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December 2016

Attract Surgeons

How to Retain & Attract Surgeons to Your ASC

By ASC Management, Leadership No Comments

Do you have a favorite store where you enjoy shopping? It may be convenient to your home or office. They always seem to have what you need.  And, when you can’t find something, friendly staff members are readily available to assist you. It may not be the least expensive place, but the service and atmosphere make the extra dollars spent worthwhile.

Think about your favorite restaurant – perhaps the excellent food was the original draw.  But you keep going back because the service and overall feeling you have while you are there adds to your overall enjoyment.  It wins out often despite the multitude of dining options available to you.

Then there’s that shop you use to service your car or bike.  When you call, they always remember you.  When you walk in the door, the owner and staff greet you as if they genuinely care about your business.  They provide you with service options that may not always be the most profitable for them, but may make the most financial sense to you.

When we consider how to retain and attract surgeons to our surgery centers, it is helpful to keep these types of experiences in mind.  I purposely mentioned retain first.   It is much easier and less expensive to keep current business than it is to attract new business.  This is especially true for surgeons in an ASC. Emulate the owners and staff members at your favorite businesses who provide you with the quality customer service you appreciate.  Ensure the actions and attitudes of everyone at your center convey to your physicians their business is valued.

Surgeons use ASCs for a variety of reasons.  Here are six ways you may be able to attract them to your center:

  1. Consistently provide outstanding customer service. One size doesn’t fit all.  Surgeons value different aspects of their customer experience.  They may be drawn to measurable factors – low infection and transfer rates or high patient and physician satisfaction, for example.  Or, it may be as simple as the reliable availability of competent staff, the proper equipment, and necessary supplies.
  2. Save them time. When you save surgeons time, you improve their quality of life.  This can be as simple as your center being near their home or office which reduces time in the car.   On time starts and rapid room turnover times strongly impact surgeon time.  And, if the scheduling process is convenient for physicians and their staff, they are more inclined to use your ASC.
  3. Ensure quality. In today’s healthcare environment, quality should be a given.  When we are asked to revitalize struggling centers, we rarely encounter ASCs providing poor quality of care. Surgeons look for measurable factors when assessing quality – make this information available to them.   They also want to see the high nurse to patient ratios they have come to expect in an ASC.  Lastly, quality usually comes down to perception – is your staff knowledgeable, skilled, and experienced?
  4. Offer extensive managed care participation. Provided you are not an out-of-network center, physicians and their offices do not want to have to choose their site of service based on remembering which center participates with which third party payor. Being able to offer surgeons the full spectrum of managed care plans in your market makes your center a more desirable place to work.
  5. Provide return on investment. Most investors subscribe to a simple formula.  If they are receiving distributions – tangible ROI – they are much more likely to participate.  If distributions are far and few between, investor participation decreases and your ASC has minimal opportunities to recruit new surgeons.  Managing your center in a fiscally responsible way with financial stewardship in mind affords you opportunities to both retain and attract new physicians. 
  6. Add value. Be able to answer the question, “What have you done for me lately?”  Constantly look for ways to add value to the lives and practices of the surgeons who use your ASC.  Focus on the items I’ve outlined above and never rest on your laurels.

Rob Carrera – President and CEO

Billing Solutions

Billing Solutions: Forensic Collections – Lost Revenue Found

By Revenue Cycle Management No Comments

If you suspect your existing billing solutions service or internal business office isn’t managing your accounts receivable well, you are likely concerned about uncollected revenue.  Perhaps you recognize that acting quickly may allow your facility to recover lost income.

To obtain the objective data you need to make an informed decision about next steps, enter forensic collections mode.  Your goal?  Leave no stone unturned.

During your search for this potential uncollected revenue, include these activities:

  • Analyze the A/R and payor mix. Look for sizable changes or significant swings in outstanding balances.  Ensure you thoroughly examine patient balances.
  • Investigate write-offs including bad debt adjustments. Are the write-offs consistent with the reimbursement terms outlined in your payor contracts?
  • Examine billed charges. Review payors being billed.  Are your secondary payors being billed after the primary payors have paid?
  • Inspect implant billing and reimbursement. Compare the results to your contracts.  If separate reimbursement is allowed for implants, are you billing them accurately and receiving full payment?
  • Determine when the last fee schedule increase occurred. Are your billed charges keeping pace with your contractual reimbursement?

