Ep. 109 - Downcodes, Takebacks and Timely Filing: How Payers Really Win (ft. Chris Acevedo)

Most people think a doctor’s visit ends when they walk out of the exam room. It doesn’t. That visit triggers a maze of prior authorizations, coverage rules, coding decisions and payer tactics that can make or break a medical practice months or even years later.

On this episode of Working Healthcare, host Meredith Hirsh sits down with Chris Acevedo, CEO of Acevedo Consulting, who grew up watching his mom run practices and now helps physicians across the country navigate the business side of medicine. Chris walks through what really happens before and after a visit—from front-desk data entry and benefit checks to denials, timely filing traps and surprise takebacks on claims that payers already processed and paid. He explains why one technical error can cost a practice both the drug it infused and the reimbursement it thought was safe, creating what he calls a double whammy.

They dig into downcoding policies, constantly shifting Medicare rules, ABN changes, and why “just because you got paid doesn’t mean you get to keep the money.” Chris shares how good doctors get pulled into fraud and abuse nets designed for true bad actors, and why practices who never intend to cut corners still wind up at risk when they ignore incident-to rules or skip basic reconciliation of fee schedules and payments.

Throughout the conversation, Chris argues that practices must treat compliance and revenue integrity like any other core expense—alongside cleaning crews, accountants and legal counsel—because no one else will protect the dollars that keep their doors open. He also makes the case for patients owning more responsibility for their care in a system where payers carry outsized leverage and physicians burn out under constant whack-a-mole regulation.

If you work in a practice, lead one or just wonder why your “paid” claim still looks shaky 18 months later, this episode gives you a clear, practical look at the rules behind the medicine.

Contact Chris:

Website: www.acevedoconsultinginc.com
LinkedIn: www.linkedin.com/in/christopher-acevedo-34b3579

Contact Meredith:
Website: meredithhirsh.com
Instagram: @workinghealthcare
Facebook: WorkingHealthcare
LinkedIn: @meredithfhirsh
YouTube: @WorkingHealthcare

Transcript

SPEAKER_01 0:00

If you're getting value from working healthcare, I have a quick ask. Follow the podcast and leave a five-star review on Apple Podcasts, Spotify, or wherever you listen to the podcast. That simple action helps more physicians and leaders find these conversations and better understand how our healthcare system actually works. And that matters because we can't fix what we don't understand. You gotta run it, gotta run it. Most people think that when they walk out of an exam room, the visit's over. It isn't. There's so much. You have the policies, the compliance, the players, the coding, the auditing, the edits, the PBMs, the vertical integration is extensive. And having the right people behind you to support you and have your back is so vital. I just interviewed Chris Acevedo. He and I have known each other for about 25 years. And he is, even though he doesn't say he's a king, he's a pawn, I will tell you, he's the king of compliance. You will not want to miss this episode. Chris Acevedo, welcome to Working Healthcare.

SPEAKER_00 1:28

Happy to be here. Thanks for having me.

SPEAKER_01 1:30

It's like interviewing my brother, a brother from another mother, right? Your mom is one of my mentors. She was one of my first podcast episodes, I think episode 11, Gene Acevedo. And uh I I adore your entire family. Even Marcus, who's Benjamin's age.

SPEAKER_00 1:47

Absolutely. I think we're going on almost 25 years of friendship. So it is absolutely a pleasure to be here and share this uh experience with you.

SPEAKER_01 1:55

I wanted you here because you and I teach together at FAU, although I just had my last class last week, and I think you're on it as well.

SPEAKER_00 2:05

June will be my last class after on and off the last two decades of teaching with the executive education there. Yeah.

SPEAKER_01 2:11

You definitely did more than me. I gave eight years. So I gave eight years, and you and I have presented together at the Palm Beach County Medical Society, and we run in the same circles because I do the administrative side. You are very much focused on compliance, billing, coding, regulations, like that's your jam. What do people not understand about the whole process? Because the doctor's visit doesn't end after the patient leaves the exam room.

SPEAKER_00 2:42

Yeah, well, the, you know, oftentimes patients don't think about the business of healthcare. They think about the what I would call clinical transaction between themselves and the doctor, right? And maybe some of the staff members in the practice. Uh, but the overwhelming majority of the time spent in the business of healthcare is outside of the room between the patient and the doctor. Right? If you put your, if you put your mind in the body of a patient who's having a visit today with whatever their specialty doctor is, well, stay rheumatology, since that's where I know your husband practices. Uh that patient doesn't even realize before they walk in the door that that practice has spent minutes to perhaps fractions of an hour getting all of their pre-approval work done. If they're on some type of uh drug-based procedure, there might be financial assistance that practice is working with, right? So you have all of that before they walk in the door. Then they walk in the door and the front desk staff have to make sure that all of the information is correct, because if it's not correct, there could be a reason that the doctor at the end of the day isn't able to get uh paid for the work they did, right? Which would shut down the system.

SPEAKER_01 3:55

And I don't even think people realize if information is incorrect in the system and it gets sent out to the payer, if the administrative team, the billing team, are not reviewing the denied claims, you could hit a timely filing issue where, oh, I found it 61 days later. And United Healthcare is a really big uh player in only allowing you to bill within 60 days. I always tell people when you negotiate contracts, follow CMS's rules. So you have 365 days, but then it's a denied claim because of timely filing.

SPEAKER_00 4:36

Yeah, so you you have you run the risk of A not even being able to have your claim considered for payment, right? Because you didn't get the information, the all of the accurate information in timely. But on the flip side of that, depending on who the payer is, right? And here in Florida, uh we have a number of practices and physician offices that deal with Medicare as their primary payer, right? And um those payers, again, depending on who they are, can go back years later and say, oh, by the way, there was this technical error you had, and we want the money back that we paid you for that visit. Um, and so you're out clearly the money for that visit if you don't have a leg to stand on with that technical denial reason. But God forbid you had some expenditure for that visit. So maybe you had uh a drug or biologic that the practice paid for that they got reimbursed. Well, that's having to be refunded too, right? So you're hit with what I would call a double whammy there, where you're out the expense of the product that you provided a patient, your staff time, and then you're out the reimbursement that you've already spent because it was given to you two years ago.

