We are going to give everyone a couple of minutes to trickle in as we admit them into our virtual lobby and then we will get started in the next minute or two. Welcome, coming in. Wonderful. Hope everyone's doing good today. One more minute. All right, we're going to get to 4.03. All right, I'm going to get us kicked off here so we can be respectful for everybody's time today. So first, thank you for joining. This is our third and last webinar of our three-part series, which was Maximizing Revenue and Value in 2022. We are very excited to have some guests with you today that I know you will thoroughly enjoy. Today's topic is about Empowering Practices and Implementing Internal Coding Audits and Quality Improvement Plans. So really letting you guys learn some ways that we do this or can be done. My name is Dana Crosby. I'm the Senior Director of Engagement and Practice Development at HCCI. And I'll be your moderator today for this call. I do want to go over a few housekeeping items. As you may have questions, you can definitely throw them in the chat if you would like. But we are going to have a Q&A session at the end. If you're shy and don't want to participate in the Q&A, I will be grabbing questions out of there and putting them in a queue for us to address later in Q&A. But we really, really want this to be interactive. So we encourage you throughout the webinar and especially in the Q&A, turn on your cameras, unmute yourself, and we can just have a collaboration. I know we have some shy people out there, but it really seems to meld a lot better in that kind of session. So I'm going to encourage you to do that. I also want to remind you that a recording of this webinar and the deck today will be available on the HCCI Learning Hub. And you'll be able to access those by end of day tomorrow. So I know that will be asked a lot. And we will recap you guys and make sure you know where to find that as you go in. If you do step away, please make sure you mute yourself if needed or turn off your video. So that's a little bit about housekeeping. And now I'm going to go through some legal slides that I have to tell you so we can move forward, Brianna. None of the planners or faculty for this educational activity have relevant financial relationships to disclose with ineligible companies whose primary business is producing, marketing, selling, reselling, or distributing health care products used by or on patients. That was the first one. The second one here is just a statement about your CME credit, making sure that you are aware that some of these activities come with a CME credit that you'll want to look into and get. Those directions are there as well. Now I will very excitedly present to you our three presenters. Brianna Plintzner, who is our Senior Consultant and Manager of Practice Development, HCCI. I know you guys who have been in the series are very familiar with her. We are also joined by Odessa Hoykus, MD. And she's actually a physician and a practice owner for Berg and Geriatric Care. And then Ada Tapper, who is CEO and founder of ACT Health Solutions. I like to say these guys, these two, are in the trenches. And they can walk the walk and talk the talk. And I'm excited to have them join Brianna today to really share those firsthand pieces that they are doing in their practice, how they've benefited with it. And I know you will glean a lot from the presenters today. With that, Brianna, I'm going to turn it over to you to walk us through objectives and go from there. Thank you, Dana. And thank you, everyone, for joining us today. Really appreciate your time, especially those of you who are invested in participating in this now the third webinar. I'm so excited to have these fabulous co-presenters Dr. Pringus and Dr. Tapper. I know you're going to enjoy hearing from. And we're going to make this really conversational towards the end so you can learn from their firsthand experience and insights. Our goals today, we want to identify tools and resources that you all can use to assist yourselves when you develop your own internal compliance plans and what that might look like. Some things are really simple and don't have to be super formal. We're going to talk about the value and the benefits to peer-to-peer auditing and what that might look like on your own team. And then the case examples are when we're going to hear from Dr. Pringus and Dr. Tapper about some things in their practice that have really made a difference on quality improvement and coding accuracy and benefiting their reimbursement models. So I wanted to start with just a little bit of grounding. So why does it matter? Why do we have to talk about coding and compliance and documentation when we have so much other important aspects of clinical care? But I really hope, especially during this webinar, to tie together why this impacts clinical quality and why this impacts the care that you're providing to your patients and your caregivers, as well as how you interact with your team. And ultimately, you have to be there to have a sustainable program to provide care and to be there for your patients. So that's one of the tie-ins. But I wanted to start here. And I'm going to invite Dr. Pringus to chime in first. I would love to hear from our presenters in their own words. Why does quality documentation, accurate coding, and fostering that culture of compliance matter to you? How would you talk about this in your own words? And Dr. Pringus, I'll start with you. First of all, thank you for having us. I think this is a great opportunity for us to connect. And I'm always happy to talk about the work that we do. And I think this particular aspect is important. As you said, it's not always something that we prioritize, also as physician owners. But I realize that really, and I'm going to start with the third part of the question, fostering a culture of compliance. Because unless you have that, you won't have accurate coding and you won't have quality documentation. So I think this is kind of where it starts. And I think why it's important is that when you look at a medical practice, we all need to earn our money. And I think it's important. And we all know that at the end of the day, we are the billing providers who do it. It's our documentation that gets audited, that we get paid for. So I think there's this kind of mindset. So it's the doctor who's responsible for all the documentation, needs to be in compliance, when I think it's really important to give everyone, every single team member in the practice, some ownership of care. And eventually, that care will translate into revenue. And instead of looking at all the different roles, administrative, clinical, as these islands, it really has to be clear to the whole practice that we are part of one system. Yes, eventually, it's going to be the one note that's going to translate into billing. But we all need to know how to document so we are all compliant. It's not just our compliance. And I think this is why it's important that the intake person that may never see an actual patient only gets the demographic data, understand that it needs to be documented accurately. And then the next person, the medical assistant, the nurse, knows how to document. And that's all going to translate at the end of the day into a note that, again, is compliant, reflects the work that was done, and can be coded accurately. And I apologize. I have a motion sensor in my office that sometimes doesn't realize I'm here. So with that being said, I think that fostering a really strong sense of accountability, ownership of the care, of the work that every single team member does, eventually that leads to overall compliance, makes you less vulnerable for audits. It doesn't need much in a chain of things to lack in order to be more vulnerable. And one thing that I do like to emphasize in this context is because of the work that we do, which I have to say, I think most people are here because we have a certain passion that drives us into this field, because it's not easy work and it's very difficult and it's often very fragmented. So if you're here and you do this work, it's frustrating. If you don't see translate into income, right? And I think it's important for us to kind of shake that almost embarrassment off and say, but we need to earn our money, do it well. And how do we do it best is by really meeting these aspects that you just touched on. So to me, that's something really important is fostering that culture within the practice. And as a practice owner, I have to say, it takes a certain level of comfort to be transparent about how the business works and involve everyone into that, right? So not everyone is comfortable with that, and it doesn't mean you have to lay out your last tax returns, but just kind of explain to every single member, look, when you do the intake, guess what? That's gonna translate into certain outcome measures that we may be paid on. Or so I think it's okay to kind of open yourself up as an owner and say, yes, we love what we do, but it's not free work. We've really worked hard to get here and we all need to work together. So we all, at the end of the day, can get paid for the work that we do. So I hope that answers those aspects. It does. I love that answer, and I'm gonna build on that. So that's perfect. I couldn't agree with you more. Everyone has a role in the business aspect. Ada, what about you from your perspective? Hi, first of all, thank you for having me here on the panel as well. And hi to everyone. So why does quality documentation and accurate coding and fostering a culture of compliance matter? Well, most of all, for me, quality documentation means accurate assessment, put into writing for continuity of care. And when that happens, then you can basically code appropriately. So the next one that's gonna pick up on you, whether that's another provider of facility or whoever, can see exactly what's going on with that patient and can then continue to care or change that care depending on what they're there for. The accurate coding is more for the practice. Well, and so for the patient as well, but the accurate coding is you want to bill for what you did. And many times we don't do that. And most of us are out there giving quality care, and the coding is a reflection of that documentation. And when all of that comes to place, that patient can take that chart or documentation anyplace else, and someone can then continue to care appropriately. And I think all of that would then lead to a culture of compliance if all of that is done correctly. I love that. Thank you. I couldn't agree with both