Here are a few examples of what my team and I have discovered while in forensic collections mode.

  • Our analysis of workers’ compensation claims revealed payments equaled 100% of billed charges. This rarely happens which lead us to dig deeper.  We compared the state’s work comp fee schedule to the facility’s charge master.  The state’s fee schedule was much higher than the facility’s charge master which hadn’t been updated since 2006.  We promptly notified the payors (per their contract requirements) that an increase to the facility’s fee schedule was scheduled to take place in 30 days.  Consequently, the facility realized an immediate increase in work comp revenue.
  • A review of Medicare claims revealed when a secondary insurance was active but not being billed. We queued up all claims within timely filing and billed them to the secondary payors.  The results were an increase in payments to the facility, a decrease in bad debt, and correction of balances erroneously being transferred to patient responsibility.
  • We reviewed ortho cases where implants were being used. Our analysis revealed the facility never billed for implants.  We discovered facility personnel knew their contracts allowed for implant reimbursement when claims were filed with supporting documentation.  However, they were unable to obtain implant invoices from their hospital partner thwarting their efforts to pursue payments on implants.
  • A review of patient balances revealed patients had not received statements in more than seven months.
  • In our review of claims denials, we discovered claims were never appealed. Payor payments were merely accepted.  The balances between the billed charges and the allowed charges were written off without first confirming their accuracy with the contract terms.
  • When changing patient accounting systems, a facility turned their entire A/R over to a collection agency. If they had opted to work that A/R themselves, hundreds of thousands of dollars could have been easily collected.
  • Facility contracts were not loaded into the patient accounting system. With each passing year, contracts and fee schedules changed but the cash poster’s memory did not.  Explanation of benefits (EOBs) were not compared to contracts.  Amounts received were accepted, correct or not.  Remaining balances were written off.  Credit balances were never refunded.

The examples go on and on.  It doesn’t have to be this way.  Audit early and often.  Be willing to dig a little to uncover potential problems and fix them.  When you do, your reward is a nice increase in your net revenue per case and happier investors!

Carol Ciluffo – Vice President of Revenue Cycle Management

ASC Reimbursement

Already maximizing ASC reimbursement on your commercial contracts? Now what?

By Payor Contracting No Comments

I am often asked, “What if I’m already maximizing ASC reimbursement on my facility’s commercial contracts?” Three responses quickly come to mind.  First, how do you know you’re receiving optimal reimbursement?  Second, have you capitalized on moving cases from the hospital setting to your facility to create a leverage opportunity on your lower acuity procedures? Finally, if you truly do know you’ve already secured maximum reimbursement, don’t draw fire.

How Do You Know You Are Receiving Optimal Reimbursement?

From my bleacher seat, you don’t know what you’re capable of securing in terms of reimbursement unless you’ve answered at least two questions.

Have you thoroughly analyzed how your major commercial payors reimburse your ASC for the services you routinely provide?

Measuring how your ASC is reimbursed for its top volume procedures is a great place to start. This will allow you to assess your facility’s market parity and identify differences in reimbursement among your key payors. Since differences sometimes create opportunities, this analysis could help you identify ways to increase reimbursement.  It could also assist your facility in establishing practical renegotiation goals. Please see my blog Payor Contracting Tip: How to Determine Market” for additional details on determining market parity.

Has a payor contracting professional evaluated your opportunities?

This starts with hiring an impartial third party who possesses the knowledge and expertise necessary to analyze your facility’s contracts with, and corresponding reimbursement from, commercial payors. This party should also be able to fully negotiate third-party payor contracts. Having this additional set of eyes on your reimbursement when evaluating trends is priceless.

Moving Cases from Hospitals to ASCs

Your facility is most valuable to its payors when it can help them lower their costs.  Simply asking for reimbursement increases will not work in your favor.  In fact, payors may view this approach negatively and be less likely to grant you the reimbursement increases you are pursuing.   However, if payors can save money by moving high acuity cases from the hospital setting to your facility, they may see value in what your facility offers which could facilitate increased reimbursements.  Only then will they be willing to dig deeper into their pockets to pay you more for lower acuity procedures. Please see my blog What Opportunities Can You Leverage to Increase ASC Reimbursement?” for additional details on moving cases from hospitals to ASCs.

