Speaker 1: Hello, good morning, this is Dr. Eric Bricker and thank you for watching A Healthcare Z. Today's training session is on success stories in healthcare finance. Now, so the first one, I'm going to go into more detail around the company that I founded, Compass Professional Health Services, and our successes that we had in healthcare navigation. And this is not meant to be some sort of like pat on your back sort of thing. I mean, at the end of the day, we were just super fortunate to be able, you know, we were kind of in the right place at the right time to be able to help these folks. And I just wanted to show you kind of how the voice versus exit manifested itself at Compass. So Compass, as I mentioned, it was tools and support for healthcare consumers. It took the form of a personal healthcare concierge, where our health pro and you would interact with your health home by phone or by email. And we had an app as well. You could do some self-service looking up things as well. And you would get your Compass navigation service through your job. And so you'd have your medical, your dental, your vision insurance. Then you would have your Compass Health Pro to help you navigate all those. And our Compass Health Pros were basically like administrative experts. We didn't do any clinical decision making. I mean, that was between the doctor and the patient. But for all the morass and quagmire of healthcare, that's what we were experts in. And let me give you the specific examples. OK, here's this. You're like, OK, fine. These are true stories. OK, now, we had a member in Florida who was like the 20-year-old daughter of the employee of a municipality. It was a very large county, big self-funded employer in Florida. And so this 20-year-old daughter was still on the plant. She went to community college. And she had a part-time job. And she had a condition called gastroparesis, where her stomach didn't move the food along. It didn't empty into her small intestine. So the food would get backed up. And when that happens, you get nauseous. As you can imagine, you throw up a lot. And you lose weight. And it's incredibly painful, because your stomach gets really distended. And when your stomach gets distended, it's very painful. So she had this constant abdominal pain. It's like a miserable existence. And she had a local gastroenterologist that she had been seen for this. And he had her on like 12 medications. And this had been going on for like three years. And it wouldn't get any better. And she had been to the ER like eight or nine times. She'd been hospitalized like three or four times. And it was really affecting the entire family. She had to drop out of college. She had to quit her job. I mean, it was a disaster. And so her dad initially contacted us. And then we worked with this young woman. And it turned out that there's a Mayo Clinic in Jacksonville, Florida. And the Mayo Clinic in Jacksonville, Florida, specifically has a gastroparesis outpatient program, where you go and you have to like stay in a local hotel. But you see their multidisciplinary gastroparesis team like every day for six weeks. And it's not only a gastroenterologist, but it's also a pain management doctor. And it's also a psychologist and a psychiatrist as well. Because outside of your nervous system, your digestive system actually has the second highest concentration of neurons or nerves in your body. And so your thoughts and your emotion and your nervous system actually has a huge impact on your digestive tract. And so between or among those three specialists, and over the course of that six weeks, they were able to get her from like the 12 medications literally down to two. And her symptoms dramatically improved. And she was able to go back home. And she was able to restart junior college. And she was able to go back to her job. And so the punchline is, is that our health pros would actually travel for like open enrollment meetings or like wellness, you know, vendor fairs or whatever, to the employer. So one of our health, our health pro for because we assigned health pro so that they had a relationship. So you had the same person working with you. And this health pro went to the county wellness fair. And the father was there too. And he came up and he was like literally almost in tears. And he told the health pro this story about his family and his daughter. And he said, not only has this changed my daughter's life, but it's changed our entire family. Because when you have a sick member of your family, like it affects the entire family unit. So it dramatically changed the husband and the wife and the other siblings lives as well. So, I mean, just huge success personally for that woman and her family. Okay, next up. So anyway, long story short too, the punchline there is, is there are absolutely pockets of excellence within American health care. I mean, arguably what she got in Jacksonville, she might have not been able to get like anywhere else in the world. I mean, it was awesome. So the point is, is that there are absolutely pockets of some of the best care you can possibly imagine. We're incredibly fortunate in this country to be able to have these pockets. The challenge is, is getting to them and getting the care and then not having the billing be a disaster and financial ruin afterwards. And guess what? That's possible. It's totally possible. Okay, next up. Ophthalmology CPT code. So this is, so just very briefly, there's this thing called medical policy and medical policy means that you have, it's an actual term. It means you have health insurance, but, and the medical policy is all the buts and all the buts are things like, oh, or specifically a lot of times they're coding related, which is like, okay, if you have this particular diagnosis code, you can only bill for these particular CPT codes with that diagnosis code. And that's exactly what happened in this ophthalmologic example where a member of ours had an in-office laser retina treatment by the ophthalmologist, but that laser retina treatment is only approved for certain diagnosis codes. It's not by approved. I mean, approved by the insurance company for payment, not clinically approved. I mean, it was totally within the like recommendations and the guidelines of the ophthalmologist for them to do this laser procedure for this person's retinopathy. And they, because the ophthalmologist billed a particular diagnosis code with the particular