of you more. You know, again, the only thing that I would add, excuse me, which really honestly you both have hit on is it really does represent your patient's complexity and the trajectory of their disease. And the other kind of element that we have to add to that now is with the interoperability and patient access rule, your patients have access to their medical records. And with health information exchanges, you know, being more prevalent, so do your partners. And if they're not able to, you know, look at your note and see a clear and concise way how the patient was doing, how you're treating them, what kind of decisions and discussions were going on, that's going to impact care. I have to say, even as a patient, I was surprised when I logged into my patient portal the other day, and I could see my full progress note. I had to literally stop myself from auditing. Like, wait a second. Nope, I'm a patient. I'm not auditing this note right now, but they really do have full access. Maybe your health system and your practice isn't there yet, but that's something we want to consider too. And again, you want to get paid for the work that you're doing. You guys are providing high quality, comprehensive, complex care in the home, and you deserve to get paid for it. You know, it's not pinching pennies. It's not, you know, trying to, you know, game the system. It's really just getting paid appropriately for the work that you're doing. And Adasa, you and I just think so much alike because my last point is exactly what you said. Every team member has a role in practice sustainability, and we really have to foster kind of that understanding. So I get a lot of questions about kind of revenue cycles. So I wanted to talk a little bit about kind of factors that impact revenue. And I love that intake was brought up too, because that's one that I don't think people realize how much that ties into revenue and revenue cycle management. You can't just see every patient regardless of insurance, especially if you're a new practice or an independent provider. You have to understand what insurances you can and cannot take. And if the patient has an HMO or they have a managed care Medicaid plan and you're not the assigned PCP for that network, you really want to do, you know, number one, understand that before you start a care relationship, but also take the time when you're collecting those new patient forms and those insurance cards and that information to verify that it's accurate and correct at the start. We know how confusing insurance is. Almost every patient's going to tell you they have traditional Medicare when they might have a Medicare Advantage plan. You really want to get that right from the start before you start receiving denials or don't have that information. Even an incorrect address that doesn't match their Medicare information can result in a denial. So really put the time and emphasis into that intake process. That's going to lead to that correct coding and claim submission. And then denials are really costly and really time consuming. So don't just give up when a claim is denied. You know, who's going to work on that? Who's going to, you know, call the pay or try and appeal or look at the reason and see if there was, you know, maybe just a modifier missing or some sort of education element that you need to provide. You may outsource your billing or, but you, you know, someone on the team still has to have an understanding of that so that they can kind of flag, you know, issues when they arise and understand if there's something that needs to change. The other thing, kind of thinking more of the leadership position is your payer contracts. Do you know, do you review those annually? And before you sign them, you're credentialing with a new payer. Do you actually look at them? I had a new physician who was getting credentialed send me some of his payer contracts the other day too. And I was looking at the fee schedules and, you know, the covered services and the reimbursement. And, you know, it said we pay 80% of the fee schedule rate. Well, that's a commercial payer. What is 80% of their fee schedule rate? Is that comparable? You want to know that before you credential with that payer. So understanding that, you know, utilizing those partnerships. And then we always like to kind of stay away from that productivity world. You know, we, you know, we're not, we're moving away from paying providers on productivity. You know, hopefully we are moving away from work hard we use incentives and things like that but there still has to be an expectation and some accountability. You know, what do you need to do, especially if you're on fee for service to keep your doors open and to be able to provide the kind of care that you're doing. That should be a partnership between the clinical and the administrative. You're not sacrificing quality but there is some expectations and accountability like there is in all aspects of our life. So understanding all of those factors that impact revenue is really critical. And then also just understanding how that ties to your expense. Our people are our most expensive asset and our most important. But again, if you don't have that revenue you can't provide fair compensation for your people. So thinking about that, you know, not getting ahead of your skis and kind of scaling up too quickly or investing in expensive infrastructure and overhead that's not really necessary. And then partnering with the right vendors at the right cost at the right time. So all of those things are gonna kind of impact your practice sustainability. So again, kind of these aren't traditional coding things but they all tie into practice sustainability. The other thing I like to talk about is kind of this balance between efficiency and quality care. We have to think really strategically about how we make the most of the care that we're providing and how we do it in the most effective and efficient way that doesn't sacrifice quality and also gets us paid for the work that we're doing. All of these things could be tools in your toolbox. You know, I even think of coding different services as tools in your toolbox. Right now we know that telehealth is a tool or a resource for us. For those of you that may or may not be aware the public health emergency was extended. It was set to expire in April. It has been extended through July 15th, at least 2022. And then we also have additional legislation that was passed, the Consolidated Appropriate Act of 2022 that's gonna say whenever the PHE finally ends they're keeping that telehealth flexibility in the home for 151 days past whenever the PHE ends. So it's not going away anytime soon. You might as well use it when you can if you're not in the area. Again, it shouldn't replace that in-person care but maybe you're also using your nurses or your other clinical team to facilitate those visits or to do an assessment when you're not in that area. Even informal partners like your home health agencies, you know, if you're not able, if you get a call from a patient about an acute and urgent need and you're not in the area do they have home health? Can the home health nurse go out there and do an assessment and report back to you? So how do you think about things like that? You know, using really smart systematic care management protocols and believe it or not when CMS designs programs like chronic care management and transitional care management they're trying to give a framework for quality. So thinking about kind of how you're proactively managing your population and that ties into what's defined as an advanced primary care capability such as risk stratification where you're looking at your whole panel and you're saying, okay, all of my patients are sick. All of my patients are complex but who's the sickest of the sick or who's having an exacerbation or who's, you know, just came home from the hospital? How are you making sure that your patients that need you the most are getting more of your attention and more of your time when they need it? And I can never not mention geographic scheduling. It will make or break your practice. If you're a home-based practice, it is so unique. You have to understand, you know have a plan for a scheduling guide, use map-based tools. You can't just, you know, get a call from a patient and drive her all over. Where are you going to be on what days of the week or how are you going to manage that and cluster patients together in the most effective way? And then again, leveraging technology. Sometimes if you have a remote patient monitoring program that real-time clinical data might be able to help you understand when you really need in-person care versus when you can use some of these other tools. And then when we think about medical necessity this is kind of my checklist for, you know medical necessity can seem so nebulous and it can seem kind of like regulatory mumbo-jumbo but all of those things that we talked about and how that ties into clinical care this is kind of like how I would define medical necessity. If I pick up your progress note or if I look at your EMR can I tell why you really needed to see the patient that day specifically, not just a follow-up or a new or they came home from the hospital. What were they admitted for? What was going on with them? How have they been doing for the chronic conditions you're assessing since your last visit? Am I able to really understand if they're stable or if they're poorly managed and what you're doing about it or what you're talking and considering with them about and the specific medication adjustments that are being done and the care plans that are being provided, facilitated how are they monitoring? If I'm just looking at your EMR, you know is that patient really as sick on paper as they are when you're in the home? Again, especially as a non-clinical auditor I'm relying on a piece of paper or an electronic piece of paper, your EMR to tell me what went on in the home. And if we think about all of these things, again that's really like Ada said, that's your continuity of care. That's really telling the story of the care that you're providing for these patients. So I wanna kind of turn a little bit and talk about what is formal compliance standards and programs look like. I get a lot of questions on these, this original guidance and I pulled specifically the OIG compliance guidance for individual and small group practices because looking at our attendees today I think that's most relevant to all of you. This was originally published back in the 2000s when it was meant to be voluntary. As a