On this episode, I and build drugs in urology using ZazDuri as a case study. Stay tuned.

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Welcome to episode 294 of the Urology Coding and Reimbursement Podcast. I'm your host, Scott Painter, my co-host Mark Painter, Dr. Ray Painter. And today we want to continue our discussion. We had Mark presented information on our June 2026 monthly webinar about buy and bill drugs, which you can go check out. But we wanted to continue this discussion on the podcast. And Mark wants to hit the highlights, I think, again, of what's going on out there right now, and you know, what can a practice do to make sure that they are protected in the buy and bill drugs? So Mark, you want to take us through this? Sure.

Drugs across the board have a low margin, right? I mean, we're at ASP plus 6%, whether it's, you know, your testosterone or your antibiotics or your bladder installation drugs. Across the board, they've got a margin on them that really makes it such that if you do not collect on virtually all of them, then you're underwater with that particular variable cost relative to your practice. And certainly that's one of those areas where and it hurts to lose money. And I've always looked at this, you know, in a through a couple of different lenses. It hurts to lose money that's based on time, without a doubt. And so that's, you know, get not getting your EM codes paid for, or maybe not getting a procedural pay for. But boy, it hurts a little bit more financially when it's all about the variable cost and that money is out of your pocket. So you're paying to provide that care to someone else. So for some reason, that's just one of those things that mentally is tough, but a loss is a loss. And so when we look at buy and bill drugs across the board, we really want to make sure that we are dotting all of our I's and crossing all of our T's. And we have seen a significant uptick in medical records reviews and RAC audits for specific drugs. Now, those are focused on some of the higher dollar items, and that's just the met that's just kind of the focus of the RACs because they get a one-third bounty for recover for recovery. We're also seeing the UPICs take a look at this. So drugs, I think, are a target, but well, not think. It's pretty obvious that drugs are a target for review because we spend so much on drugs, and that's one of the faster growing areas in healthcare costs. So Medicare's taking a look across the board. Then, but before we get deep into that part of the equation, I want to start with the prior auth part of this, because we've had a couple of groups that we've been working with that recently had basically some staffing issues, and they weren't able to get prior authors on some of their drugs, and it went for a little period of time. And you know, going back and looking at things, it's you know painful to let a group know that we can't recover those costs because the prior authorizations were not done or were not done appropriately. And you know, I certainly understand why that happened to them, but those losses are difficult to take. So wanted to first start off with making sure that we address that prior authorization portion when it comes to drugs, because sometimes those prior authorizations are not as clear as they should be. They're not as easy to work with as they should be. And that's the payer side of the equation. Sometimes you'll get a quite uh a pushback on a payer specifically, or a change in the regulations that didn't require a prior authorization and now does. So you've got to keep an eye on what requires a prior authorization. But the other part of this that we're starting to see come into play, and it's one of those double-edged swords, is an increased use of patient portals and collecting information from the patients before they come into the office, which I think is a great idea. But it does still require significant monitoring and double checks. So if you can get the information from the patient relative to their health care insurance, any change of address, any of that you can get before they come into the office, that lightens the load on your staff. So you definitely want to pursue that. But you do want to make sure you're checking those things when they come into the office. You want to make sure you're running your eligibility checks, make sure you're seeing those eligibility checks all the way through. Those are things that we see made mistakes that are made. Now, the EHRs and your tools are getting better at that, but they're not perfect. And so ultimately you want to make sure your staff is well trained and well focused on getting that information because we do have a lot of migration as patients are moving from plan to plan, especially in Medicare Advantage situations. So make sure you've got a good policy protocol procedure in place for those prior authorizations, get those done. And if they're not done, it's time to reschedule. I mean, it's that's a risk that I know is hard to walk away from when the patient's there and has that need, but it really is a piece of the puzzle that has to fall in place these days in order for you to get your appropriate reimbursement for all of those services. So double check things, watch your payer bulletins, and make sure you have good policies, procedures, and protocols relative to your prior authorizations. The other thing I'll mention really quickly before I'll stop and we can talk about prior offs is there are groups that are now trying out some of these AI-assisted prior authorizations. Those again are time savers if they work. And ultimately they should be leveraged. We should be trying all of this, but we do still need to monitor those things. And the other piece that I'll throw into the equation is that there is a new rule that's supposed to go in the first part of January that's going to increase the requirements for a prior authorization, leveraging AI tools. And this is really much more clinical information that can be submitted through the prior authorization portals in order to get the prior authorization. So, right now, a predetermination, which is yet another pathway to check whether or not a particular service is going to be paid and how much it is paid, requires a little more than a prior authorization. So there's a little more information that's given up front. It takes more time, and not all the payers have prior predetermination set up, but the information you get back is relative to the patient's plan and should be reflective of what you're actually going to be paid. So it's kind of like a mock claim, if you will. Whereas a prior authorization is just if these codes are submitted in combination, will these get me paid? And the general response of yes or no, that's kind of that prior authorization plus a number that says, yeah, you checked this. So the predetermination is something that, because of its extra work, isn't something you want to do all the time, but it might be something that you pursue for some of your higher cost items that you're dealing with. But the change that's upcoming is going to allow the payers to look deeper into the order. So we've got a lot of these new drugs that are out there, and Zusduri is a good example that is specifically targeted for recurrent intermediate risk non-muscle invasive bladder cancer. So that's it's got a fairly specific use. So this new process that they're supposed to implement in January, now I'm skeptical that they are going to actually implement it in January. Everybody looks like they're a bit behind. But if they do implement it in January, it would actually allow the payer to check the order or and the entire patient record of the visit prior to to see if the patient actually meets those underlying qualifications to receive the Zesturi. So that's the other piece on the front end before a patient gets a drug that you want to make sure you're setting up. Now, I'm going to recommend you do it now, even though we don't have this prior authorization wheel in place, that you really take care to set up your electronic medical records to put the clinical reasons why a patient is going to get a particular injection in the medical record and attach it to the orders so that your team can easily get those prior off because they've got all the information they need in that medical record and served up to them in the order. So take a little bit of time, look at what you can do with your orders to justify those drugs and make sure that you're requesting the appropriate drug and authorizing the right drug and the units that are associated with it.

