much in physician offices where a physician can, uh, administer these drugs. Uh, a lot of it obviously is gonna be in cancer centers and, and infusion centers and things of that nature. But in the offices, uh, it's, it's still allowed and still part of the, um, of the treatment regime and, and and such with, with the various physicians. So you need to think about, as we deal with this, think about how your, uh, practice may or may not, uh, have the patient volume to bring on. Uh, you may have just a few patients that need, and again, I said I wouldn't, uh, uh, mention too much about the, um, brand names, but, uh, I'll mention one. Speaker 0 00:04:51 Prolia, for instance, that's a osteoporosis, uh, therapy. You may not have, um, one, but one or two patients can you, can you, uh, provide for the several thousand dollars that this drug is gonna cost you, uh, and your various administration, uh, schedules and such with those patients? Maybe you can, but what happens if that patient and, uh, you know, again, word of mouth, things that you do, um, in your, in your marketing, now that, that turns into 10 patients and you're, you're, you're, you as the physician, you as the practice are putting out a, a significant initial cash outlay on a buy and bill program cuz you've got to buy the drug, you've gotta store it. And yeah, there are some just in time procedures that, that can, uh, affect you, but you want to make sure that, um, you are committed from a cash outlay perspective, uh, on the front end to, uh, to, to handle this, this type of investment in your practice. Speaker 0 00:06:04 So again, think about as you, uh, as you're setting up your accounts with your distributors, you'll, you'll have a, um, manufacturer, and those are the, the companies that we've all heard about. You'll have the manufacturer that, uh, will be representing this to you, but you will then actually purchase these drugs many times through a distributor, uh, that is a large, and you wanna stick with a large nationally known, uh, entity. They'll set you up with an account, uh, check your credit history. Uh, the reason for that is you'll have a purchasing ceiling for a while. So it's a, it's essentially a credit limit. It may be a purchasing, um, uh, limit as what some of them will call it. And a lot of that is because you have 90 to 120 day terms, uh, to pay the bill in full or pay that invoice in full. Speaker 0 00:07:05 And then what will happen from there is if you pay early, then you get a percent or so discount. And they all differ, uh, as, as it relates to the various, uh, distributors and the actual drugs themselves. And so you, what you're trying to, uh, manage is your cash flow as you're waiting for the insurance reimbursement to, uh, to pick up and come in. And, uh, we'll talk some more, a little bit about discounts and rebates in, in a moment. But, uh, as you think about this, and you are going to get into this sector and get into this space, it's real important to understand the cash requirements that are, are going to affect your business because you are going to order it, buy it. Uh, you don't have to wait to file the claims and reimbursement and such, uh, to actually pay the, pay the bill. Speaker 0 00:08:01 But a lot of, uh, practices will begin to wait for that reimbursement to come in to use that reimbursement to pay the invoices. And then, uh, if there's, uh, some of the profit that's left over, then that certainly, uh, is part of your overall investment gain, uh, in the program. So think about that, uh, as you, as you start into it. But then what, what else comes from there? Well, from the revenue cycle standpoint, the front desk standpoint, you gotta start to now look at, um, diagnosing the patient. You understand what therapy you want to provide, and you place the order, you get the drug in, in the meantime, you are looking at the various, uh, prior authorizations, all of the different controls that the re that the, uh, payers have placed on you. You've gotta make sure all of that is, is in line before you administer the injection. Speaker 0 00:09:10 When that happens and that that seal is broken, uh, that that's yours, it's, it, it's yours. You're, you're on the hook for it. And, um, you wanna make sure that you've done all your homework ahead of time with all of your, uh, payers and getting your, your, uh, approvals and authorizations in place, uh, before you move forward. Then you, and again, all of, if you think about it, man, just all of the little different pieces to get that patient back in the door, uh, you're typically not going to do that injection, uh, maybe on that, on that initial evaluation because there's some thought and process to it all. Um, but it's, it's a process to schedule the patient, get, get the invoice placed or the order placed, the invoicing and the, the, uh, drugs in. Um, if you've got an account's payable, uh, department or an account's payable function that's outside of your control, you'll want to make sure that you time that paying of that, that invoice, uh, appropriately so that you do take advantage of an early pay discount if that's offered to you. Speaker 0 00:10:23 And then you also want to make sure that you are paying, uh, in writing those checks, uh, appropriately as it relates to, again, just making sure that the drug, uh, was received