result of the Affordable Care Act, they do mandate that you have some sort of compliance program or guidance. If you're participating in federal Medicare and Medicaid programs, you know, again, some attorneys will argue that that hasn't been officially implemented or rolled out, but again, you're doing these things. How are you just documenting the simple good faith efforts that you're making for accurate coding and compliance? And I was reading, if you wanna be a nerd like me, I've included the link to the federal register document, but it actually provides some really good, just like practical, not resource intensive tips. And OIG says in their own words, some of the benefits of a compliance program are speed and optimization of proper payment of claims. I think we can all agree that's a good thing. We wanna get paid right the first time. Minimize billing mistakes. Again, a good thing. Reducing the chances of a federal audit. We all know none of us wanna get audited in a formal way. And when we're proactive about that, that's again, a good thing. And then avoiding conflicts with self-referral and anti-kickback statutes. There's more than just coding to compliance, thinking about ethics and how you run your business. So there are seven formal elements. And again, I kinda just wanted to talk through these to break it down into like, these are simple steps. I'm not gonna expect a small to mid-sized independent practice to have any sort of formal, huge compliance department and program like a health system does. It's not reasonable and it's not necessary. But how can you break these things down and make it kind of digestible for you? You know, you can do your own internal monitoring and auditing, or maybe you have a third-party billing company that helps you with that. When we think about implementing standards, that's very specific to your practice. I mean, you may say, okay, this is how we handle time-based services. This is my expectation of a template for new patients versus established patients. This is how we're gonna document when there's non-compliance, simple things like that. That's what they mean by standards. What is the bar that you're holding your own team to from a documentation perspective? And the compliance officer or the compliance contacts that should be an S on that could throw people off. That doesn't have to be a formally trained, necessary compliance person. And there could be multiple people that serve that role in a smaller practice. Ideally, you want some sort of, on your billing and coding team, someone in that realm, but maybe you also have a clinical person, someone that, if there was a new provider on your team that felt like they were being pressured by their peers, you're publicly saying during staff meetings, hey, these are your compliance contacts. If you have concerns or you feel like you're seeing something that's not right, or you don't understand why you're being asked to code or document in a certain way, this is someone that you can go to without being worried about repercussions. It's gonna provide you resources, support, and it's gonna kind of help us champion our compliance efforts. And participating in this webinar even is a way of training and education. So are you just documenting all the things that you do annually? Hopefully you're providing some sort of annual education. Codes change every year. How are you keeping up with those changes? And it never hurts to have a refresher either for your providers. And then of course, worst case scenario, if you do identify an issue, how are you acting on that? And then when we think about open lines of communication, OIG simply defines that as, are you talking about it in staff meetings? Do you have a bulletin board? Those are just two examples. Again, all of these things do not need to be regulatory mumbo-jumbo. You can just document the good faith efforts that you're making in your practice. And then if you do find an issue that you have a policy or in a plan for how you would act on that if you had to. So some practical tips. If you're doing your own auditing, which again, I recommend that you do some sort of annual internal auditing and monitoring once annually. It doesn't have to be huge either. The first tip is gonna be, don't go crazy. Reasonable and small sample sizes. I would say no more than five to 10 progress notes or claims or services per provider during a 12 month calendar period. It can be that small, that simple. You don't also have to do it at the same time. Maybe you break it out into quarters that you're just looking at and providing some real time feedback and making sure that there's no issues. Looking at data can be super impactful and powerful too. When you look at, some of you may be familiar with bell curve reports, and that's just looking at the percentage of billings for each code that your providers are billing overall. Again, how many 99349s versus 99350s or 99337s. And if you have one provider that's significantly under coding compared to the rest of your team, maybe it's just an education piece. So looking at some data for your team as a whole can give you some really good insight as well. And then especially, we're in home-based care. We do services and provide things that are unique to us. What might be some risk areas? Maybe you do a lot of procedures at home and you're using things like that, or again, you're doing a lot of telehealth or you wrote out something brand new, you never coded for TCM before and now you do. So you might wanna monitor that. We talked about kind of standards. Again, when you're doing those reviews, everyone has that sense of accountability of what's expected to them, and they know that, and that's communicated to them when you're doing these kinds of things. Again, in addition to kind of some internal monitoring and auditing, provide some sort of education, refreshers and resources to your team. And then if you have a new provider, typically I would recommend at least for the first two weeks, two weeks to 30 days is kind of the standard that you're monitoring all their notes and their claims so that they can make sure that things are going appropriately, that they're documenting and coding appropriately, or they don't need some additional help and resources. So again, none of this is super big lifts. You can use your team and kind of implement some of these practices. So I wanna pause and talk a little bit about peer auditing, and this could be something more formal. Maybe this is part of your annual process, but ideally if you can, you want not only someone looking at your information from a coding and a documentation perspective, but also a clinical perspective, because I, as a non-clinical auditor, I'm not gonna catch those quality things that you've rolled out at the practice level. So how are you also looking at it just from a clinical quality perspective? And Odessa, I wanted to turn to you. I know this kind of organically happens in your practice if you wanna share a little bit about that. Yes, sure. And if I just can follow up on a couple of thoughts that you brought up that I wanna kind of touch base on. You brought up the big structures versus us small independent practices. And I love to emphasize the fact that doctors, I know there are a few providers here, a few docs, but there are also people from the business aspect, right? Of medicine here. And as docs, maybe I missed that part, how to run a practice in med school, but I know for sure, I personally learned zero, right? Yet we are being thrown into this complete business world, and now we are expected to run it, know how to run the staff, how to be compliant, right? Compliance officer. So I think just looking at that, there's a whole different challenge for small practices versus big companies. We don't have the advantage of having CFOs or other compliance officers. So whatever system you're in, see what kind of resources you have and utilize them, right? And if you're a small independent practice, then like you said, don't go crazy. And I wanna kind of give you guys from PCI a shout out, if you can't do it on your own, seek professional help and learn it and train yourself to do it because it is such an important part for us, providers, the business aspect of it. So I'm glad that people with training actually are involved in medical care because you gotta teach yourself. And over time, when I started onboarding other providers and compliance and auditing, as you said, it really happens more organically in our setting, especially with a new provider, you kind of wanna look over their notes. I think personally that if it happens in real time, connected to a recent case, that's very fresh, that that sticks the most even with, and not just providers, right? Again, nurses, admin, MAs, anyone who has documentation and make it clear, I'm not doing this to micromanage you. I'm doing this to make sure we stay compliant. I'm doing this for our job security. I'm doing this so we can get our paychecks because I want mine, I'm sure you want yours. So this is all part of the big picture. What is our common goal and objective? We wanna provide good care. And so again, if I shoot you a message or an email, hey, that note could have been a bit more detailed here or a bit more detailed there. This is not documented like we discussed at the last meeting. I also emphasize again, it's not to micromanage you, but just to kind of refresh things and make sure we all stay safe, right? We keep each other safe. So I think that's one objective of the way we audit each other. Again, I think it's also important that if you're kind of the boss or whatever role you're in, that it's okay to say, and I want you to give me the same feedback. I myself, I am guilty of not documenting as well as often my MPs do. Their notes are beautiful and they're so detailed. And I was like, oh my gosh, I wanna write notes like that, but I can't, right? I don't have the time. So I need to learn for myself, what do I really have to document? What is efficient? And how much do we need to really communicate with each other? So it's nice to learn from each other. And it's okay if someone tells me, you saw this consultation report, but it took me a really long time to put the pieces together would have been helpful if you would have documented it here. So I think responding to that with, you know what, that's great. That is great input. Thank you. And I think that's important too for us to learn, you know, so auditing each other, not just auditing down. I think audit always has this kind of flavor of, you know, someone up there is auditing someone