Don’t Draw Fire

Once you determine a payor is paying your facility exceptionally well, do not request changes on your contract unless forced to do so by the payor.  If, however, a payor is utilizing percent of billed charge as their payment methodology – a rarity among major payors these days – you can offset increasing costs of care by performing modest charge master increases annually.[1]  Doing so allows your facility to maximize reimbursement afforded under percent of charge reimbursement without drawing fire because you tried to renegotiate your contract.

[1] Pinnacle III encourages facilities to thoroughly research whether its commercial contracts have charge master increase limitations prior to implementing changes.  This will allow them to avoid any unintended consequences of any adjustments made.

Dan Connolly – Vice President of Payor Relations and Contracting

Boulder Surgery Center

When Your ASC Outgrows Your Physical Space

By ASC Development No Comments

Boulder Surgery Center has experienced steady growth since its inception.  The ambulatory surgery center (ASC) opened in 2005 in the heart of the Boulder community with a vision of becoming an orthopaedic-focused surgery center of excellence.  It quickly established a foothold in the community and became a center of choice for many orthopaedic patients.  Eleven years later Boulder Surgery Center is a bustling facility.  Due to robust case volumes, highly aligned physician practices, and attentive management, the center expanded and relocated to a newly built, state-of-the-art facility.  It is the premier location for outpatient orthopaedic care in Boulder County. 

The new facility is equipped with five operating rooms, one procedure room, and 20 pre-op and recovery bays, including four recovery rooms available for overnight-stays in the facility’s 23-hour care model.  The surgery center’s largest affiliated physician practice, BoulderCentre for Orthopedics, is located directly upstairs, occupying the entire second floor of the new building.

Robust Case Volumes

When the new building project began in 2015, Boulder Surgery Center performed an average of 307 cases per month – an increase of 15 cases per month from 2014 and an increase of 25 cases per month from 2013.  Increased case volume led to increased prosperity.  The exemplary care provided by Boulder Surgery Center physicians and staff was steadily gaining recognition in the Boulder healthcare community.  This became part of the equation which led to the plan to expand into a larger physical space.

Highly Aligned Physician Practices

Boulder Surgery Center hosts specialists in orthopaedics, including hand, pain management, podiatry, and sports medicine.  In April 2016, Boulder Surgery Center’s two largest orthopaedic practices, Boulder Orthopedics and Mapleton Hill Orthopaedics, merged to form BoulderCentre for Orthopedics.  Four additional physician practices – Boulder County Foot & Ankle Care, Foot & Ankle Care of Boulder County, University of Colorado Sports Medicine Clinic, and RISE – are also served by the surgery center.

The BoulderCentre merger was a significant step in strengthening physician alignment with Boulder Surgery Center.  The merger placed 13 out of 20 of Boulder Surgery Center’s utilizing physicians in a single practice.  The newly formed BoulderCentre for Orthopedics and expansion of Boulder Surgery Center led to their move into the same newly constructed building.  Boulder Surgery Center occupies the first floor of that building while BoulderCentre for Orthopedics, including the group’s physical therapy office and MRI imaging, occupies the second floor.

Boulder Surgery Center is held in high esteem by its physicians.  The ASC’s physicians think of the facility as an extension of their own practice.  All 20 of the facility’s utilizing physicians are investors in the surgery center.  The ASC’s physicians collectively hold a 50% ownership stake in the joint ventured center, with the local hospital, Boulder Community Health (BCH), holding the other 50%.  Boulder Surgery Center benefits from having the perspectives of their hospital partner, BCH, and management firm, Pinnacle III, in the board room.  The ultimate drivers and decision makers, however, are the physicians.  In this way, Boulder Surgery Center maintains its vision of an orthopaedic-focused ASC of excellence.  The physicians at Boulder Surgery Center enjoy being involved in the process.  As a result, Boulder Surgery Center has become the preferred surgical facility for the invested physicians, contributing to a case volume on which the center can rely. 

