Ambulatory Surgery Centers are experiencing an uptick in medical travel inquiries from consumers willing to fly or drive to access high-quality surgery at a lower price
But the number of ASCs that have an established medical travel program in place is quite low.
Here at SurgeryShopper.com, we are in daily contact with many ASC administrators around the nation. They are eager to list their bundled price surgery packages on SurgeryShopper.com, but when we ask about medical travel, most explain that they set up their program with the intention to target and attract local patients who live in town or nearby. Then, once they’ve posted their offers online, people start calling from all over the place. Very few have formally established a medical travel program, per se. And if they have, they don’t call it “medical tourism” or even “medical travel“. Some call it their “concierge model” and explain that the difference is that the bundle includes the hotel arrangements and a little more in the way of travel facilitation for the patient and their companion.
We believe, gauging from the comments we’ve heard, that the reason for not developing a formal program for medical travel are a) they don’t see enough volume to justify the effort, and b) they don’t know how to go about it. This information you’ll learn in this article will help if you are in the second category.
One ASC Administrator we spoke with said that back in 2013-2014, he traveled to meet with Dr Keith Smith, of Oklahoma City who was championing transparent, bundled price, surgery packages and had managed to garner lots of PR and media attention. He says that Dr Smith generously and openly offered to copy the flow and layout of his website. He took him up on the offer and in 2018, only four years into the bundled price surgery program, a whopping 8 percent of the cases were bundled price surgery accounting for 30% of profits. The center is up 200% in bundled case bookings in 2019, from 2018 sales. The ASC has, in 4 and a half years, treated patients who traveled in from 40 states, by private car and by plane. That’s compelling!
What’s more, the administrator shared that for the past 4 years, the program simply “evolved”. He admits that while they thought they had all the bases covered, the ASC is now mired in contracts with TPAs and other network organizers that aren’t appropriate. Many are simply variations of a PPO contract that fail to differentiate the bundled case product from typical PPO agreements that pay “whenever” they pay, and want broken down bills on UB and CMS 1500 forms and then pick apart bundled case prices and pay them incorrectly. The staff spends a lot of time chasing down payments and reconciling payments because the contracts were never really intended to pay a “single line item” bundled price claim.
Transactional Document Set
So, to fix this, they’ve started filling in the evolutionary gaps with a formalized agreement with the surgeons and anesthesiologists who participate in their bundled case rate program. They also had new agreements drafted for use direct with employers, TPAs and other network organizers, broker and benefits consultant marketing agreements, and even a consumer agreement to explain and memorialize the understanding of what the patient has agreed to insofar as exclusions and inclusions in the episode of care. Out of the draft agreement they quickly realized that a few other documents and forms would be needed to manage the program. One was a definition of a “clean” bundled price claim. This document would be attached to the main contract document to serve as a crystal clear definition with a narrative explanation and a sample clean bundled price, single line item claim on a UB-04 and a CMS 1500 form. Another addendum was a delegated credentialing and privileging agreement. This enabled employer fiduciaries to access program services sooner with transparency into how due diligence is carried out in their accredited ASC. Another document was a Program Manual, that explained how the program works, how billing occurs, when payment is expected, consequences of breach, and expectations of pre-authorization validity and reliance. This document set rounded out their transactional documents.
Internal operations document set
Another document set was necessary for internal operations. A new patient intake form, initially on paper, would need to be incorporated into the Electronic Medical Records forms library specifically for bundled price surgery cases.
Our go-to expert on all things medical travel, Maria Todd, of AskMariaTodd™ says that “This form must focus on continuity of care issues – especially if the ASC is accredited, because handoff is a survey item as it relates to patient safety, quality, and the ethics of providing care to a patient who won’t follow up locally.” Without this, your surgeons won’t feel comfortable discharging the patient after one visit because the standard of care is usually about three visits during the 90-day post operative period.
A proper handoff means speaking with the patients’ specialists or PCPs back home and arranging the first post-op visit back home. But it also means a proper handoff prior to admission to that surgeon’s service. The entire process of handling intake on these cases should be assigned to one or two designated focal points so that there is around the clock accountability during business hours. They should be assigned responsibility for coordinating the quotes to patients, coordinating medical records and image reviews by and pre-booking interviews with the surgeon by phone or web conference. These services are not free and must be figured into the fees paid to the surgeons. Otherwise, resentment sets in, and rightfully so.
Typically, 30 minutes is sufficient to review films, records and past medical history, presenting chief complaint and speak with the patient. As of Jan. 1, 2017, CMS has made an exception and will now allow Medicare coverage for non face-to-face prolonged service codes 99358 (Prolonged evaluation and management service before and/or after direct patient care; first hour and +99359 …each additional 30 minutes). Codes 99358 and 99359 are time-based and include “the total duration of non-face-to-face time spent by a physician or other qualified health care profession on a given date providing prolonged services, even if the time… is not continuous,” according to CPT®.
According to Todd, there are other codes that can also be used, but the idea here is to include the acknowledgement of the physician’s time and expertise and involvement, even if the case doesn’t result in a booked surgery in the near future. It could also be the case that the patient needs and desires to have surgery but the ASC setting is not appropriate given the patient’s unique health circumstances. In any event, having a code to post and a fee associated with the code aids in business intelligence and program analytics. The average for this service is about $60-70 per 30-minute interval. Another incremental charge that should be calculated into the fee you pay your surgeons is for an admission handoff call and a post-op handoff call. These are similar to what physicians bill using CPT 99367, (Medical Team Conference, Without Direct (Face-to-Face) Contact With Patient and/or Family). The dollar value on these calls is approximately $100 per call. The amount is not calculated in the bundle if the patient is already known to the surgeon and the surgeon will follow the patient and be involved in their aftercare. This cost tag is then attributed to the medical travel program side of the ledger, separate from the bundled case rate.