down here but when in fact it's a very, just very, you know, natural process that should happen between colleagues and every team member is a colleague, right? So it shouldn't be this, or it's just us docs or us MPs. And, you know, so yeah, so this is, we have a more formal way to do it during our annual reviews. And I think that this counts into the whole feedback. And I think it's typically a very well perceived, it's very well perceived. You know, I think everyone likes to hear constructive feedback. And for us with documentation, it does often reflect also what we do and, you know, how often we think this note does not reflect. So the hour that I spent and the heartache that I poured into this visit, right? And it doesn't have to be all, you know, but it should reflect it to some degree. So again, you can then also code things like the prolonged face-to-face time, right? You need to know what you want to code and how you can really get paid for the work that you did. I always say, I don't want to get paid for work I didn't do but every single piece of work and blood that I, you know, shed for that visit, I do want to see some form of return, you know? And yes, it's great to get the emotional return but it needs to translate into, you know, real revenue as well. So I think the auditing process is important amongst peers, amongst each team members, and encourage them to even just, again, audit, give feedback to each other, whatever you want to call it. If audit is intimidating, word it differently. You know your team best. You know, feel what feels good for them. Yeah, I appreciate that you said that too. Because again, it doesn't have to be a formal audit. You know, that's a strong word, but, you know, we're going to do kind of a review or a kind of recap or refresh of how we're doing, you know, position that however you want. Ada, anything you want to add to anything I've said so far or kind of, I know you talked about this a little bit in the sense of kind of how you, maybe not audit, but, you know, keep an eye on your clinical assistants and their role in documentation. Yeah, I just check most of the things that I check with my clinical assistant is how they do the chronic care management and making sure that they're following up appropriately and touching on the touch points of the chronic condition and that, hi, how are you? I'm fine. And then that's it. And they put down the time. It's more about actually finding out what they're doing, how they can do better and provide a little education and counseling on each call as well. So I monitor that. And I think, as you know, one of the way I have audited is sending my documentation to you to review and for you to give me feedback as well. So that is how I do it without having a real peer that I'm working with. However, since I'm talking, I've reached out to another friend of mine who also has an independent practice and I told her, and so we're going to get together and do that as well. Yeah, absolutely. And like I said, I mean, when you're doing those things too, some of the opportunity for kind of resources and support is even having them shadow how you document or shadow another peer for a couple of days or at the end of the day while you're doing notes. And is your team sharing smart phrases and macros or this is what I do to make documentation efficient or how do you document this? Comparing against your peers too can offer a lot of shared learning and just kind of get comfortable with that feedback and find your friends certainly. Definitely. All right, so I'm going to move on from there. So as you're thinking about what to audit or what to put your attention on, here's some specific risk areas that I would consider. Again, telehealth has been an active item on OIG's work plan. CMS has come out and said that, because there's a lot of advocacy to permanently expand it, they plan to do a lot of auditing specifically to evaluate the quality before they decide what they might change from a legislative perspective. So, even though it's been going on, if you're still using telehealth or audio only versus E&M video visits, that's definitely something I periodically keep an eye on. If you have remote patient monitoring, that digital health is still very new, still very fresh. Have you done any monitoring or review of your RPM program since it's launched? Care management services, again, Ada mentioned chronic care management, which we talked about during the last webinar as well. This past year, there were what called CBR reports which stand for comparative billing reports where CMS actually sends you information and says, hey, based on your CCM billing patterns, this is how you compare to how it's being billed nationally and how you compare to regionally. And if you got a report that said, you're a little outlier or this is different or significantly above your peers, it doesn't mean that they're auditing you for sure, but I would definitely want to be confident in my CCM program if I got one of those CBR reports. So, something to keep an eye on. Are you looking at open encounter reports, meaning are there notes that are open for seven to 14 days? Best practice to get those notes signed and completed within 72 hours. That also means that you're not getting paid in a timely manner if you're not doing that. So again, maybe your templates are overpopulated and you need to look at templates so that you can help your providers be efficient if that's really an issue. And when we think about compliance concerns outside of straight coding, scope of practice, what can an MA do versus an RN, things like that. Looking at denial history, reasonable collection efforts means there's some OIG compliance guidelines about writing off copays and that you're treating Medicare and non-Medicare patients the same way and that you have a policy that you're not just writing off everything that's not within kind of a clear policy or parameter. And then in this world too, virtual staff, if they're located outside of the US, Medicare doesn't pay for services outside of the US. So are you using virtual staff members for billable time, keeping in mind some of those unique considerations. So I wanna move on to the fun part of the webinar where we get to hear from Odessa and Ada and we're gonna still have plenty of time for Q&A too. So again, please be thinking about your questions. If there's something you want us to expand on, we're gonna have time to circle back to all of this. But Odessa, I'd love to just give you a chance to talk a little bit about what Bergen Geriatric Care is and then we can get into some of your experience. Okay, well, we're moving so fast. Thank you. I feel like you really wanna hear from us practices, which is great. So thank you. Yes, so I am the owner of Bergen Geriatric Care. I'm a solo physician. We are, of course, a geriatric practice, home-based. I would say probably more than 80% of our patient population is in assisted living settings. And then we have freestanding homes. We have other congregate senior living settings that we serve. We have, we offer, again, through the year. So we've been, we're turning 10 this year. And over the years, we've actually not grown in census as much as we have grown in care that we offer. We now offer behavioral health integration, TCM annual wellness visits, cognitive assessment. So we've added on just layers of care. And we have about 400 plus, 450 plus minus patients. We are, we were two full-time providers. I just more recently added on another full-time provider in the hopes to maybe add on just a little bit more census, but actually not much more. This is kind of where I'm seeing where we're gonna stay. I do have, what I think a lot of people think is a lot of supportive staff. I have nursing, I have medical assistants that come with me on site, and I do utilize virtual staff. I have strong admin support. So I have about 10 full-timers, I would say, and then maybe a couple of part and per diems that are part of this practice. Great. So again, kind of tying back to how maybe certain initiatives that may or may not be tied to coding kind of tie into compliance and just overall quality improvement. Do you wanna talk a little bit about your behavioral health integration care management program? Why did you start that? How did you kind of go about implementing that? Any lessons learned? Yes, many, many lessons learned. And why did we start it? So I think for the most part, and I, again, have to say that a lot of this I learned from you. I learned from just seeking out more formal ways to build for work that we were already doing. And I feel like I knew that we were doing more than what we were getting paid for. So I was actively seeking out opportunities to build for work that we were already doing. And this is how we then integrated behavioral health integration in there. And I needed to really educate myself on how do I do this correctly? How do I utilize my staff? Do I need to hire to be able to do this? And again, I seek professional support to make these kinds of decisions and help me with the decision-making process. And it's turning out to be a really good layer of care. And it's putting what you kind of intuitively feel you're doing, like you know it, right? But you're not putting it down. You're not documenting it in a way that you can actually build for it. So it feels good to see your work translate into an actual formal document, you know? And it feels good to be able to pull up the data and you know, hey, we spent this much time and we speak to the family and family's return is so great. Thank you so much for letting me know how many PR and ad events my mom used this month. It's really giving me a good idea, you know? And they develop relationships. So that's going well, but it's all of these components, you know, the cognitive assessments, all of these components were a time investment and they're all so far really working out well for the practice, I have to say. Now, so, and one of the challenges is of course, you're gonna add on all these components of care and your staff, right? You're constantly throwing something. I have the next thing that we're doing and the next project and now we're gonna build for this. So how do you keep them engaged? Now, I am very lucky. I have a fantastic team. Most of them have been with me for years and they're also really highly motivated, but I make it a conscious effort to keep them engaged in that process. So the pictures that you're seeing are workshops, you know, that we throw on a regular basis. When I say throw, it's like throwing a party because there's