SPEAKER_01 5:48

How did you even get into healthcare?

SPEAKER_00 5:50

Oh, wow, we're gonna hit nepotism early on. So, so um, I've been doing this for uh since 2002. Uh, luckily for me, very luckily for me, uh, my mother Jean started our firm, Acevedo Consulting, uh, in 2000. And um, by that time, she was already a pretty well-recognized expert in uh coding, billing, reimbursement, and compliance. So the the practice itself uh took off pretty quickly from 2000. I joined in 2002, um, when after, you know, as a young, young man realizing I don't want to be in wireless communications uh as a career, right? I had this job and um and I was working for Verizon Wireless. They were a great company, nothing against them, and they were having corporate layoffs. Uh and um it was good timing. So um I was really in the midst of what do I want to do with my life? I I don't want just to go from job to job, right? Uh study communications in college and some criminology, wasn't really sure. You know, as young adults, they kind of push you into making a decision really quickly. Uh and thought to myself, you know, this is a a really cool thing that my mom has a business with our family name on it. Um, and what would I have to do to be serious about that? I I was always intrigued by what she did for work. Um, I have a strong relationship uh with my mother, who was a single mother. And um, and so I would work the switchboard at the medical practices she ran at eight years old, right, over the summers. So uh it never turned me off to what she did, right? Some kids, they come home, they don't want to talk about their parents' jobs. It's so disinteresting. I I always found it intriguing. So um I really thought to myself, what a waste it would be if when she was done practicing, if this business just went away. Um, little did I know that she would still be uh uh by my side as a partner now uh and working with the firm as we try to uh coerce her into enjoying her. Yeah, which she will never do. I I love G. But but so got into it in 2002, and it was a unique opportunity because the national law that deals with uh patient privacy called HIPAA, right? The Health Insurance Portability and Accountability Act, uh went into enforcement in 2003. So um we both sat down. Um I'll say Gene and I, because it's taken me long enough to get out from her uh um wings and spread my own. So um, for work purposes, we call Mom Jean. But um, we sat down and we said, you know, this would be a really unique opportunity. There are no experts in HIPAA because the law isn't enforced yet. Um, and so I spent the first about year and a half just reading the law and was charged with developing um our privacy program manuals and policies and procedures all around HIPAA. Um, and that's what I did, just sat there back to back with somebody who was a consummate professional in the industry and learned every day. Almost I had a what I would call like a true apprenticeship, right? Um, and so cut my teeth there, um, was was working as kind of her personal assistant when it came to the coding and billing reimbursement stuff, realized I could do that too, um, and got certified in in coding. Um, had a small stint as a coder for what was at the time Hospice of Palm Beach County. Um, we do a lot of work in hospice and palliative medicine. And so um I needed some more experience. They needed a coder, worked out great. I'm, you know, it's a small, small world and timing is everything, right? Um, and so slowly but surely uh gained the confidence to uh to and the knowledge to be able to be provide trusted guidance to clients. And um at the end of the day, I think luckily because I have a fairly outgoing personality and I'm not scared to talk, started lecturing fairly young in my career, uh became a respected uh and sought-after speaker with respect to HIPAA, coding building and reimbursement. Um, and you know, 23 years later, have the uh pleasure and honor of serving some of the country's finest physicians and helping them navigate this absolutely tricky maze of reimbursement.

SPEAKER_01 10:21

Oh, way more than a tricky maze. I mean, it's utter chaos. Your son Marcus is Benjamin's age and just finished his second year in college, and he is going to apprentice for you again this summer. Does he want to take over the family business? When you I know you're not working as long as your mom. We already know that. When you decide to separate, that's I think yet to be determined.

SPEAKER_00 10:46

Uh, it was funny. Last year uh he did a uh what we would call apprenticeship summer internship, and um it was a lot of busy work, and there were there were some complaints about how, you know, I feel like I'm not learning anything, but you gotta cut your teeth somewhere. Or so had to remind him. You know, your grandmother and I were the ones who empty the trash, wash the towels, oh yeah, clean the sink, do everything from invoicing to scheduling to learning all the little things that you're doing. It didn't come out of nowhere, right? So um just stick with it, right? And this year he actually came back and said, you know, rather than interning somewhere else, he really wanted to learn more about the business and um, you know, sit in on as many calls as he could and and really gain some more experience. So I think we'll have a good, a better barometer of that after this summer when he gets a feel for less of the administrative work that we had him doing and more of uh learning about the ins and outs of what we do for our clients to um help ensure their financial wellness.

SPEAKER_01 11:51

I love that. Your mom, as I've said so many times, is one of my mentors and I adore her. I love her. I don't even say that that often how I feel about people, but that's why I think you're my brother. Don't tell Brian that. I will not. So what has your mom, because she's taught me a lot, what has Gene taught you that still resonates every day when you work with clients?

SPEAKER_00 12:19

Oh wow. I mean, the first was a really simple life lesson, not necessarily a business lesson. Um, and and it really boils down to us all being different pieces on a chessboard at any given time, right? Healthcare is such a small community, and you know, we service clients all across the country, from Puerto Rico to Portland and and uh South California through Maine, right? So we've really and Hawaii, we've had clients. So um, but at the end of the day, while while I may be a rook sometimes or a bishop, um, every once in a while I get to play the queen.

SPEAKER_01 12:55

You don't get to be a king ever?