and that, uh, you've, you're paying off of. Uh, one of the things that we, we do is we never pay off of a statement we pay straight off of an invoice. And that is the best, uh, control for you in, uh, in one, uh, compliance transparency, making sure that your, your cash is managed, uh, like it should be. So, uh, we're, we're looking at the, the decision to get into the program. Now you're in it, uh, you've, you've, you've taken the, the step forward. We're starting to process patience through, again, very intricate, and I'll use the word dance between your front and your back offices yourself. You want to make sure that you have all the controls in place before you break the seal on that injection, uh, to, to, uh, ensure that you've got, uh, the approval to do that. Speaker 0 00:11:38 And it's, uh, not necessarily a clinical approval, it is purely a, um, payer approval. And what, you know, we, if you're familiar with the timeout process in, in an or, uh, you may want to include something like that in your patients that are scheduled for these, um, these injections. You're busy, you're back there, the patient shows up, you're making the assumption that everything's being done. You may want to stop before you do break that seal. Maybe it's you that, that's the one that's, that's doing that and not a, uh, a nurse or an ma or, or an assistant. But you want to take the step, the time to ensure that, do I have all the prior authorizations? Is this ready to go? And almost show me the paper, show me the checkoff list. Speaker 0 00:12:31 Uh, and we have those available. Uh, if, um, and we'll put my, uh, email address up maybe at the end. It's jay dance kassouf healthcare.com. We've got some of those resources available to our listeners if you want to email us. And, uh, we can, we can send those over to you for your, for your, your help and your use, um, injections provided. Now we've got a bille it properly. You wanna make sure, again, to this sort almost goes back to the discussion you have with your, with your sales representatives. Uh, has this thing got a J code yet? Is it still in the experimental side of things? Uh, do I have the right code to, um, bill this? And you'll hear, uh, uh, yes, yes, it's, it's got, or it's on its way, it's in the process. Be careful with that because you're gonna be billing that experimental code, and that's gonna slow down. Speaker 0 00:13:30 Even if it does pay, it's gonna pay slow, and it's not going to be on the, the rhythm that you typically like to see and the, the process. So make sure that, uh, you, and again, you may want to use, uh, one just to test it out if it doesn't have its j code yet, but if it, if it does, then that's fine, but if it's still in that experimental, we're still waiting for it, et cetera, et cetera. You've all heard the, the spiel, I'm sure, um, be, be leery of that. No one's trying to pull any wool over your eyes, but, uh, everybody's trying to be positive and optimistic about their products. Uh, beware, uh, beware that, and, and you, and go slow. You can also get some samples. Obviously, you can't bill and collect for those, but if you want to try it out from a clinical perspective and you've done your research and you feel comfortable, uh, getting into that space with that particular biologic, then, um, ask your, your representatives for some samples to, to try those out and see how, how it all works. Speaker 0 00:14:39 So, so your documentation, clinical documentation needs to be very explicit, showing the need for it. Maybe there's some step therapy that's out there that you've had to try based on the, uh, coding guidelines and reimbursement guidelines. You've gotta try, uh, something else prior to moving into this, uh, this modality. You'll want to understand those. And again, with all the different disciplines out there, it's almost impossible for us in this amount of time to go through each, each one and list out the matrix, uh, on which ones require what. But just, uh, just be careful and pay attention to your documentation. Of course, as any good coder, and I am not one, I'm not a good coder because I'm not a coder, uh, but, uh, if, if, uh, you talk to any of your, your coders, they're gonna tell you, obviously, if it's not documented, then it didn't happen. Speaker 0 00:15:34 If it's not documented, then therefore, it's very unlikely that you will get approval that there is some medical necessity for it. So pay attention on the clinical side, the documentation side. And then as that relates to getting your revenue cycle going, we've already gone through the initial process of the prior authorization and such. Now you've gotta track that. You've gotta track the, those AR days. You've gotta track that aging as it's sitting out there. Uh, that's a huge expense that the clock is ticking as you're moving and trying to maximize that, uh, that timely pay and early pay discount that if you, if you're given 90 days, you want to pay it before the 90 days and take advantage of that one or 2%, whatever it might be. And then, uh, in the meantime, you've also got to ensure that your payment on that particular patient, uh, coming back from the re from the payer is not dragging out so that you've, you've paid too, too quick and you haven't got the reimbursement in. Speaker 0 00:16:46 Uh, like you need to sort of help