always like a fun element to it, right? And because we're also engaged in the process, we all get a kick out of it, you know? So since we started BHI, we have this many people on the program now and this is how much we made, right? And I think it gives people that sense of accomplishment and not the hamster wheel. We're doing so much, but nothing is happening. So it's nice to see that, you know, just really have something tangible that we achieve by implementing these formal ways of billing and documenting for work that we know we already do. And I'm sure that everyone who's listening in here is already doing, right? So seek out opportunities, educate yourself on, you know, billing and what you can do. Look at the work that you're doing, have someone look at it and say, do you see, you know, just do you see opportunities here to maximize, you know, the revenue as well? So. And we could talk a little bit earlier, yeah. and I love that. And I really think that the team culture that Odessa has fostered, and I can speak to just because I've had the pleasure and privilege of working with her team, really is a key element to their success. I mean, everyone understands their role, you know, they've acknowledged how much they've grown, and they've changed. And they do these workshops and do role clarity and reevaluate how they're doing. And she makes it fun. And, and that's a huge part of it. So I'm definitely, you know, investing in your team and taking the time to, you know, close the office when you do these or have someone watch the phone for a while so that you can really take the time with your team. And I think that's so important. Earlier in the webinar, we were kind of talking about kind of practice standards and how do you use these different coding opportunities. And I know cognitive assessments for you are kind of a standard for your assistive living memory care patients, correct? You want to just kind of talk about how this practically works in your practice? Yeah, so and also that has also evolved more over time. So we typically do an initial assessment, right? And a lot of it all ties together, you know, what is this patient's capacity to make the medical decisions, advanced care planning. So we always did some form of formal assessment beyond what the, you know, assisted living or other facilities would do the screens, right, you would do the MMS ease, you would talk to the caretakers. And then finally, Medicare was kind of, okay, we're throwing a new code out there, you know, maybe this is, you know, good, maybe we can tie this together. And these happen to be visits that we all have really have come to cherish, really, because they always lead to these very, the bigger picture kind of visits, right? In the home base, you know, wow, he really cannot make this decision any longer, we've been relying on him to kind of telling to direct his care, maybe we need to rethink how we're doing this, maybe this is no longer the right environment. So I think that clinically very pertinent, again, for work that we all already do. And I feel like we've probably as, you know, practitioners have, as a practice have been doing this in a more fragmented way, right during the hypertension visit, you touch base on the goals of care, and you got to see them a month later for their dry skin. And then, hey, let's talk about how's the memory going. And now tying it together in one visit just makes it also more clinically cohesive, and allows us to bill for these visits. The memory care patients and assisted living patients are always patients that we assess cognitively. Really, we try to do it for anyone where we feel that cognitive impairment, dementia is impacting their care in one way or the other, and we are expecting some form of clinical change. So those have become a really big part of our practice. Yeah. And so the big change, the huge change for you is kind of transitioning from fee for service to value-based care, and your practice is participating in cohort two of the primary care first alternative payment model. Maybe just share briefly a little bit, like, what was that like? Why are you excited about value-based care? Kind of how are you thinking about the change from fee for service to value-based care? Yeah, so that was a very big shift. There was a very big shift, and it took, like, a big gulp, you know, to go for this big jump. And we've only started the beginning of this year. And I don't know how everyone else feels here about the last couple of years, but I feel we're a bit rough, you know? So to kind of, after these years, to kind of be like, and now we're going to make a real big change, right? There was a hard sell, you know? But the biggest advantage that I can see from joining a value-based system is at the end of the day, I, you know, just like everyone else, I'm seeking balance, right? And we all work very hard. And my hope is that I'm now able to provide the care that I want to without having to check all those check boxes, you know? Did I do all these systems? Did I do all of this, right? So I think it's really important when you make these big shifts, you need to ask yourself, why are you doing this? So for me, it was a very conscious decision to say, I'm not doing this to seek out higher productivity, better revenue. But my objective was, you know, I'm okay with, and this is a random example, but I'm okay with making 10% less if I end up, you know, also working 25% less, right? To me, that's worth it. So that's kind of the big hope, you know, just ease of documentation. And I think for practices, like I'm sure, you know, all of the participants are, that really seek to make a meaningful change in this environment. It's hard, right? You try, you do the right thing. You try so hard to do the right thing, but it's not translating, you know, in, again, the revenue and the income. And I think that these systems, primary care first, is giving us a chance to change that, you know, that you don't have to hustle for the volume. And for someone like me, who also employs other providers, to take that volume pressure off them, you know, and say, hey, now you can, not that it doesn't matter, I think it always matters, you know, in terms of how efficient you are, but you don't have to see this number per day, you know, because now it's different. You get a baseline payment. That's kind of the concept of primary care first, you get a baseline payment, and then a smaller fee for the actual visits. So it's less hustle for visits, you know? So yeah, that's kind of the big hope, find better balance, really. Thank you so much for all that insight. And I heard a quote on value-based care the other day in a webinar I was listening into, that it was like, we as a healthcare system need to move towards paying for, caring for the patient rather than paying for services. And that's really the goal of value-based care. And we're still very much in fee-for-service right now, but we're getting there, right? We're starting to see more of these alternative payment models and these opportunities that are coming. So again, it's, you do what you need to do to take care of the patient, and your payment's going to be the same regardless, is kind of the big change from fee-for-service to value-based care. And I don't know if you recall, when we got accepted into primary care first, I was so excited. And I don't know how many Costco shoppers there are, but I was like, we will be the Costco of healthcare. It's going to be high quality, but the cost, the per capita cost can be less. And, you know, so yes, that's kind of how I look at it, you know, high quality, lower cost. I know about you guys, who are once I'm, you know, old enough to get medical, I still want to have a little bit funding left, you know, so I can be taken care of too. So that's how I look at it also. It's our responsibility for future generations. Yes, I definitely remember the Costco comment. Thank you. And you have to incite your team about it. So I loved that metaphor. So Ada, I want to turn to you. Talk about, tell me about ACT Health Solutions. Why are you here? Why did you start your own practice as a nurse practitioner entrepreneur? Okay. So I've been in healthcare for over 30 years, and I've been to various states and have worked in various setting doing part that I'm part of a military family. So every time we move someplace, one of my position would be working in patient's home, because I like that I get to know the patient a little bit. So when we moved here, I started doing a home-based care, working for another company along, which as a part-time, along with working in different independent practices. But I started school again, doing different things. And I would always keep the home-based visits and leave the other things go to the side. But what I started to see over the years is just unmet needs. And just, we were there one week, and then we wouldn't show back up for about two to three more months. And since I didn't make my assignment, I was like, well, what happened to this patient? And so it just inconsistent care. And then one day we were told the practice was closed. Medicare came and closed it down. I don't know why. And then I said, well, why not start my own and do care how I think it should be done. And so started my journey in 2018. I started that journey, a transition out of one business and into doing house call. And in 2019, in January, we started the whole process. And I saw my first patient in March, because with Medicare, you have to see a patient first and then do all the paperwork. And in the meantime, I did a lot of researching to see the need, the smart process and all of that to see there was definitely a need. And with the silver tsunami, as they used to call it, coming, I thought, definitely. And here in Florida, it's almost seemed like a no-brainer at the time. Anyway, so I started that. And I basically thought that there was so much when I was doing a lot of the other businesses that did risk management and all this, and then you went to these areas and you're like, wow, this is America. And they didn't have a lot of access to medical care. And so I thought I would be, you know, the health doctor, a health provider. And so that's what I started. And but then when I started the research, owning a practice and working in a practice is as different as day and night. Part of it is to get some sleep when you're working in a practice, and you don't get much sleep when you own the practice. But and so but I started looking for different resources. And for me, I'm a little, you know, so I wanted to know how am I going