SPEAKER_00 12:56

Never, never get to be the king. Uh at the end of the day, the majority of us, right, in the in the in the dynamic of healthcare are pawns on the chessboard. And we have to remember how we take a piece, when we take that piece, it is going to be reciprocated somewhere down the line, right? So that was probably the biggest lesson uh that I learned from a from a business perspective. Um, I mean, Gene's a shark, but really about putting our clients' needs first, and that begins with ensuring we know what we don't know and really staying in our niche. I mean, we at one point we thought about having a billing company because our clients all struggle with having good quality billing companies. Um, and we've thought about dabbling in other areas of professional healthcare compliance. Um, but what we do, we do really well because it's all all that we do. And I think that's been a wonderful lesson is you know, really without keeping blinders on, staying in a lane. Oh, stay in your lane. That is what I had to learn this year. Stay in my lane. And and every time, you know, I go to step out of it, I'm reminded quickly with one of those, you know, jockey whips to my horse hips that get back in the lane. Right.

SPEAKER_01 14:11

So tell me, tell me what was so difficult for you to learn. Like, what did you have to learn on your own that nepotism couldn't give you?

SPEAKER_00 14:20

Oh, wow. So um there is from a I think from a physician and office manager perspective, right? Which are really who we deal with. Some C some practices are large enough to have C-suites, right? But at the end of the day, it's the administrative leadership team and the doctors, the providers, some some advanced practitioners and doctors. Um and I think the hardest thing to learn was to ensure my approach is a talk with them approach. Because I've I've found over the course of these last two decades that a lot of the work we do is counterintuitive to their thought process for what makes sense. Um and they don't they don't like that they're questioned by a nurse in a reviewer station at a payer, right? So they don't like that. They don't like that their thought process is being questioned because they didn't necessarily use the word a nurse reviewer wanted to see on a piece of paper, right? Um, and so I've I've really had to, and I don't think it took me long to learn this because I had a good teacher, but I did learn that I have to take the approach of talking with that team, right? Um, and and trying to find the yes in a sea of no's because everyone else is looking for the no, you can't do that, right? And that's really where I think I've been the most helpful to my clients is sitting down and really providing a practical approach to some of these ridiculous rules or some of the audit findings that you look at and you're scratching your head to find out how could this nurse not recognize that GNR sepsis and bacteremia in a patient in the ICU is a complex patient?

SPEAKER_01 16:15

Oh, I I will tell you, I don't even know what those terms are, but I will tell you, oftentimes I'm scratching my head and I'm like, bring it down, Meredith, bring it down. Like I'm like, how could you not have figured that out? And you've worked with so many different entities, physicians, nurses, practice administrators, hospitals, hospice organizations, attorneys, regulators, you're all over the board. What has that taught you about how healthcare really works in America?

SPEAKER_00 16:49

It works in the trenches. It really does, right? You've got to strategize. I mean, it's almost like I don't want to minimize, especially in today, with what's going on in today's society. I don't want to minimize military strategy, right? But it is a battlefield for the providers with payers. They are constantly looking for ways to, in their minds and perhaps in their shareholders' minds, uh, ensure that they're spending the least amount for the most return.

SPEAKER_01 17:18

Yeah.

SPEAKER_00 17:19

Right. And oftentimes that means the doctors and practices are caught in the crosshairs. So that it takes, it takes thinking through a strategy. It takes really sitting down and, you know, we did it once at your house, right? Hey, we want to expand our practice. We don't know where the heck to start because we don't necessarily know what the landscape looks like from a reimbursement perspective regulatorily. Do we open a physical therapy wing or not? Think about if you would have done that and they just cut physical therapy assistance reimbursement over the last few years, right? You would have been three years into still paying off the debt that you use to expand the practice to now have a loss leader.

SPEAKER_01 18:01

But I think what you bring up is so important and crucial. It's strategy. Yes. You have to be strategic. You have to be business minded. When I teach the business of medicine, because you also teach the business of medicine, what is the goal of any business?

SPEAKER_00 18:18

To make money. Exactly. Even if you're a non-for-profit, we work for a ton with a ton of hospice not-for-profit entities. We work with physician practice not-for-profit entities, right? Um, and some some wonderful ones that do amazing work for sickle cell patients or AIDS patients. But at the end of the day, if they're not making enough money to keep the lights on, those grant dollars dry up, right? So, so yes, it's not enough today to just be a provider who wants to just see patients, right? If you want to do that, you need to be a hospitalist. And I'm not taking anything away from the hospitalists, right? But you go and you see your patient, when you're done, you have your week off after your week on, and you have an administrative team dealing with everything else. If you're gonna run a practice, you have to, as a physician, rely on the folks who can run that small business the way it needs to be run.

SPEAKER_01 19:15

What is most difficult right now for those who are trying to run these businesses in healthcare? What's making the American healthcare system so difficult right now?

SPEAKER_00 19:31

I think it's a combination of factors, right? I mean, clearly with the overwhelming number of commercial payers that have policies that at the end of the day reduce reimbursement.

SPEAKER_01 19:45

It's not even that they reduce reimbursement. Every insurance company has different guidelines. Right.

SPEAKER_00 19:51

So that's what I'm saying. So so let's so so let's start with the notion that um every year the commercial payers are trying to find a way to at the at minimum reduce reimbursement. On top of that, right, they all have their own guidelines and ways they want things done. On top of that, they create little policies that make it harder to even get to the reimbursement level you're trying to get to, right? So a good example this year, there are a number of payers, you can name them, I won't, that um have have policies in place that automatically downcode services if they're billed at a certain level, right? And so they look at the claim that's submitted and they say, oh, this claim doesn't look to us from a from a pure bird's eye perspective, whether you they're using AI or people or data mining, doesn't look to us like it would support the type of visit you've billed for. How the heck do they know that?

SPEAKER_01 20:46

So what is the fight or what is the pushback that practices can do for that? And by the way, I'll say it for you, it's Cigna NetNow. So what can practices do to fight against that?