Attentive Management

The increased case volumes and the enhanced alignment of the physician practices signaled a market primed for ASC growth.  The pressure to respond shifted to the ASC management firm to position Boulder Surgery Center for continued prosperity.  The physicians were eager to know:  How do we capitalize on the current increases in case volume and take advantage of this opportunity to seize a larger market share?

In the case of Boulder Surgery Center, both the expanding market and an expiring, non-renewable lease agreement compelled the ASC to consider alternative space options for their facility.  Fortunately, the prosperity of the ASC allowed its investors to consider the option of moving into a newly built facility that would allow for customization in the building development process. 

Due to the physician investors’ confidence in the longstanding relationship with Pinnacle III, the center’s ASC management firm, the board chose Pinnacle III’s facility development team to oversee the development of its new surgery center.  The process began with an analysis of the projected volumes, including the addition of higher acuity cases.   After determining the existing center would not allow for the projected volume, Pinnacle III developed a project proforma.  Detailed input from all involved parties was incorporated into the proforma.  After significant review and discussion, the facility’s board of managers concluded moving to a larger location was necessary for future business growth.  While an expiring lease agreement with no option to renew was the reason the ASC had to relocate, the proforma helped investors determine a new, larger facility would need to be built. 

While Boulder Surgery Center was considering the move into a newly constructed facility, BoulderCentre for Orthopedics had already made the decision to move into a new space under construction.  There was available space in this new building that could accommodate the new surgery center.  Thus, the ASC’s board made the decision to relocate here as well, foreseeing synergy and efficiencies between the orthopaedic practice, ASC, and support services which may not have been found elsewhere.  Pinnacle III acted on behalf of the owners, providing oversight of the design-build process.  The management firm’s hands-on guidance of the architects, construction team, and engineers, ensured a licensable and certifiable surgery center.  Keeping the contractors accountable to the agreed-upon budget saved the facility an estimated $100,000.

Pinnacle III also focused on helping physicians sustain case volumes during and after the move.  The physicians were surprised decreased case volume did not occur during the process.

Boulder Surgery Center moved into their new home in August 2016.  Preparing for the move required considerable planning and organization.  Pinnacle III and the ASC’s staff coordinated equipment purchase needs, relocation intricacies, and staffing processes to ensure a successful move.  Jean Day, Administrator for Boulder Surgery Center, remarked, “Under the direction of Pinnacle III’s planning and organization, we experienced a smooth move.”

The Grand Re-Opening

The facility’s physicians and staff were exultant.  This was evident as Boulder Surgery Center & BoulderCentre for Orthopedics teamed up for their Grand Re-Opening Open House Celebration, organized by Pinnacle III’s marketing team, on the evening of October 6, 2016.  Both the ASC and the physician practice excitedly welcomed the Boulder community to their new facility.

At the open house, Boulder Surgery Center hosted many influential members of Boulder’s healthcare provider community.  Attendees included surgery center physicians & staff, physician practice staff members, referring providers in the Boulder Community Health & the Boulder Medical Society networks, hospital administrators, local legislators, third-party payor representatives, medical device representatives, and many others.  The event not only served as a celebration for the physician investors, ASC, and practice staff members, but it also provided a positive boost for business.  Referring providers toured the facility with Boulder Surgery Center specialists, had an opportunity to meet new specialists, and gained confidence in the practice(s) to which they will be sending patients.  A few prospective physician specialists toured the facility and inquired about obtaining credentialing privileges.  A representative from U.S. Senator Michael Bennet’s Office attended and learned about some of the legislative issues facing ASCs in Colorado.

The evening culminated in a toast given by Dr. Drigan Wieder, Medical Director for Boulder Surgery Center, and Dr. James Rector, President of BoulderCentre for Orthopedics.  Both physicians outlined the history of Boulder Surgery Center and BoulderCentre for Orthopedics as well as the vision for the future. 

Several days after the Grand Re-Opening Open House Celebration, Jean Day stated:

The open house was a powerhouse marketing extravaganza!  Attendance far exceeded my expectations.  The feedback was so positive I expect Boulder Surgery Center will receive inquiries from professionals hopeful of working here.   Two podiatrists each inquired about the feasibility of performing cases.  They presently conduct all cases at the hospital.  Staff members’ level of pride has been elevated to near euphoria, or perhaps they remain intoxicated by the swell of happiness in their hearts from witnessing such a receptive crowd!”