to document when I see this patient? Because what am I going to do? And so I got some literature from another company that was trying to recruit me to work for them. And it came from HCCI. So I thought, well, why not go to the resource, to the source. And so I called and that April, I went into your first class, essential, essential elements. Exactly. And I learned so much in that one class, because I felt like I was asking a lot of people and everyone have their ideas. But I at that time, I didn't know any concrete thing that I can really pattern how to open the business with, you know, and I've talked a lot of people over coffee, tea, happy hours, and they all look great. But I didn't have what I wanted was a step by step. And so with that, I started a little more of a guided path to start in my practice. And I got ways of finding referral basis. And one of my colleagues who left the business, she was telling me about referral basis. So even coming into the meeting that you guys had, there was these buzzwords that I couldn't hear. And then when I got there, then a lot of things was started to jump like, okay, and I met some people there who also was giving me ideas. So that's how I started it. And, and we made three years this March. Coming up. No, it's here. April is flown by already. Yes, yes, yes. And so now, for me, just doing that, our senses have grown a quite a bit since then. And a lot of it is basically still following that roadmap into how to, to do the best you can and be reimbursed. And so like, one of the things I found, like, I just saw my patient, I coded my 9934997 and whatever. And then after I did that advanced coding class, the revenue was such a difference. I'll give you a great example. So I had my new patients, I did, you know, just the basic and I code for a new patient. This and I literally spent about two hours there. Not to mention, well, two hours altogether, because then I did the read, um, I read everything before, saw the patient and read everything after. So prior to that, I did one coding after the class. So I did prolonged coding for before and after. The visit itself was probably about a little over an hour. And then I also did advanced planning, because some of when you look at some of the literature for Medicare is telling you about, you know, you want to talk about that. And for me, the best time to talk about advanced planning is at the beginning, when I first meet them, because then they're not thinking like, oh my gosh, on the second visit, am I dying? You know, why are you talking to me about advanced care? So what I will say is like, you know, I want to know everything. So if anything happened to you, I want to treat you how you want it to be treated, if you stop breathing, and then I go down that pathway. And so it was almost twice as much billing going in doing the exact same thing. So basically working smarter coding smarter, instead of not being paid for what I did. Yeah, absolutely. And you shared some really fun pictures. I'll go to the next screen of a patient with us. And as we talked, you've done a perfect job kind of explaining your why and some of the initial challenges and how you sought off resources and really why coding matters, right? Again, we're not telling you to get paid for things you're not already doing. It didn't change the care. She's providing the same excellent care. She's just getting paid appropriately for what she's doing. And we're talking about that fee for service mentality. And I did put in the chat, just the specific codes that she referenced. You all have resources in the HCCI Learning Hub that go over all those in more detail. But I would love to talk a little bit more about your billing model too. And again, there's so much more that goes on outside of the E&M visit. There's more, all of that non-face-to-face time. Outside of the prolonged services and the advanced care planning that you mentioned, what are other revenue opportunities that you've integrated as part of your billing model that you think kind of help you with sustainability? Are we, I did, well, one of the things that I did, care plan oversight. Care plan oversight, yeah. And so you have care plan oversight, you have chronic care management, home health certification, recertification, as I said before, the advanced care planning conversation and telehealth. So I've incorporated all of those. And I think the important thing about those is to find a plan to do it and then stick with it. Because when I first got all of this thing, it sounded great. And I'm like, how am I ever going to do this? And it took me a while to actually incorporate it. And so for my care plan oversight, if you're in home health, then you need to get a care plan oversight. So after the initial certification, next month, because my understanding is you can't do it that month because that's the initial certification. But next month, you're talking to these patients, you're talking to the home health providers, they're calling you, all of these things. As soon as I talk with them, I just jot it down because my phone keeps them, keeps the time. And I jot down the time right there and then and I put it in the chart. And so on the second to last day of the month, I look down and I am adding up how much time I spent. And most of the time, it's over the 30 minutes for the care plan oversight for that. In regards to chronic care management, a little bit of the same, but then that is a set time that we talk to the patient or when they call us that we're talking about these situations about what they're doing. Then, well, the recertification is also a given. And my understanding is you can do it in the same month, just not on the same day. So you can do the recertification, but you can also do a care plan oversight. So if your patient is on home health, except that first month, if they're still there, you can bill for that. And I think that's like $106. And you can bill for that. So you're billing for every time someone you're interacting with the medical care provider with that. And some of the things I do because about 20% of my patients are either mentally challenged or intellectually challenged. And so I am talking to a lot to the pharmacist or their site provider. And that's also you can get paid for. So I'm making sure that those things that we are documenting. Transition of care. If they're in the hospital, you know, and I try to be, you know, mindful. If they went to the hospital for UTI, I'm not going to kill myself to see them seven days, because that is not critical. You can see them within the 14 days. But then, like, if they're in there for, you know, congestive heart failure, and they come in, come out with a live death, that's someone you want to see within 72 hours. And yes, you want to bill for that. We call it TCM seven, you want to bill for that within that seven days to get everything that to bill for what you're doing, because this patient is critical. And you know, by the time they come out the hospital, all their medication has changed. And you're spending that time. And so we bill for that as well. The other revenue we just started, like Odessa is the DCE program. And DCE program and is one of the used to be one of those buzzwords before direct contracting entity. And it's basically like a new ACA ACO program that Medicare put on. So it comprised of the healthcare provider and a supplier and they call them the participating and the preferred provider. So it's all these medical providers or under one umbrella or a legal structure to other to provide care for the patients. And now I had to read up about that, I think I've been these guys for about three months before actually pulling the trigger and signing the letter because I'm an independent practice, if I mess up, then I'm not going to get any revenue. And even this, this is this is very fluid, because even as I signed the documentation, the day before I signed it, they had another change because they used to give you a capitation. Now that has changed. And they'll give you the exact money that you're making as if you went in and saw that patient as for your fee for service. And since then, I've learned that has changed again. And so you know, I'm still kind of looking at it, you know, kind of to see how it's doing. But what happened last week, and this started in January. And Odessa, I was not thinking I was going to be the Costco this I was like, what did I get myself into? And one of the reasons I went into it, I spoke to one of my colleagues who was doing it, and is because they were getting additional help for their patients. And my patients, probably a lot of patients these days, I think they come out under one day that they needed to stay in the hospital, and they come out really sick. And so this program, for me, seemed like it will offer me additional care to take care of my patients. And that was my deciding factor. After then I started talking to them, and they said, Well, every month, they're going to meet with you, and they're going to talk with you about your patient and everything. And so they did have a rough start. And, and, you know, but I didn't realize how new new it was, but they did have a rough start, but they they caught up. And so last Friday, the nurse sat down with me. Well, even prior to that, I had a patient, this is now what they do. I had a patient and he was just throwing up from all day. And she just happened to call him. And I was telling her I got to go. And she said, Well, what can I do to help? And I said, Well, what can you do to help? And she said, I can go over there and I can assess the situation for for you. And I can help you. And she said, What do you think? And I said, He probably needs some IV infuser. And I can send it to the hospital. She said, Well, let me see. And if he needs that, I will help you set that up. I'm like, Okay. So I went ahead and I saw my other patient. It just so happened the the patient his his own sister, who's his caregiver is also a nurse practitioner. So I got very good feedback from the hostess. She said, That's a good system. You're have Ada, she came, she did everything she helped set up, just about everything. And then she sent me a report. So I was very happy with that. Unfortunately, we didn't keep him out of the hospital. But we he went one day later, but after you know, there's only so much you could do in the home before you are saying okay. And so we did send him in, but I got to see what they can do. And I like that. And then on last weekend, we last Friday, we sat down and we went over all of my patients that they have, and came up with