SPEAKER_00 21:01

So the first thing you have to do is ensure you're knowledgeable. So you have to have folks, you have to have a pipeline of information, right? If you don't know this is happening, and and then you don't even know to ask your staff if you're in leadership or a doctor, you don't even know to ask your staff, is this happening to us? Is this automatic down coding happening in a way that we weren't even aware of because nobody's reconciling, right, the claim we submitted with the dollars we submitted to what we got paid, right? Because there's no, there's a reason code for that down code, but there's no denial it was paid, right? So if all you're doing at the end of the day is submitting claims and checking a box that those claims got paid, you're not doing enough. You've got to know that those claims got paid at the amount they were supposed to get paid because you've loaded that fee schedule and there's checks and balances. And that's where we started the show off, right? At where we talked about the bulk of the work not happening. In the doctor-patient transaction, right? That's the real nitty-gritty work that has to be done is the checks and balances, inspecting what you expect. Know when a new rule is starting, right? So another silly, not silly, but another example, right? Medicare, CMS just changed their ABNs, advanced beneficiary notices, right? I'm not going to go into all of the details, but when you're putting a patient on notice that they might be financially responsible, they change the ABN. Effective this week, the new ones have to be used. What is the difference between the old ones and the new ones? Let's just for argument's sake, say semantics, one line. There's something different in a box here versus the box over here. But if you're not using the new one, guess what could be a technical denial reason to go back and get money back, or say that you didn't properly notify a patient to get paid and you need to refund patients, right? So, but if you didn't have someone pushing that information to you that this changed, do you have someone on your team looking for something like that? The overwhelming majority of doctor practices don't have that.

SPEAKER_01 23:06

Even insurance companies say it is the practice's responsibility to know the rules. To know the rules and to seek them out, even though they're changed and uncovered and covered up and uncovered and covered up and then buried very deep in the minutiae.

SPEAKER_00 23:23

So I'll revisit your question about what did I learn? Because that made me think of something else. Is I I had to learn where to find as much of the information as possible and not be scared to have it pushed to me and have information overload, right? It's my job to have more information than you, right? And so if you're getting all of the same listserv publications and notifications that I'm getting, well, you have the information at your fingertips. You might want some help interpreting things, right? Or practically coming up with a solution. But my real value to the clients on top of those things is heading off that information first, notifying you first. Hey, Meredith, Mark, here's something that you have to be aware of that you didn't necessarily know so that you're not financially at risk down the line.

SPEAKER_01 24:10

And even if we had access to all of the information that you have, who has the time?

SPEAKER_00 24:16

Sure. No, understood.

SPEAKER_01 24:18

Yeah, that's the biggest challenge. And I'm looking at all of the players and all of the parts within our system and everything that you oversee at Acevedo Consulting. So from your vantage point, where does the system break first? Because you have coverage, you have reimbursement, regulation, documentation, coding, compliance, and then payer behavior. Can you even choose one?

SPEAKER_00 24:49

Where where the breakdown lies first? Yeah. Oof. They're so layered and interconnected. That's that's a difficult question to answer, right? Because you'd think it'd be as easy as doctors are fed up, they can just stop. Right. Well, we won't just we just won't take any more United Healthcare. We won't take any more Florida blue, right? It's not that easy. That's what happened to us. And you can't abandon your patients, first of all, right? You're you're yes, you can make the business decision, the hard decision to say, you know what, Maddie Smith, she's just not going to be seen.

SPEAKER_01 25:26

It's difficult. And going back to the business side of medicine, we had to step away from Humana. After I spent three years negotiating that contract, they came back 18 months later and wanted to reduce my reimbursement literally to 65% of Medicare allowable. How do you run a practice on 65% of Medicare?

SPEAKER_00 25:48

It's a Medicare practice at that point.

SPEAKER_01 25:50

Yeah. Right. And we're not set up for that. They almost yelled at me and thought I was such a terrible person that we would not provide care to their patients at 65% of Medicare allowable. Then we had to step away from Aetna because there were so many denials and coding changes and non-coverage guidelines that when I did the math, we were getting paid at about 68% of Medicare allowable.

SPEAKER_00 26:19

Yeah, and unfortunately, the insurance companies have that leverage, right? Because they they the we're in a third-party payer system, whether you like it or not, right? So you can go to concierge medicine or a direct pay model, right? If you have the luxury to do that, if you're in the right specialty with the right patient population, a population that can afford it. You know, we we do a lot of work with concierge medicine practices. They they're um do amazing work for their patients because they can dedicate more time and things like that, right? But you have to have the right population to do that. So the the insurance, the payers have the leverage, right? Medicare is by far the largest payer. They have the leverage. You can't negotiate your rates with them, right? Um and and and then on top of that, they have the leverage of if you change your mind later. So you go back to Humana and say, you know what? We'll come, we we do want to see these patients. It hurt our business, and we want to come back and see them. Tail between your legs, right? Not only could they say, well, the deal that was on the table is no longer on the table, they could say, sorry, our panel's closed.

SPEAKER_01 27:28

We don't want you at all. Which actually brings me to something very important that I spoke to our students about last week. When you're in negotiations and you want to hang your own shingle, you have to make sure that there are payer panels available to you. Now, with Medicare, yes, but then you have to look at DME. Durable medical equipment right now, on hold. It's been on hold for I think two months, maybe longer, but it's on a six-month hold. So if you are thinking you're going to dispense DME, uh, think again.