Todd warns that if the ASC or hospital is accredited, and your surveyor finds that you are operating a medical travel program and don’t have these handoffs covered in SOP, and have a place to record that the handoff team conference discussions occurred you will bump up against problems and may need a corrective action plan (CAP) to pass your survey.
Billing and receipt accuracy
Another responsibility to be assigned to your internal focal point is a quick glance at bills and receipts to ensure that they match quotes and contracted fees before submitting them for payment. Ensuring that the bill goes out timely and accurately helps to ensure payment comes in as expected and that there’s no ambiguity.
Consent and discharge forms and acknowledgement of the bundled price inclusions and exclusions
A bundled price surgery case is handled in many ways, the same as a “business as usual” line-item bill for services. But one extra step Todd advises for bundled surgery cases is a patient form that is signed on the pre-admission acknowledgements that the case rate covers some services and not others. Then, with discharge papers, a second acknowledgement is signed when the patient (or guardian) has a clear head indicates that follow up care is not included in the case rate beyond one discharge management consult. The patient should initial this, and also initial that they understand follow up is to be handled by a certain named physician, and that their appointment has been booked for a specific date and time, and “may be subject to additional fees.” They should also sign acknowledgement that they will/may receive bills from a pathologist for any specimen examination, per-operative lab tests, follow up imaging studies, compression garments, DME rentals, and even hyperbaric oxygen services in the case of stem cell transplants, and so forth.
The travel component
In Todd’s experience over the past 35 years of domestic travel management and program development and operatons improvement, she notes that more patients travel to surgery destinations by private car than by air. That means that coordinating travel for them should include maps, planned stops, and hotel arrangements enroute in both directions, not just at the destination.
Todd is a fan of and uses Uber, Lyft and AirBnB services when traveling, but explains that these services may not be appropriate for medical travel arrangements. She states that for car and driver services, ASCs and hospitals should arrange with a private hired car and driver service, when needed. There should be a checklist to verify driving history, insurance, and what kind of vehicle will be used to ferry patients and companions to appointments and back to hotel. For example, tiny vehicles aren’t appropriate for orthopedic patients and those having just had abdominal surgery. The same goes for Escalades and similar vehicles or vans that may require climbing to egress and ingress.
As for hotels, she explains that good deals on hotel stays are not good deals if the accommodation is inappropriate to meet the patient’s needs. placement of wall plugs, internet service, carpet, live plants, stairs, grab rails in bathrooms, all need to be on the checklist. Rooms where patients will be assigned should not exceed the third floor. Hotels should assign patients to rooms with beds that have protective mattress covers in case of wound seepage. Hotels should be proximate to food and beverage outlets and delivery services, grocery and prescription delivery and have adequate security for vulnerable patients. They should be located within a mile or two of Fire and EMS services. Any assistance needed should be prominently indicated on the hotel’s registration and room assignment software in the event of an emergency. The typical stay for a medical travel patient is often much longer than a transient guest, so rooms with a small kitchenette (Hyatt Place, Candlewood Suites, Springhill Suites, Marriott Residence Inn, and similar) should be sought over just a plain hotel room. Medical travel guests often move slower than their non-medical counterparts, so ensure they have a way to stay dry as they move about the hotel premises and from and to parking facilities, especially in rainy or snowy locations. Todd’s industry best-selling books, The Handbook of Medical Tourism Program Development and the Medical Tourism Facilitator’s Handbook cover these issues in detail and should be mandatory reading for all concerned in the administration and operation of a medical travel program. They are available from any retail bookseller, worldwide and also from the publisher, Productivity Press. The detailed checklists in each book will shorten your learning and preparatory curves by many hours. No other similar handbooks are available at the time of this writing.
Funding for marketing and program development
Todd explains that what you might need to invest in your program development will cost under $10,000, all in. That includes a web page that describes your bundled price surgery or cash pay surgery program, and lists some fees you want to promote. The other costs are the document sets, and time to set up the travel relationships with hotels and car service, a trip to the airport, a relationship with a local travel agency and time to develop your bundled case rates. But what a lot of ASCs overlook is a potential source of free money and grants sponsored by local tourism convention and visitor bureaus, and economic development councils. If you can quantify how much you attract in visitor spend with tax-paying (for profit) businesses in town, and if you can substantiate claims about hotel length of stay and impact of transportation, food and beverage, home health services, hotel, grocery spend for self-catering, tourism and sightseeing activities, etc., your local bureaus may grant as much as $5000 in many locations to help you develop and promote your program with videos, website and more. If you add videos, you may be able to obtain free use of B-roll footage that they own for your video editor to incorporate into your videos, thereby reducing shooting time, setups and costs.
Todd says she knows for a fact that a domestic health travel program can be planned, set up and launched for under $10,000 because she’s done it hundreds of times all over the world over the past 35 years in her career in health travel program development. “The biggest problem is finding competent and experienced consultants who know the hospital and ASC setting backwards and forwards.” Todd explains that a marketing consultant isn’t a competent medical travel program developer. “They are marketers,” she adds. A brand consultant isn’t a program developer. “They do branding. Neither of these consultants know process within healthcare,” she explains. Each has a rightful place assigned to tasks in their wheelhouse, but they are rarely, if ever, knowledgeable about healthcare operations, quality documentation, contracting with employers under ERISA regulations, patient safety, medical ethics, accreditation standards, patient flows, billing and payments, and all the moving parts of clinical issues and pricing to be addressed.
To get in touch with Maria Todd to help you plan, launch or improve your program for bundled prices and cash pay surgeries, or to add medical travel or contracting directly with employers, contact her by phone at (800) 727.4160.