a plan as to what needed to be done, whether they're going into, well one, you know, some of them going to the hospital because they don't have transportation and I set everything up and they said we're good, and then they don't go and say oh my transportation failed, or you tell them medication and the pharmacy is not going to pay for it or it's too much, and they don't tell you and they end up in the hospital for whatever reason, but then when you're talking they're helping to stop that, we're working on transportation, we're working on different things, so that I found to be very helpful, and so I'm still waiting, so I'm patiently optimistic that it's going to go the right way, they are reimbursing me, they're still having some, they're still tweaking that, but as long as they're giving me my money, I'm okay, but they're still tweaking it, and just being honest, you know, one time I got a credit card type of payment, then the other type was a direct payment, and then this one was a check, so they're still tweaking it, and I could appreciate that as long as you let me know what's going on, and so, but again, what I find the most helpful is the additional eyes and ears for my patients. Yeah, and just for the context, thank you so much Ada for all of that insight, but just for the context of the audience, so the direct contracting entity, that was a new, again, a different alternative payment model, it's in primary care first, Ada's not, you know, she's a small independent practice, there's a large ACO structure, but they have to have what is called their participant and their preferred provider network, so Ada, even as a small individual practice owner, was approached by this larger DCE to be a participant provider, and that's why she's able to, you know, be paid under that structure for these payments. Now, you know, some of you may have heard that direct contracting, as of January 1st, 2023, is going to a slightly different model, but it's not going away to ACR REACH, so again, there's another opportunity for all of these big agencies, CMS posts that on their website, go to ACR REACH on the CMMI website, and look for if there's, you know, they publish who these entities are, are they in your area, can you approach them, all of these payers, if you will, are catching on to that home-based care as such a solution, so even Ada, as an independent practice owner, I think, you know, a lot of the time I talk to people, and they're like, well, value-based care just isn't, there's no opportunity, and it still is very hard, but I wanted Ada to share about the direct contracting opportunity to say, hey, even me, you know, little guy, you know, 100 patients doing this all on my own, I still found a way to be a participant provider for this larger ACO structure, and she's now, you know, being able to see, so each one is able to set their own payment arrangements with their participant provider, that's completely up to the entity, so again, you have to do your research like Ada, and make sure you're getting paid appropriately, and you're getting some of that shared savings since they're taking on the risk for your overall patient population, so just wanted to take a minute to kind of make sure everyone understood that. I've also included some resources for you all here, how do you stay up to date, these are some listservs, you may or may not know that the Medicare Learning Network has a whole provider compliance tips page, there's a ton of information, those compliance plans and guidance that I talked about provided you links for additional resources there, but now I am going to transition it back to Dana. Thank you, and thank you all, great information, and love to hear always directly from practices. We are going to transition into our Q&A, I see a couple that are in the chat, I'll call those out, but I do encourage you to feel free to take off your video, take off mute, and ask correct questions directly, but I'm going to start with Doug's question, is 99358 billable for cumulative activities over more than one day, and how does that compare or contrast with chronic care management? So I can go ahead and take that one, so 99358 is the prolonged services not in face-to-face code, so that is not a cumulative service, that is when either before or after an E&M visit, it has to be worked directly related to that visit, and you spend at least 31 minutes of non-face-to-face time, you as the provider, kind of going above and beyond, so it's a time-based service, so you have to document start and stop times, total time, and then what did you spend that 31 minutes doing? The two examples that Medicare gives is extensive medical record review before a new patient encounter, or maybe you get those records after, or family care conference, maybe you see a new patient and then you have to have an extensive, you know, 35-minute conversation with the son or the healthcare POA after, so it's not cumulative, it has to all be on the same date of service, but it can be on a different date of service than the actual E&M visit, as long as it's directly related. It is bundled with chronic care management, so it can't be billed in the same month as your CCM time, so I know a lot of practices that will use prolonged services non-face-to-face for that, for their new patients during those lengthy conversations while they're still getting consent for CCM services, and then chronic care management is just much more flexible after that, after they're enrolled and you have that comprehensive care plan, it's getting paid for all that non-face-to-face work and that care management that goes on in between visits per calendar month, and CCM can be, you know, cumulative throughout the month, is another big difference. All right, Renee, I'm going to put you on the spot. You said, where is this located? I think that came up in the discussion. Yeah, I'm going to ask about the DCE. Where can we find out additional information about DCE? Yeah, I'm going to stop sharing my screen, since I want to see all your cases anyways, and then I will find the link and throw it in the chat, but again, direct contracting, those entities, that's our, they're ending their first year of participation, so there's not, you know, they already have their participant and their provider networks, but they will be introducing a new round of what's called ECR REACH next year, so you can, one of the links I put too is for the CMMI listserv. If you don't already subscribe to the CMS Innovation Center, that's how you can stay up to date on value-based care opportunities. You can also go on CMMI's website and search by your state and see what value-based care opportunities are in your state, but I'll put the link in the chat for the ECR REACH, since that's the new one that's starting next year, and those are not, those new entities are not announced yet, but you can certainly keep an eye on those. I wanted to ask one additional question, because I'm in the middle of getting credentialed, and one question came up from my credentialing person was about taxonomy codes, and I wanted to ask what taxonomy codes are you all using for primary care and home-based primary care? What taxonomy codes are being used? So, taxonomy refers to specialty. Ada and Adessa, do you just want to share what specialty? I think it depends. I mean, it could be internal medicine, family practice, you know, palliative care. It depends. What did you say, Adessa? I say, yeah, it definitely depends. One of them I have here is 363LA, either 220X, I can't read my own handwriting, I'm sorry, but if you do a 363LA, I think it's 220X. So, but it just depends on when you pull it up, especially when you're doing the NPI, you'll see the different ones that's available, because there's one, like, if you're just doing nurse practitioner, or if you're doing primary care, geriatric, right? So, it just depends on what your specialty is. I'm going to put a CMS link to in the chat, Renee, for taxonomy codes. Okay, and the reason why I ask is because my credentialing person said she wanted to know if I needed a special certification. I tried to explain to her that I didn't need a special certification to be, to do home-based primary care. And so, and I had even reached out to the people that do that for NPI. And so, I just wanted, and I told her I would come, I had a meeting today, and I would ask you all, you know, the gurus, and to find out what you guys are using, the NPI numbers you guys are using, on to make, you know. So, thank you for that. Hi, hi, Brandy, is that you unmuted? Brandy, we can hear you. It was me. I am so sorry. I was actually speaking to my daughter, but I do want to ask a question. I guess my question would be, for those of you who are currently actively in practice, what advice would you give to an aspiring home health care provider? Know what you're getting into, first and foremost. I've had several people who wanted to do it, and after they spend a day with me, or go on a visit by themselves, they said it's not for me, which is fine. Just know what you're getting into, and know what it's about, and just do your homework for the area you're in, and find a niche, and get your referral partners that you can have, but definitely know what you're getting into, because it's a lot of sweat and tears at times, to be honest. Yeah, so to, you know, kind of build on that, I feel exactly the same way. I think we sometimes have a way of romanticizing home-based care, right? Oh, it's so cute. You go into the homes, and then when you look at pictures of grandchildren all day, no, like, it's really hard work, right? And I've had the same experience. I've onboarded new staff members, and, you know, and they really want it. They love what we do, and they see it, and they feel it, but they can't do it, not because you just, I think you need to have a personal drive to do this. Otherwise, it's hard to justify for yourself while you're out on the road, you know, can be a bit lonely in the field, right? So, I think you really got to ask yourself the hard questions. What do you love about the work? I personally, you know, so I want to say something about being a guru, right? I personally, taxonomy code, I would not even know where to, like, look up that information, okay? So, there are certain things I do not like about this, you know, that's all the paperwork. So, I feel one of my talents, if I find people who know better than me, and I'm okay with that, you know, I don't need to do all that by myself. So, I think, and then for home health care providers, some people love the complete independence, being out there