SPEAKER_00 28:00

Yeah, you and and and again, how do you know that going in that there's a moratorium on something, right? That you're thinking about doing, right? Or maybe there's a practice in another state that's doing something really innovative, and you say, Oh, I want to do that too. I want to do in-office dispensing, but you have no idea about all the little nuances, right? So I do think, well, while I'm not trying to make a plug for vendors, I do think there's a place for professionals who have the knowledge base to get you through something, right? You took over that class of mine. Yes, yeah, outsource, right? When to outsource. And um, and you know, I I watched a recent comment from uh Kevin O'Leary, the Shark Tank, uh, Mr. Wonderful, right? And he's he despises consultants, right? I I think I don't want to speak for him and and I don't want to, you know, say whether I whether I'm siding with him or not, but I think what he despises is somebody who just tells you like all these things you need to change without any real practical solutions.

SPEAKER_01 29:03

Oh yeah, like it kills me when I have vendors who come in and teach me how to run my practice or want to tell me how to run my practice. I'm like, have you ever been a practice administrator? Have you ever run a medical practice? Have you actually even worked inside of a medical practice? But they all like to share information. But what I thought was really interesting, and I had not known this about your mom until I interviewed her, she actually ran a medical practice.

SPEAKER_00 29:32

So she ran her first practice back in the 70s. Yeah. Yeah. She ran a uh practice up in New York and really cut her teeth there. And I'll say to that point, you know, I had about a six-year hiatus from consulting, where I went and was the COO of uh multi-state medical practice and uh vice president of physician services for the largest privately held hospice. So I was in the provider hot seat, right, and had to deal with these problems. That was a great experience to really get me to understand the pain points at the end user, right? Rather than just sitting in an ivory tower in a consulting office. Um, and I do think I brought that approach when I came back to the firm as a as a positive for our clients.

SPEAKER_01 30:15

It's always great when you can learn all aspects. It is so difficult to be able to run a medical practice right now, and there's so many different entities. And doctors want to provide the best care that they can to their patients. Do you think the system rewards them for providing exemplary care, or do you think the system rewards them for playing the game?

SPEAKER_00 30:43

I think that there are relationships that a practice can have with certain bundled care networks, if you will, right? ACOs, um, some value-based options. Even Medicare has some unique payment alternatives, right? Alternative payment methodologies that you can get into where you are rewarded for quality medicine at minimum for keeping costs down.

SPEAKER_01 31:11

Yeah, but the way they attribute that, Chris, is so insane. We don't even need to get into that, but it's crazy.

SPEAKER_00 31:16

I think the problem with our system, the third-party system, and I may take heat for this or not, I think the biggest problem is the fact that there is assignment of responsibility. I think that um whether you like it or not, as a patient, you have to own some responsibility in the maintenance of your care. And far too many patients don't want to own any of their own responsibility.

SPEAKER_01 31:40

We've talked about that on previous podcasts, and I don't think you should take heat for it. You're not just sitting there idly by. This is your body, this is your life. You have to take responsibility. You can't just go blame a provider. It always shocks me when I don't know if this is a great example, but the surgeon cuts off the wrong limb, but it was marked when the patient was alive, like and they are totally coherent. And you're thinking, hmm, maybe this was a problem as a patient, and I should have been aware of it. I mean, that is a stark, crazy example.

SPEAKER_00 32:15

I understand where you're where you're going with that, but you have to take responsibility. Yeah, I mean, I so I do I think, you know, if if the model was better, I think that if you were a doctor and you demonstrated you got a patient to quit smoking, you should get paid more for caring for that patient, right? Which is which is where the risk model really plays to with with Medicare, right? If you can, you're given this bucket of money to care for the patients. And if you can keep their utilization down, which to the payer means they're paying less and conceptually they're healthier, that's why they're paying less.

SPEAKER_01 32:53

Yeah, but that doesn't happen because again, I go back to it's a game. So when somebody has that risk model, the doctor, they get a lump sum of money to take care of the patient. If the doctor refers that patient out to a specialist, they've now lost the money.

SPEAKER_00 33:10

Well, so that's where I think it's if the doctor refers the patient out, they're doing so. They know what's going on. That's part of the risk reward game, if you will. What's not fair is that the patient gets to just go somewhere else on their own. The patient gets to decide, I'm gonna go get this CT scan.

SPEAKER_01 33:33

But does that really happen?

SPEAKER_00 33:34

Oh, absolutely. They'll well, maybe not in that way, right? Because they can't bypass if it's a if it's an HMO, they can't bypass the primary care physician, but they can make it to the point where that physician finally just says, here's the script, go get the darn CT scan.

SPEAKER_01 33:53

But so many doctors do that. We have patients who watch commercials on TV and they see that one of these pharmaceutical drugs is the best and the brightest. And they went and played mahjong, and their friend is also on that drug. And so they go to the doctor and they're like, This is the drug I want. And doctors are just tired of fighting against patients. It's similar, I think, to teachers. When I was a teacher, it wasn't quite as bad, but my best friend is a teacher. She's like, I am so tired of fighting with parents. Right. Just give the kid an A.

SPEAKER_00 34:30

No, I I hear you. You know, that's that's uh any medical advice given on a pickleball court, right? They come back to the to the doctor and say, Well, you know, Maggie told me I should be on this. Right. Um I think that that to a large extent because of lack of tort reform. I mean, there are again, there are so many, there are so many influences here, right? Because of a lot, because of a lack of tort reform, right? You have doctors who are scared to get sued. So they write the script, they write the order, right? They know that there's a litigious society out there that um the moment something happens that they it was impossible for them to foresee as a physician, but it happens and they didn't write an order. And even if that had nothing to do with, they're getting sued. Right. So um there are there's this confluence of outside influences on that doctor-patient relationship, right? Um, would it, wouldn't it be nice if the doctors could have their lifestyle income subsidized, right? Um, and they didn't have to worry about it, right? It would be, I I actually think it would be a good thing if there was a, and I don't know how you would calculate it, but by specialist, right? They were, they were our tax dollars paid for the care we get, similar to Germany's structure where there's also a private, robust uh uh commercial system, right? If you can afford more healthcare, you buy it, but there's nationalized healthcare. And the doctors, based on their training and specialty and board certifications, they get an income. And they can do outside work. They could be medical directors somewhere else, they could do work for pharma or or uh device companies, they can lecture, they can do all kinds of work. So their income isn't capped, right? But for the care they provide Monday through Friday in a clinic, this is what the going rate is. And there's no negotiating with insurance payers for that baseline rate, right? Now, you also work with, I'm just like Florida Blue happens to be one of the commercial payers in this made-up market, right? And you're a five-star provider with them, and so they pay you a certain rate and you're happy with it. Great. Right. So, yes, doctors can still have the uh uh financial, the financial reward of all the schooling they put in, right? And it's still a profession that makes sense to put the amount of training and the liability that you have, or there has to be that reward for it. It can't just all be because I want to serve, right? Um, but but in today's capitalistic society, it just has to be reward for that.

