Thank you, just for a point of clarification, Neils is really going to get into more of the data, the codes and stuff, this is more general out of review of how to incorporate advanced practice providers into your billing schema. So I'm going to leave you with the hard part. So describe compliance issues with respect to the advanced practice provider, parentheses, physician assistant, nurse practitioner that impact reimbursement, discuss challenges and opportunities for reimbursement strategies with advanced practice providers and really just understand the impact that effective APP billing can really have on your practice and the strategies to help implement those. Disclosure, I do have a royalty from Springer for a book and it does cover some billing components of it, just my full disclosure. Also, this is a disclaimer, this is not meant to construe legal advice, I am not a lawyer. These opinions are mine based on my research, my interest in this topic, not SCCMs or my institutions. And the main disclaimer is that we could all have this discussion and CMS could change the rules as soon as we walk out of here, so I did my best and I mean that. So we'll talk about the safe integration of APPs into your practice in terms of coding and billing schema. And there's a couple of things that really, even in 2023, I'm still surprised to learn, some institutions really still need to focus on this. So when you first register with Medicare billing, you go through the credentialing process and you should be, as an advanced practice provider, under Medicare Part A. Sometimes, and there's been cases where APPs are lumped under Part B, but if you're gonna really, effectively, bill and code in conjunction with your physician partners, that's not allowed. That's almost like a double dipping because APPs are billing providers, both the national societies and nurse practitioners and PAs say that APPs should be under Part B. Now, there are exceptions, so if you're a full-time director or you have some large FT that is not associated with actually providing care or billing for E&M services, then you may go into the Part A, which is basically the cost report of Medicare and in terms of how they pay and reimburse for all the services they provide for that hospital. So that's something that still needs to be hashed out. Also, you wanna make sure that you have appropriate employer-employee relationships in terms of billing and coding. There are instances where, for example, a hospital may hire advanced practice providers to cover the night shift while a private practice is providing critical care during the day. Because of that, neither group can really interact or utilize each other's billing because there is no W-2 relationship. So to offset that or to make sure that there's a clean differentiation, you either have to have a true W-2 relationship where your employer is actually paying you for the services and you basically get a W-2. And or you have an independent contractor, you know, think locum tenens where you go into an area and you file a 1099 and so that really links that association. Or in very rare cases, you can become a leased employee. In that sense, you really have to be paid fair market value. Failure to do so exposes your institution to things of violations of anti-kickback acts because what they don't want to see is that, you know, the hospital is favoring a particular group practice by hiring the advanced practice providers to bring in revenue and that's not permitted. So I think every advanced practice provider, regardless of your institution, should understand the compliance issues in regards to Medicaid. Importantly, I always think about this is by you entering into this Medicaid agreement, you become a government contractor. So you have obligations. And as a taxpayer, fraud and abuse is a big problem. I pay my taxes every year. I pay my healthcare costs every year. And fraud and abuse accounts for up to $60 billion in lost revenue for our taxpayer. And there's a difference in fraud and abuse are the two worst things, but as you can see here is when you commit fraud is like knowingly billing for services that you did not provide or documenting things that shouldn't have been there, really trying to drive for a different type of cost. And abuse or practices that include unnecessary costs, you know, ordering tests because it may, you know, you're getting some revenue for that. The reason this is important is because this exposes you to criminal exposure. And imprisonment, very rare for overall. Fines are definitely there if you can look up all the OIG reports. But most importantly is exclusion. If you get penalized for this, you may get excluded from Medicare. And if you can't bill for Medicare, that's usually a large portion of practices. And so that can really impact your ability to generate revenue and be productive. Again, you know, the highlight there is in between January 2017 and March 2019, Medicare OIG said that they provided $2.4 billion of critical care services. Now based on my source, this is I think, you know, the 99291 and the 99292. So that's really impactful. So the government has a big stake in terms of money to make sure that if they are not paying for something, they want to get it back. And so they do that by recovery capabilities. And the key here is that, and I believe this, that if you make an error or you find that there's been irregularities in your practice, you should really just call the government and say, hey, come check this out. I think that's better than them finding it out and them doing more of a thorough investigation because