on your own. I found it lonely. I did not, even though I had the nurses, even though I had, you know, kind of the facility teams and the patients, I love working with an on-site medical assistant. I love having a team in the office that I communicate to. So, ask yourself why you want to do it, and just like we tell our patients, you got to have realistic expectations, right? So, it's not as romantic sometimes. Oh, you're so flexible, so you can do whatever you want with your day. No, I would say, you know, with the flexibility comes the unpredictability, right? You kind of have to stay until it's done. So, you know, the whole nine-to-five thing doesn't work out, but it works out for me, you know? So, I think that's another thing that I think I would be very clear on. And make sure when you start it, you educate your patient appropriately, because some of them think because you come to their home that they can pick up the phone and call you anytime and say, you need to come and visit me now. And it doesn't matter, I've given out the papers and, you know, on Saturday, someone called and said, you need to come and visit us now. I said, what is going on? And, you know, he had had diarrhea twice for the weekend, but they want me to come out and see him now. I said, we do not visit patients on the weekend, as per, you know, the insert. However, I went ahead and tell them what to do. And, but, so you're not going to come, they, you know, and it's like, no. I mean, and at the end of the day, if it's an emergency, then there's 911. And so, but you have to set that guideline, not because you're being mean or anything, but you also have to take care of yourself. And I think with Odessa, I didn't realize that part of it, I was actually lonely, because I don't, I don't have the luxury of having an MA. I would love to, but, but I was listening to it, you know, I think people are scared of that overhead. I, I encourage everyone look into it, it saves me time, it saves me documentation. At the end of the day, they pay for themselves, kind of, that's, I just want to throw that out there, look into cost versus benefit. No, I've, I've done that. But since the, the pandemic, everything has went up, like, ridiculously. And, you know, for the prices, I can pay an RN. But, but the thing about it is, you don't realize that in between those visits, you are there by yourself. And so you have to be real insightful about taking care of yourself. I love to just get it all done. But sometimes getting it all done is at three o'clock, and I haven't eaten since my coffee this morning. You know, so you, so when you're doing all of this, you have to set up a realistic expectation, not only for your, your patient, but for yourself. Yeah. And we have looked just to build on, I mean, there's pros and cons to the MAs, and there's not one or right way you have to think about what's good for you and your practice, too. But we have looked at the finances that you can see about two more visits a day with an MA. So if you're seeing about two more patients a day, then that essentially funds the MA for the most part. But again, you do have to consider, you know, overhead. The other benefit with an MA is they can drive while you're documenting and doing things to kind of save you on time. But again, that's not going to be affordable always from the start. But you know that if you have an MA, you know, the finance, fee for service aspect where you should see about two more patients a day to fund that position. Yeah. And to Brandy's point as to, you know, what advice, again, really think about, you know, when you want to be a home health based provider, again, look at your personality. How do you work geographically to Ada's point is what resources do you have? You know, we have mobile urgent care services, for example, dispatch help that be utilized, right? Familiarize yourself as if you can't do it on your own, can you get support from other, you know, community resources. So once you kind of have those pieces together, then you can kind of gauge better how much burden it's really going to be on you. All right. Thank you. Thank you. All right. Any other questions? We still have five minutes. You have a captive audience here. I like to say these ladies have walked in your shoes. Ada, I have a question for you. You know, and you kind of alluded to it, you know, you're out there on your own. How do you motivate yourself? How do you get up in the day and you say, you know what, you know, you took this on and you're doing it. And I know you said, you know, you're lonely, and I'm sure COVID was a difficult time. You know, how did you dig deep and keep trudging along for this? Well, I guess I should say thank you both for doing it. But you know, it's a lot. It is, but there's a couple of things I started to do. I started first, I used to wait until I get home to make all my calls. But now I have my assistant conferencing the call to me. So I am taking care of calls while she documents it while I'm driving in between. So that cut down on my screen time when I'm home, because all the people that need to be spoken to or whatever is done while I'm driving. So that's one of the things I do. The second thing, I listen to different things on the radio about whether, you know, what I need to be need to be done. But most importantly, I had a rough day and the patient called and they wanted her to give Dr. Ada a message. And she has spina bifida. And I was like, okay, what's going on now? I was at the end of the day. And that call was purely to tell me she caught the bus on her own. I'm using hot to her back to her family's home, which was about a 45 minutes drive. And then you remember why you started to do this. You know, before when we met her, she was in the home with her sister, they were not happy, we convinced her to go to a group home. And she met her new boyfriend. And she met she had a different life. And she would not. And I would like to think if we didn't come into the home and saw something that didn't, because her mom was taking care of her and mom died, his sister took over. And I would think and it was my psych colleague is also a mobile provider. And we sat down and we said, what can we do to ease this burden? Because this is definitely a caregiver burden. The patient is having somebody's taking care of me issues. And one control. I mean, but she's a paraplegic, but she wants control, and she needs control. And at 57 years old, and only your mom, you know, and so we got together and she's in a group home. And she's happy. She's happy. And I don't think she would have gotten that life if we did not make home visit. Because, you know, when you go to an office, somebody they see only what's in the office. And that's a different another thing to add to, um, I think it was brandy about what you want to do. You have to, it's a different relationship when you're going to someone's home, rather when they come in the office, because when you're going to a home to take care of them, they're in charge. This is Yes, this is your practice, but they're in charging your home in their home. And you have to be mindful of that, and how you address them a lot of time and how you tackle some of the stuff. Because if you don't, that's going to make the relationship. Well, it's not going to last, it's not going to be a therapeutic relationship. And either one of you what you're going to fire the patient or they're going to fire you if that those groundwork is not set. Yeah, great points. That's absolutely true. I know, I always think I've, I've gone on some ride alongs. And I always think to myself, I remember one six out particular, I was with Dr. Paul Chang, and a patient was talking about how greater eating habits were, and, and she's really doing this. And he and I walk over to the kitchen and open the fridge, there was no good eating habits happening in the house. But, you know, it wasn't a bad thing. It wasn't a shame thing for anyone. But I think you do get a different perspective. And I think Ada, that's a great point that you're kind of going into their den, you're going into their space. And that adds a different dynamic. I do think you get you have the opportunity to get a lot closer with their patients. When you see those, like you said, the pictures on the wall and family maybe as being there as well, you get to have conversations with them. But yeah. And so Ada, when I looked up your practice, right? Google, I think one of the first things I thought was really just like brave, you know, I was like, wow, she's so brave doing this. You know, that's kind of, I think the first impression that I had. And, you know, and to your point, Dana, right, it's, it goes both ways, you also trust them to keep you safe when you go into their home, right? So it's really, I think a lot of it revolves around mutual trust between the patient provider from the second they enter each other's spaces. So I think that alone is a completely different groundwork for relationship. Yeah. It definitely brings a level of intimacy, but also Ada, to your point, a need for boundaries and putting those up. I'm just going to quickly, I know it's 530. I want to be respectful of time. If you have questions for us, if you want to get a hold of us, you can give us a call here at the hotline. You can send us an email at the help email. This webinar and all the webinars that we will be having, you can find dates and topics on our webinars and also our tips and tool sheets. There's a whole lot to see at that HCC Intelligence Resource Center. It's purely there for educational purposes. We hope they help you. If there's something that you don't see there that you would love to hear, have a resource on, or know more about, please let us know, reach out to us. And with that, I just want to make sure, does anybody have any other questions that we didn't get to? Okay. I do want to, I can't hang up or disconnect without thanking the presenters. Brianna, always full of knowledge. Odessa, Ada, thank you for bringing your stories to the network and this group. And I am sure they found it very helpful. And I want to just thank you all for joining us. And more importantly, thank you for what you do out there. It's hard work, but it's good work. Thank you for having us. Yes. Thank you. Yep. Thank you all. Bye-bye.

Bergen Geriatric Care

home-based geriatric practice

quality care

coding and documentation practices

behavioral health integration

reimbursement

additional services

cognitive assessments

transitional care management

staff engagement

billing opportunities

work-life balance

building trust