SPEAKER_01 37:22

Not only that, it's delayed gratification for doctors. Most of them, the average amount that most doctors graduate in debt is about $300,000. So how do they continue to pay that off? How do they have their families? How do they take care of patients if they're constantly worried about putting food on their own tables? Who wants to start going into medicine at the age of 33?

SPEAKER_00 37:47

Right. And they can't all go work in a mockly and get their debt wiped out, right? It just doesn't work, right? So you need metropolitan, urban, urban area trained physicians to work in those areas. But I do think if you took assignment out of the mix and there was more responsibility on the patient just having to do what they had to do and less responsibility on a third-party payers profit line, right? Um, I do think there's some answer in that equation, right? Um you know, I know that that um I'm not an expert in socializing medicine, or uh, but there there definitely has to be a better way. I'm tired of seeing seeing my friend physicians burn out. My best friend's a primary care physician. He's in the process of fire selling his practice because he doesn't want to deal with it anymore.

SPEAKER_01 38:38

And how old is he?

SPEAKER_00 38:39

My age, 50.

SPEAKER_01 38:40

Yeah, that's the problem. Yeah. You know, we we talked about this because our moms are baby boomers, and your mom is continuing to work. My mom worked until the end, and you and I are looking at them saying, that's not the life we want. We do not want to only identify with our job, our profession, and what we're doing for everyone else. What about our families? What about our time? What about our sanctity? And so you and I are about the same age, and we're going, okay, uh, we might end up leaving before our parents. I mean, not in our situation. I know what you mean. But it's it's difficult because you do. It's yin or yang, it's all or nothing. There, we have to have a middle ground. And a lot of this and a lot of what comes at us is because we, I believe, are constantly playing whack-a-mole. And you work a lot, I know, in the fraud, waste, and abuse area, or at least Acevedo Consulting does. Your mom loves to tell me stories about how she testified or how she had to deal with the DOJ. How does that impact the good players, which are probably, I've gotta believe, are 98% of doctors. How does that impact us?

SPEAKER_00 40:02

The bad players, how do they impact? Yeah. I So one of the things that in my in in one of my um compliance courses that I teach, I talk about the dollars that are spent with Medicare contractors just to ensure the $1 that they paid you is paid correctly, right? So you've got a cert contractor, uh fraud contractor, the general contractor, the Mac who's paying you. You have a recovery audit contractor, right? Then there's the commercials have those same types of in uh uh uh contractors, and Medicaid has them. And then there's the OIG doing their audits, right? So um, so they're spending all this money just to ensure that first line dollar was paid correctly. And and yeah, they recover exponentially more money than they spend, right? Some of that's on the backs of providers who just made innocent mistakes, weren't committing fraud, didn't realize what they were doing wasn't allowed, right? Whether they should have or not, but they weren't committing fraud. There was no malicious intent, no deliberate disregard or or uh deliberate ignorance, right? Um and and it's because of the bad providers that they find, right? The doctors who are diluting chemotherapy drugs and billing for them, the doctors who are um and and and licensed physicians, right? Not just, you know, not just immigrants from another country who are criminals, right? These are licensed physicians, some some foreign, some American, right? Um, and they are they are out there having patients provide their provider numbers, giving them $20 in a sandwich, and then billing for infusion that never happened, right? Or they're taking kickbacks for home health or uh whatever the other referral might be, right? So because there are so many of those that keep getting caught, the government keeps looking, right? Um, and and then the good providers get caught up in that in that fishing net, right? It's almost like commercial fishing. You get caught up in that fishing net like a dolphin, and um, and because you perhaps had an EMR that didn't sign your orders when you ordered infusion, and there's no way to print out a signed order, you owe all that money back for those infusions, right? You just get caught in the trap. So it absolutely makes it more difficult, the the bad providers, um, which is why we don't feel bad with the work we do with the DOJ, right? We do a ton of work with the Department of Justice when it when they present a case to us, we look at the merits of the case. And if it's a bad provider, yeah, let's go get them. Let us help you, Department of Justice, go get them.

SPEAKER_01 43:02

It reminds me of one of the pearls Gene taught me. And it is just because you don't know something doesn't mean you're innocent.