laser CPT code, the insurance denied it. They said, you can't bill. Yes, we'll cover that CPT code. Yes, we'll cover that diagnosis code, but we don't cover the two together. You can't, we don't pay for that CPT code with that diagnosis code. And the ophthalmologist was like, really? And of course, anytime any physician or doctor doesn't get paid, they just bill the patient. Like the knee-jerk reaction is just to bill the patient. So of course, the patient got the bill from the ophthalmologist and it was like low thousands. I'm going to say it was like $1,300 and they contacted us, right? So that was the reason why we got involved. And so the problem is, it was lots of problems with medical policy, but one of the problems with medical policy is that it's highly inconsistent across carriers. So that particular carrier might've had an issue with that diagnosis code and that CPT code, but other carriers have no problems with that at all. Another specific example of that is for pulmonary function tests or PFTs. You go into this like, almost looks like a telephone booth and you breathe into it. It measures your lung volumes and you use it for sort of the diagnosis and staging of COPD and asthma. And there are like specifically for this one Blue Cross plan that we were looking for, they would, and it's a series of CPT codes. This one Blue Cross plan that we worked for only paid for two of the CPT codes. Whereas other Blue Cross plans in the Blue Cross Association would pay for all four. And it's like, well, why would only one Blue Cross plan pay for two and the other Blue Cross plans pay for four? It was like rather indiscriminate. And so if you happen to be on that one Blue Cross plan that only paid for the two, like you would get balanced billed for the other two from the pulmonologist. So anyway, we went back and you can go through the appeals process and guess what? When you go through the appeals process, there's first level appeals, guess what? Almost every single first level appeal gets denied. So like we just do it because you know you got to do it. So nobody should ever stop after a first level appeal. Like that's like a guaranteed denial. Like first level appeals like shouldn't even exist because it's just basically an automatic denial. OK, then there's second level appeals and there's third level appeals. OK, so you can do three levels of appeals and the third level appeal even has to happen through arbitration outside of the insurance company itself. And so because we had expertise in the appeals process, then we can run through that. And all you have to do is provide the clinical documentation and have the ophthalmology medical director at the insurance company look at it. And they're like, yeah, that's actually a standard of care. Like that's not weird. Like we should totally pay for that. And they did. So anyway, the next one was we had we did gobs of this, right, where this this, you know, this gentleman had prostate cancer and needed to have a prostatectomy. And his urologist at an in-network urologist originally scheduled him at a facility for his prostatectomy that the in-network allowed amount was going to be $75,000 and literally like two miles down the highway at another in-network hospital with the same urologist like urologist would do basically his surgeries at those two hospitals. It was $25,000. It was a third of the cost. It was $50,000 less. And we're like, look, I mean, you like Dr. Jones. You keep Dr. Jones. You don't switch for Dr. Jones. Just switch the facility to a different hospital. And Dr. Jones was like, OK, that's fine. I mean, I can't do it on Tuesday there, but I can do it on Thursday. And so literally, and we did this. It was a relatively it was a holding company and the holding company had 150 employees and they were self-funded. So they were kind of smaller on the self-funded side, but they were the holding company for several like much larger companies. Like they had like a forklift company that had like 3000 employees. And so the CFO of the holding company would joke around and be like, yeah, just that one surgery alone paid for Compass for like the next 30 years. OK. And then lastly, so that's an exit of an example of exit, right? So you just exited the system, right? You just exited that particular hospital. But like, look, we're just getting out of here. Optho was voiced and then gastroparesis was exit as well because you just exited the existing gastroenterologist, right? We didn't try to up manage the gastroenterologist. We didn't complain to the gastroenterologist and try to get him or he or she to change their treatment plan. We're just like, we're voting with our feet and we're going to go to a different provider. Sometimes you just got to walk away and you got to go somewhere else. And then the last example was there was a gentleman who was an administrator of a. Make sure you guys are doing OK. You guys can still hear me OK? Write in the notes if you can. There was an administrator at a at a also at a community college who had unfortunately had to get cardiac cath and stents and he was getting balance billed by the hospital for $15,000 incorrectly. And he was an older gentleman and he was actually. I'm delaying his retirement because he thought he had to work longer to pay off this $15,000 and when we went back in, we identified the error that the hospital had been making. They basically had not been writing off the discount from the insurance company correctly. And so that 15 grand should have been written off because it was just part of the discount for being part of the network with the insurance company. And like he was able to retire sooner. So like these things literally that was a huge time. He'd been working for years and he was like delaying his retirement by like over a year so he could pay off this extra $15,000. And so it's a huge ramifications, huge financial ramifications here. Like it's not just health care is not just like quote unquote expensive. I mean it dramatically impacts people's lives. He had bought like 20 acres out in the country and he was going to put a single wide trailer on it for him and his wife. Like that was his retirement dream was to live in a single wide trailer out in the country and he had been delaying that because of this $15,000 bill. Okay. So that's an exit of voice, right? We didn't just, you can't just walk away from that bill, right? So we had to use our voice to correct it. Okay.