cover that, that, uh, initial cost. Uh, you'll hear a lot about rebates. Oh, we'll, you know, if you order so many within a quarter, and it's typically a quarterly, uh, threshold, you'll hear about, uh, rebates on volume. And that's a, it's a loyalty business, obviously. Um, you are, you're going to be thinking about, oh, if I got, how many more do I need to get in order to get this particular rebate? And the rebate is an additional percentage typically on everything that you've purchased during that particular quarter. And there may be, there may be certain thresholds you've got to hit 50, or you've gotta hit a thousand, or you've gotta hit 500, whatever that, uh, that particular, uh, drug is, and whatever the, um, manufacturer and the, and the, um, the distributor allows for you to, to, um, take advantage of that. Speaker 0 00:17:52 It's gonna be, it'll, it will vary based on the product. So the rebates, then you finish a quarter, the rebates may come later, the next quarter after all the reconciliation and counting and such comes about. So again, you as the practice, yeah, you may be have been reimbursed, but what happens if that reimbursement is not as much, or it doesn't cover the full cost of the drug that you've already paid for? You've, you've outlaid that cash, you've paid that invoice, you've gotten, um, you've taken advantage of the early pay discount, you've gotten your money back from the payer, but it's still not enough to cover the cost that you paid for the drug. And you say, well, why would I even want to get into a business like that? And that's because of the rebate program. The rebate program, if you hit all the thresholds, and that's a big if, uh, you get that, uh, rebate check a quarter later. Speaker 0 00:19:01 So you're waiting three months to get that check. It comes in and you can essentially, on your books, look to see that it offsets that, that loss that you may be taking. Now, that has happened on every, uh, one of the, uh, biologics. It's, it happens on some, uh, they're, but it's one of those that you want to pay attention to. And, you know, Russ, I think part of what we try to do, as we say, we try to enhance the business of medicine, we try to maximize revenue, and, uh, we also want to just give good solid, practical guidance to those practice managers out there and the physicians and everybody that's just struggling to, to keep going and provide good quality care. Uh, these are just things to think about as we, you know, as we, um, provide good guidance and, and, and assistance to, to the, our, our friends out there in the field. Speaker 0 00:19:58 So, again, the rebate can help you get to a profitable situation with your biologics, but just keep in mind the time, value of money to the point where you've got where you get that rebate. So, um, it's, it's, it's something to, to line out, draw out on a piece of paper and kinda look at your dates and, um, uh, and think through that. Now, let me kind of chase a little bit of a rabbit with us here. And that is, you'll hear as, and you start to look at many of the, um, the cost of these drugs and, and what it's costing you. Well, let me put it on my credit card and I'll pay it with my credit card. And I'll either I've got a cash back credit card, or I've got a, you know, significant point, uh, uh, advantage with my, uh, with my credit card. Speaker 0 00:21:01 I get frequent flyer points. I can get, uh, gift cards, whatever it might be. That's all great. It's all you, it's perfectly fine. You can talk to your accountant on how that works. But, um, in a full disclosure, I'm not a, I'm not a, uh, CPC coder, nor am I a cpa, but, uh, I, I do, uh, have experience in this, this, uh, management field that's for sure in seeing the, the ups and the downs of it. But on the credit card piece, all that timing that I just talked about goes out the door. Now you are at the mercy of your credit card statement. Yeah, you can still get the early pay discount, but if you're trying to wait to say the 88th day to pay on a 90 day term, and you use your credit card to pay, uh, that invoice, now you've just moved 88 days up to your 30 to essentially 35, 40 days on a credit card, credit card billing cycle. Speaker 0 00:22:08 So whatever you pay, the, the, uh, distributor's invoice for the biologic, whatever you pay that when you use a credit card, just know that you've just, um, accelerated your time structure and your timeframe. So, um, uh, and you say, well, and, and you want to pay that in full on your credit card because it serves you no purpose really, to carry the interest on the credit card while trying to maximize a timely payment discount. All right? Um, a couple things that you'll also want to, uh, keep in mind is that you do get the respective, and we're, again, we're not gonna get into all of the, all of the, uh, CPT codes, but you'll wanna make sure that as you bill, uh, for these, you also include the proper administrative, uh, administration code for the injection fee. And you'll need to work with your coders, uh, to make sure that, that you're, that you're using the, the right one. Speaker 0 00:23:14 Uh, don't get too aggressive with that. That's word to the wise. Just because, uh, it's out there doesn't mean it's the exact right one. You may want to be a little more conservative and pay attention to