SPEAKER_00 43:13

Yeah, absolutely. So there's this for for since I've been with the firm, uh, there is a slide that both Gene and I use when we do education. It's from an attorney, Larry O'Day, and we give it attribution, right? So all for plagiarism with attribution, right? But it's the iron laws of Medicare. It's and it's meant to bring a little bit of levity to what we're gonna discuss, because it's not always positive, the things we're talking about, right? Sometimes it's payment cuts or changes that you have to prepare for. Um, but it's, you know, just because it has, I'll I'll I know some of them by heart, right? Because I've been doing this so long. Just because it has a code doesn't mean you can bill for it. Just because you can bill for it doesn't mean you can get paid for it. Just because you've been paid doesn't mean you can keep the money, right? Um, and it goes on and so forth. And the last two lines. Are basically there's always some uh I believe they're both Yiddish terms, right? There's always some Schlamiel who knows who did who uh who who knows uh who who didn't know, right, that they should have known. And there's always some Schmendrick who knew and did it anyways, right? Uh and so um that's the world we live in, right? Uh it's unfortunate. Um but because of the constant rule changes, I mean, if I if you were, I'll take a step back for a second. If you were opening a business today, and I were to tell you it's gonna be uh a multi-million dollar small business, right? Small in the terms of the number of people it's gonna employ, right? And that business is going to generate uh gross revenue in excess of ten million dollars, um, and you're gonna have a good profit margin. But every November, somewhere around the first week of November, you're going to be told what the rules are that you have to play by in this business for selling your widgets, documenting how you sold those widgets, and what you have to pay for those widgets. I'm gonna tell you by the 15th of November, and you're gonna have till January 1st, December 31st, to make those changes for next year.

SPEAKER_01 45:29

Can I edit that a little bit? Absolutely. And say sometimes the final rules are not even enforced or implemented or known until after the first of the year.

SPEAKER_00 45:42

Sure. And and and right, so there there might be some interpretations that come later, right? And and Medicare, they haven't done so in uh recently, but they were notorious for publishing guidance today, May 15th, with an effective date of February 15th. Yeah, right. So, hey, this is the guidance we're publishing today, but it was effective 60 days ago, right? If you were to start a business, and I said you could that's a business you could start, or you could start any other business where you don't have this problem, and you can't pay people to get patients for you, right? To get widgets, to get buyers for you. You can't pay people to thank them for getting you those widgets, right? You'd say, well, let me start a different business, right? And so most physicians don't go into this thinking any of that, right? When we talk about the business of medicine. They just, I want to serve patients, and and and yes, it's going to be a good career dollar-wise down the line, but none of this stuff has gone over in medical school, right? Uh, we there are some medical schools here in South Florida that we do some education for their graduating third and fourth year residents or their graduating classes, the the some of the doctor of NP programs. And these folks are going to have the business of medicine affect their lives for the rest of their lives. And they're in a four or six-year program, and they get maybe two hours worth of lectures on this.

SPEAKER_01 47:12

I read some statistics that actually said medical students only get about five hours in rheumatology. So think of the burden that we have. They get two hours of business training and five hours of rheumatology training, and then they go into their residency program.

SPEAKER_00 47:30

Absolutely. I mean, you're you're stuck with the burden as a practice owner if you if you say, all right, I'm going to expand my clinic, my medical workforce by bringing on a physician assistant or an advanced practice RN, right? So they've got whatever their two years of advanced practice training is, but there's no real fellowship for them. Your practice is their fellowship, right? But you have to absorb that. There's no extra pay for that. You've got to absorb a two to four year learning period, paying them full salary. Now they come out wanting more than almost as much as some of the doctors make. Right. And I'm not saying that's a bad thing for them to want that, but the reality is they're not worth it without the fellowship training.

SPEAKER_01 48:16

They're not worth it. And pure ratio, right?

SPEAKER_00 48:19

FTE to expense.

SPEAKER_01 48:20

And oftentimes they come out thinking that they can see patients right away. Or they worked at a minute clinic care, yeah. Right. For six months, and they come out thinking they know everything and they want to see patients right away themselves. I mean, I you and I have taught about incident two billing up the yin-yang, and I literally should have an entire working healthcare podcast episode on that because I know that we bill properly, but I'm gonna say this is another gene tidbit. Who needs to know the proper way to code for incident two in any practice?

SPEAKER_00 48:58

The advanced practitioners.

SPEAKER_01 49:00

Thank you. See, we come from the same world. That's why you're my brother. How can practices, doctors, protect themselves?

SPEAKER_00 49:11

So I I think one one of the things, and and I think it's it's reinforced in the lecture I took over for you, right? Is that doctors have to let the right people protect them. Right? They're they should know everything they need to know about practicing medicine. Um, and some of them know a lot about the business of medicine. I don't want to take anything away from the entrepreneurial, business-spirited physicians that are out there, right? Overwhelmingly, though, they just want to practice medicine. They don't want to, a, they don't have the time for all of the nuanced business components. Andor B, they don't want to do it. They want to see patients, right? Um, and they may want to do innovative things and they may want to dabble here and there, and good for them, but clinically, right? And they may want to do research and stay on top, and that's wonderful. Be a lifelong learner. Um, but but the best way to stay safe is to invest and budget, right? It should be a budgeted line item for whatever you want to call it, non-clinical resources, right? Outside, and and you might be big enough as a practice to bring in somebody full-time. Um, but I think I think doing it fractionally is an easy way to do that, right? Um and um and and even from uh from a managerial perspective, right? There are so many hats your typical practice administrator has to wear. So how do they stay on top of HR law plus compliance from a fraud, waste, and abuse perspective, plus just business compliance, right, uh issues. Plus, we got to know are there changes in when our doctors have to get licensed, what vendors we can deal with, right? Here in the state of Florida, now for the last, I want to say two and a half years, right? When you renew your license as a provider, you've got to attest to none of your vendors that you use storing information outside of the continental United States or Canada. If you didn't know that existed and you're and and what the the repercussions of that or the consequences are, and you have someone else kind of attesting for you, as doctors often will do, right? Hey, I did everything I need to go fill this out, right? Um God forbid the state finds out that you didn't do that correctly.

SPEAKER_01 51:37

I think it's similar to accountants, right? We all have accountants doing our business accounting work. We're not going to HR block to do it once a year in the business world. We have lawyers for different entities. People are always like, Do you have a lawyer to recommend? And I'm like, What type of law? Because we actually brought in an employment attorney that is on retainer. He's fractional. And we have him because we've gotten to the size where, listen, I've done a really good job up until this point, but now I need to focus on some other things. And I'm not a lawyer. I need to have somebody who lives and breathes this. We've worked with you forever since literally Mark finished his fellowship because we wanted to make sure that we were following the rules, we were being compliant. Who has time for all of this?