Boulder Surgery Center experienced steady growth and prosperity over the course of their first decade in business affording physician investors an opportunity to consider:  Is now the right time for expansion?  The board, after pragmatically assessing its options, agreed it made sense to take advantage of space available in one of the community’s new building projects.  Ultimately, Boulder Surgery Center’s board members made a confident decision to expand based on robust and sustained case volumes, highly aligned physician practices, and attentive ASC management.

If your ASC is experiencing sustained growth that is outpacing its physical capacity, a project pro forma is essential to visualize the new business model in an expanded space.  Consider contracting with an ASC solutions company like Pinnacle III to guide you through the process.

Jack Mast – Physician Liaison

Busy Professionals

Time Savers for Busy Professionals

By ASC Governance No Comments

For busy professionals, there is no doubt we live in a world where time savers feel like life savers.  Work-life balance is essential but it’s increasingly difficult to achieve.  During my tenure managing numerous surgery centers, I sought ways to make my days feel less daunting and leave feeling more accomplished at days’ end.  Here are a few tips I’ve gathered over the years to organize and save time in my daily routine:

1. Take time to start your day with a short exercise period and/or meditation.  Both activities can help you organize your day. If your mind is scattered, your day is likely to follow suit.

2. Ensure your day’s agenda and goals are realistic. Prioritize your task list to ensure you complete the most important items first.  Create a flow to your routine that allows you to smoothly transition from one item to the next.  Nothing gets accomplished if you are trying to tackle multiple projects simultaneously. 

3. As you accomplish your agenda and goals, check them off your list. Take a moment to relish your success.  You got something done – acknowledge it and let that propel you toward tackling the next item.  Crossing items off your list can be a small but significant reward for staying motivated.

4. Minimize disruptions and personal interactions by using this technique: If someone enters your office space unscheduled to chat and there is no extra time in your schedule, stand up.  This non-verbal cue signals you are involved in something or have somewhere to be.

5. Stay on task when in meetings and on conference calls. Tangents and side conversations waste valuable time.  Focus on the purpose of your meetings.  If you discover an unrelated item that warrants discussion, schedule another time to talk about it.

6. Do not procrastinate. If it’s on your daily list, do your best to complete it.  Procrastinating drains the energy you sparked from accomplishing your previous task.  Avoid losing the momentum you built.  If you continuously dive into mindless to-do items, you’ll find yourself having to complete all the important tasks you avoided at the last minute and under greater stress and anxiety.

7. Keep phone calls concise and on point. Long conversations not only create fatigue, they cost you time.  Suddenly your day got a lot shorter while your list stayed the same length.  Don’t let long phone calls throw a wrench in your routine and create unnecessary chaos.

8. Ask for help or delegate when the need arises. The onus doesn’t have to always be on you to handle everything.  If you work with a team, there is a reason you call them teammates.

9. Take time out for yourself. This may be a 10 or 15 minute break to get your mind off the work you are doing and rejuvenate. These little breaks can go a long way to help your mind reset and refocus.

10. Move unaccomplished items to the next day’s agenda. It won’t always be possible to tackle everything on your daily to-do list. Don’t push yourself to the limits for the sole purpose of crossing them off.  Sometimes it’s just not worth it.

11. Create your next day’s agenda and action plan before leaving work. Just like a football team studies before a game, get ready for tomorrow by figuring out your action plan ahead of time. This will allow to enter your office ready to go when you arrive in the morning.

12. Stay hydrated. This is not a time saver, but helps with clear thinking and prevents fatigue. Taking care of your body is crucial to your ability to attend to tasks while not draining yourself in the process. Your health should always come first!

These tips can lead to an easier-to-manage routine that should help you be – and feel – more productive.  Being productive does not equate to constant fatigue.  These adjustments take time but will go a long way toward helping you feel energized.  Busy professionals should feel accomplished at the end of the day.  Hopefully these tips help get you there!

Rick DeHart – Principal Partner