which one, uh, which one of those administration codes actually, um, fits the, the, the type of drug and the type of type of modality. Again, uh, some other practical thoughts as a practice manager that you'll want to consider. Spoilage is a big issue, mainly because of these temperatures and storage temperatures at which these drugs need to be kept. Uh, just think about, you know, if you're not, if you don't have anyone there on a Friday, you don't wanna order Thursday for a Friday delivery because it's gonna be warm, uh, immediately. Um, it does come, these will come if they are required for, for refrigeration, it's gonna come all packaged and such, but it can't withstand a weekend, especially here in Alabama, uh, uh, in, in a thermal cooler and such. Speaker 0 00:24:19 It's not gonna be, um, what it needs to be from a temperature standpoint on Monday. And then you think through all of the patient scheduling and yeah, the, the manufacturer will probably replace that, but you've got patients that are showing up, you've gotta reschedule that and, and waiting for those, um, those, um, deliveries to, to be replaced and talking to the distributor and getting it all done. The other part of it is, uh, again, space. You gotta have the right, uh, refrigerators. You don't want to use your refrigerator in the, in the break room. That's, that's a big no-no. Uh, a lot of times you're gonna, you want, might wanna look into a, um, uh, Speaker 1 00:25:06 You mean you can't put it in there just with the pasta salads? No, Speaker 0 00:25:09 No. You probably don't wanna stack it up there with the, with the Snackables and Jell-O and whatever else that's in there. Probably not a good thing. All right? Uh, especially if you think about too, yeah, okay, yeah, fine. Speaker 1 00:25:23 I keep it in there. Are there practices that have actually done that? Oh, Speaker 0 00:25:26 Absolutely. Oh, absolutely. Absolutely. Speaker 1 00:25:28 Okay. Yeah, Speaker 0 00:25:30 And I'm sure there's, everybody could raise their hands. Um, I won't talk about the pickled eggs I saw in the jar of those in the, in the lab one day there for refrigerator, I think. Is that for an experiment? Speaker 1 00:25:46 No, it's Speaker 0 00:25:49 Lunch. Speaker 1 00:25:49 It's lunch. Yeah. <laugh>. Speaker 0 00:25:51 Okay. So, uh, but again, uh, dedicate a freezer or a refrigerator, uh, for your clinical, I mean, that's just good common practice. But you may want to consider now with the Bluetooth, the wifi, the, uh, apps and such, there are app type, uh, thermometers that you can get those in those on your phone and let you know if, if the power's gone out, something's crashing. Uh, you can pay attention to that and go and, and come up with your alternative cooling source. Uh, maybe it's at night or over the weekend. Uh, make sure that your insurance will cover this spoilage that you've got the right limits. You may want to double check your deductible. Always a good opportunity to have your insurance agent come in each year. We, we, we really stress that. But as it relates to this context, sit down with, I'm getting ready to move into this new space. Speaker 0 00:26:54 I'm gonna have some very expensive items in clinic in my building. What do I need to do from a coverage standpoint? What is that gonna make mean for me from a, um, from a, uh, deductible, you know, $5,000 deductible? That's two injections right there, cost. So maybe it's worth it. And you wanna look at those, um, those coverages with your insurance agent each time you, you move into some of these, uh, these spaces as it relates to biologics. And then lastly, again, just, uh, pay attention to the ordering and the time that, um, it takes for you to, um, get all of that in your patient schedules and such. And, uh, you'll, if you, you gotta watch all those little details. If it turns out to be a really nice, uh, clinical service for your patients, it's a good revenue producer for you. And if it's making $200 profit per shot, you have a thousand of them a year. Speaker 0 00:27:57 Yep. I mean that, uh, that's six figures, uh, in, you know, as far as profit's concerned. So, uh, and that's just on the drug cost. So think about it that way. Be smart, be wise, be ethical on everything that you do, which we know you're, you're going to. But, um, we're here to help you. We're here to help you think through this. We want you to be successful. We enhance the business of medicine. We try to help you maximize your revenue, and we hope that, um, this has been helpful for you. And if you have any, uh, questions, you'll have our contact information on the screen. Until next time, in our next episode of Revenue Radio, we are, uh, glad that you're a part of us and we hope that you, uh, are well and stay well. And, uh, we'll have a great, uh, piece of information for you on our next episode. Thank you. And, uh, I'm Jeff Dance with Kassouf Healthcare Solutions. Speaker 2 00:29:00 Thank you for tuning in to the kassouf podcast Network. Resources for today's episode are linked in the episode notes. Thank you to our producer Russ Dorsey, and for Kassouf for powering this podcast. Be sure to stay up to date on new episodes and more information about today's episode by following at kaso Co. Until next time, thanks for tuning in.

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