SPEAKER_00 52:28

Yeah, it just it as you're laying out what practice expenses are, it needs to be a budgeted line item, right? It's the Affordable Care Act mandated compliance programs. That doesn't mean that it mandated you downloading something from compliance today and putting it on the shelf, right? Um, and and there's plenty of guidance about what an effective compliance program actually is. And the Department of Justice has a great memo that gives its prosecutors, right, gives its investigative arm guidelines as to follow as to, hey, if we're investigating Meredith because we think she did something bad, and this isn't specific to healthcare, this is corporate compliance guidance, right, for effective programs. So I'm the investigative authority. I'm looking into whether or not I want to charge Meredith with a crime. There's a memo that outlines all of the things I need to consider about your compliance program, right? What's the culture? How many dollars based on the size of your practice? What do you do when you find an error? Do you report things correctly? Is there evidence that you've ever reported anything ever? Right. Um, and kind of like what's the structure? And it hits a number of topics. And so, yeah, just like the practice has to account for a cleaning crew, accounting services, compliance services should be there. Right. Um, and and I I happen to take a unique approach. When someone asks me what I do, I generally don't say I'm a compliance consultant. Because it would bore people. Yeah, but I think there's more to what I do, right? I I usually say I help physicians optimize their reimbursement with a compliance focus so that in the event they have to defend it, the money is as safe as it can be.

SPEAKER_01 54:15

And it's important because I get ideas all of the time as to what new codes are available. I remember sitting in on a meeting and learning all about principal care management. And then it went out the door because it was 2020, and that's when COVID happened. And then when I got my boots pulled back up a year and a half later, I was like, let's look at this PCM thing again. Let's look at chronic care management. So having somebody to help you develop ideas for additional ancillaries is so important.

SPEAKER_00 54:45

Yeah, and I think, and I think there are folks who just do that, who do revenue optimization. And that's great too, right? But I do think that one of the things that physician practices, some healthcare entities, the larger the entity, the less it happens because they have all these checks and balances. But the small entrepreneurial practice, they don't stop at mile marker two or three to say, what are the compliance guidelines here? What are the what are the guardrails we need to have? Right. They get to mile marker nine on a 10 mile road and then realize holy expletive, we needed to make a left at mile marker three. Right. Um, and if you're already billing for it, sometimes that's too late, right? So um I do think compliance as a speed bump on the front end, it shouldn't slow you, it shouldn't slow, it shouldn't slow you to a halt, right? But absolutely, hey, we want to bring this on. Okay, it yes, we've gotten some performa from vendors. It looks like it makes money. Well, the vendor's always gonna tell you how good it's gonna be. They're selling you a product, right? So now it's hey, compliance professional and legal team, what do we need to know about this that we may not be thinking about?

SPEAKER_01 55:59

I want to ask you, what is that one thing that you see that practices get wrong most often?

SPEAKER_00 56:10

Can I can I use the incident two card here? Because that's that's probably the one thing they get wrong often. So when when a practice is committed to using that benefit category, and I think it's there for a reason and it's good, right? Um they don't spend the time educating the advanced practitioners on when they need to press the stop button, right? Because if I'm a patient and I'm going to see, I'm going to see Evan in your practice, right? And I'm a I I don't care sharing this, right? I've been seeing Mark and Evan for years. Luckily my gout is controlled, but every once in a while I need uh I have a flare-up. Hasn't happened in years, but uh, but let's just see, I'm seeing Evan in follow-up, right? If Evan doesn't know the rules for when we can bill that visit under Mark, Dr. Hirsch, and and I come with a new problem today because I pulled my shoulder playing basketball, and I bring it up, and Evan, your great PA, does treats me perfectly, does everything he needs to do, but it's a new problem which doesn't qualify as an incident two billing. And if he doesn't know that, then that bill's gonna go out under mark and you're gonna get 15% more reimbursement than you otherwise should have gotten. Right. Um, and that's gonna be, you know, the case time and time again. If I'm there for the gout and Evan says, you know what, let's change you from this dosage to that dosage, and there's no documentation by Dr. Hirsch that says, in the event of X, make this change. That's a problem, right? And so not enough people really take the time um to expose themselves to what the rules mean. They just think, well, the there's a patient, I have an NP, the doctor saw them at one point, so we're fine. And they need to know the rules. Correct. Yeah, that that to me is the the biggest um problem that that is low-hanging fruit. The other, from a business perspective, is people don't load their fee schedules and check to see are they actually getting paid what they were supposed to be paid?

SPEAKER_01 58:14

Yep, a hundred percent all of the time. I want to wrap this up and ask you if you could fix one entity within our American healthcare system, you have one wish, Chris Acevedo, what would that be? These are the incentives, these are the players, these are the policies, anything, what would make the greatest impact?

SPEAKER_00 58:41

I I think there definitely needs to be a push away from pay for the number of fee-for-service widgets the doctor performs. I don't think it's healthy for the system for a do for the for the overall reimbursement model to be tied to how many X, Y, or Z a doctor does in a day.

SPEAKER_01 59:11

Chris Acevedo, thank you for joining me on Working Healthcare. If this conversation hit home or it made you think a little differently, don't keep it to yourself. Share the episode, tag a friend, or post about it on social media. Connect with me on LinkedIn to keep the conversation going in between episodes. If you've got a question, an episode idea, or someone you think I should feature, send me a note at MeredithHirsch.com. Thank you all for the five-star reviews. They help more listeners find the show. New episodes drop every Tuesday. Subscribe so you don't miss what's next. Tune in weekly as we explore the inner workings of healthcare because you can't fix what you don't understand.