I think, you know, they want to be reasonable as well. And I'm not a government employee, so I hope that's the intention. So self-reporting is definitely accounted for or advocated for. But the government uses data analytics, recovery networks, software to see where there's discrepancies. And sometimes if there's like, you know, one area where somebody's billing in a particular area, that may trigger some recovery audit groups or development of OIG work plans, which is the Office of the Inspector General. And currently there is a work plan in place for critical care that they're continuing to work on since I think 2016. And I keep waiting for all the data to come back, but it's a slow process. Now in the other cases, the last case is that individuals may on behalf of the government file a report if they do see, you know, fraudulent behavior. So you also have your workers, coworkers, or the coders or billers, if you're really trying to push the system, they may trigger a lawsuit against your practice if they see that there's fraudulent or abusive behaviors. And the incentive to do that as a whistleblower is that if they do recover a portion of money, that could amount up to 25% of the recovery. And in some case reports I've read, that could be up to $25 million in one particular one. So yes, you may never practice again, but that's a pretty good retirement package if to leave medicine for. This is Crater Lake, Oregon. I always like throwing a little bit of Oregon into my slideshows. So then we get down to the, now we get past the Medicare and Medicaid, but what are the rules, regulations, and the red tape? What are the barriers to effective practice? National, state, the local practice system, or even down to the hospital system. National level, we all know that there's like national rules and regulations, and every one of us who are an advanced practice provider, even physicians, know that the 85% reduction, or I'm sorry, the 85% payment for advanced practice providers does cause some issues in how we engage our relationship and how we effectively are utilized in our areas. State level, every state's gonna be different in terms of their laws and regulation, how advanced practice providers practice. Some states may favor nurse practitioners over PAs, and how the integration of those practices could offset of who's being utilized, and also could impact how those practices could be effectively. My bottom line is you should hire the best person, that best person who's an APP should practice at the top of their license, so this isn't a one side versus the other, but those may impact how your practice can effectively be utilized. And it's also important for laws, regulations, to allow the APP to practice in the most favorable manner, and what's really being pushed forward is really the optimal care delivery, or the concept of the practice at the top of your license. And then we get down to getting more local level, and as the off quote, all politics is local. So then you get down to your practice environment, whether you're in a large academic center or a small private practice, how are you and the physician colleagues interacting, what are the motivations behind coding and billing, and really making sure you have clear understanding in how you're utilized so you can be most efficient. What are the drivers for the practice in terms of reimbursement? Talking money is hard, none of us like to do that, it's hard, it feels awkward, talking health care is, but again, this keeps our lights on. Is the model, from the practice, is it an RVU based model, productivity model, base salary, et cetera, is it the eat what you kill model, where the physician may have to have all the revenue so that way that gives them the income, or are you in a center where maybe there's a very loose practice model where yes, we just do the bills, we keep moving forward, and it may not be as something that's very often discussed, maybe some larger academic centers because of the volume, it's less about the revenue and more about just making sure that you're at least effectively being billing for the appropriate amount of the services. All these probably need to be examined, and may lead to strategies to improve your productivity and also to provide optimal care. The bottom line is that in each of these organizations and in practice, you have to deliver a collaboration to enhance the revenue and productivity, not to create competition, so we come into that mindset. None of us, I don't ever expect to get a bonus on RVUs, but I do hope that my physician or partner colleagues would be able to get it, I just want to be paid a fair wage and get to do critical care. And there are also some perceptions, misperceptions. Some organization may feel that, because of some person's license, that they're higher risk of liability or less liability within that practice in regards to the scope of practice. And there's also this perception of decreased revenue with the utilization of advanced practice providers. While at its core it's true, 85% is less than 100%, but if you also look at what the cost of hiring an advanced practice provider, it's much less than a physician or more physicians. So if you're using the APP effectively, in spite of the reduction in the cost, you actually have a higher rate of return for every time an APP sees the patient, even though it is less than 15, or a 15% reduction. And then really, even in 2023, I have to say this, because I just heard this the other day, that yesterday, that this still happens, are you using your APPs effectively? If they're effectively working as scribes and just scribing for the physician as they go around, that's an inappropriate use of that resource that could be deployed elsewhere or could be optimized in that sense. Are you using them as a scribe and scribing for you? That they could be done at a much cheaper rate and you can leverage the use of the APP in another area. Also, using APPs for roles that could be completed by other team members, aka outsourcing. You know, I'm the first person to tell you that I will go get somebody a cup of coffee or do something every now and then, but if their part of their role is actually doing the scheduling or doing administrative functions that aren't being recognized outside of their other role, then you really have to ask yourself how that practice environment is really working and could there be better optimal use for those individuals. And then it's really important, I think that the APP works very much in conjunction with the coders and billers, because what you see is that at the end of the day when you do start printing off these reports, the APP work is oftentimes really hidden in the EMR and in the coding and billing schema. And you may do certain things, but because of the way the systems on the back end work, your relative value units or those things that get put in the computer may not be captured. So that is a problem. So some organizations you can use dummy codes where you can put in there, so if you do perform a particular level of service and it does get billed under someone else or your involvement in the care, you can at least see what your quote unquote productivity may be. Also there's two areas, the performing provider and the billing provider and making sure that when you're doing split shared billing or doing other services where you do have that opportunity to do split shared, that if you perform the service and it gets billed under the physician, those things are identified, so that way at least you get the exposure and the credit for that. And in some cases, in terms of private payers, they may require that everything gets put under the physician and then again, you're hidden in the work. Learning from the coders and billers, why did they up code something when you clearly, if you clearly documented that somebody was sick and you thought it was a lower level code, maybe they up code. You should know what those, what happened, why did they see something that you didn't see and same thing with down codes, why did you down code this? Did I just fail to document? Was I not explicit enough? Learn from those opportunities. And then for education information and proof coding and documentation, this is a continuous feedback loop. Hospital level, you get down to the very root. If your hospital bylaws inhibit your way to deliver effective care, then you have to have that discussion and really make sure that everybody understands that that impacts the practice delivery and keeping the lights on. So these are just some other examples, like if there's a mandate that you, you know, an attending supervises everything that you do, and you know, if that's the safest thing and that's the hospital policy, I understand, but it does impact that, that's an opportunity lost for the physician to go do something else or to, especially if you're competent and that's appropriate. That's an opportunity lost for creating efficiencies in care. Co-signing requirements. You know, if that's a mandate for the hospital, you know, just co-signing notes, that's more time the physician or that has to stay up late at night clicking all the boxes and that does not seem like a good thing. But we do have many challenges ahead and we've had great opportunity and there's been a lot of changes and I think, you know, Neils will talk a little bit more about that. Thank you. But, you know, there's new rules for CMS that are coming out and I'm really curious how that's gonna impact some of the care delivery and the relationship between APP and physician teams. I think split share billing is a good thing, but how CMS orchestrated it may be challenging and then there is this new clarification of the 99292, which may impact how the numbers come out over the next year. And then there's also obviously, you know, the impact of the cost of healthcare and the drivers there. Workforce shortages, you know, including the burnout that we have, how can we make it more efficient? And then how does the technology really drive some of the things that maybe make our jobs easier in terms of the documentation, which may impact our reimbursement. And then of course, Medicare is a finite bucket. We're all drinking from the same cup and if more money is going to this, there's less somewhere else. So we need to make sure that we have a good revenue stream going forward and a sustainable revenue stream. Bottom lines, design the care team for optimal use, including APPs at the top of their license, that impacts revenue. I believe in that. Include APPs in understanding the revenue stream and system and the impact that they make on the organization. And also develop internal audits, education and checks to assure compliance and improve efficiencies. And I'm gonna leave you the last thing. One of my early coding and billing mentors, George Sample, always said, just remember when you're documenting, what did you see, what did you do? If you put it there, most of the documentation pains will go away and hopefully that'll tie into Neil's discussion. Thank you very much for your time and I appreciate the opportunity.

compliance issues

advanced practice providers

billing practices

Medicare billing

fraud and abuse