Do you have any comments, questions?

Mark, it sounds like you're saying you need to get all the information, including the insurance from the patient as soon as you can. But before you give one of these expensive drugs in the office, you want to be sure your office has checked to be sure you meet all the requirements that insurance company is requiring before you give the drug. So that morning or that day, you need to check and double check. I'll give you, you know, I'm at that age where I get to see a lot of doctors and how they practice from the other side of the fence. And I'm having one procedure that, and I'm on straight Medicare with a supplement, but I've got one procedure that I'm being scheduled for that had several preliminary things that had to be done. And the practice just told me they had to wait for insurance approval but each step of the way. Well, Medicare doesn't require that, but their practice set it up so they would be sure and not miss anything.

So I'll I'll again I'll put in one quick issue there and mention that, yeah, expensive drugs are one thing, but all drugs, right, are an issue across the board. So it's not just the expensive drugs that we've got to look at. Obviously, that's a that's one where it's you've got a little bit more margin to work with. But I Ray, I think that's smart of that office because that really goes back to the LCA or the LCD, right? Making sure that they've jumped through every hoop that is required for that procedure that you're gonna have in their documentation if they get a UPIC or a RAC, because you're right, Medicare doesn't have prior authorizations, but they do have take back abilities. And, you know, the old days of if you got paid for it, you were safe, are gone. I mean, this the amount of rack audits, the amount of UPIC opic up activities that we're having right now are is significant and it's bearing the RCM team. And it is ridiculous, in my opinion, that we're focusing on such ticky-tac issues of yeah, there wasn't a bladder diary in the patient's chart when clearly all the documentation says the patient had 50% improvement. I mean, this is ridiculous paperwork administrivia that's being required. But that's the way the rules are set up. And so we really need to build our EHRs, as your office has done, to make sure that we follow those protocols, even if it's not a prior auth, it's a protection from take back. So it's a little bit of both. Getting your money, yes, and then keeping your money.

I've got a couple questions for you. You had what is your, I guess more of an advice question. What's your advice for these private practices out here there that are having higher turnovers? And I know you you've built in your own RCM team a lot of protocols and procedures, and that's what you're telling everybody to do. Make sure you have those in place. How do you maintain those when that experiential knowledge leaves the practice? And I mean, do the urologists and some of that's do urologists have to learn this and be able to teach it? Or what do you recommend in that? Because you can't always depend on the the admin staff to be there and to carry that protocol or procedure onward very, I guess, completely without the full experiential knowledge.

So it is incumbent on the admin staff to monitor this. So we do lean hard on the admin staff, but we also try and distribute some of those responsibilities downstream with supervisors and those types of folks. So leadership is important, and it is leadership from the top down that really focuses on making sure that your personnel follow the protocols that you establish. So the team that we've put together has been very good across the board, and I give Mary Ann a ton of credit as our operating officer to who has really put into place a couple of different things. One is obviously the protocols, as you've mentioned, need to be followed. They need to be fairly strict, they need to be understandable and executable. But the other part of it is the training that goes in place. When you have turnover, bringing on a new person to work there, consistency and training is important. So if you've got staff that's is staying and that has trained a lot of the staff and they have a set training program, that's helpful and certainly is something that should be executed. What I see a lot of praxis do is leave the training of staff to other members of the team that are doing the same thing. And while it's helpful to have those members of the staff communicate with their counterparts to give them hints here and there, they are probably not the best training folks. So you want to make sure there is full training and understanding of what's being done. Because often task-oriented workers don't understand the bigger picture, and that hinders the overall training and understanding of what's happening. Videos are a good thing if you can create videos, and they're fairly easy to create these days with the technology that we have, so that people coming into the practice have a required set of training protocols that they need to go through. So train, have the protocols, and then the last part is the enforcement. It's having some measurable evaluation of those individuals to make sure that they are accomplishing what they're supposed to relative to those protocols. So train, protocol, monitor.

That's great advice. And then my second question is when and around the audits and the UPICs and the racks, when there are takebacks happening, is there any wiggle room at all to go back to the manufacturers if you made these errors? But if you're out the drug money, is there any way to recoup that?

Not really, is the easy answer. No, I mean, technically, as you get those services you've billed for, you're only billing for costs incurred. And the manufacturers might be able to help. Maybe they've got experience with with other with others of their clients that have gone through the same thing. They might be able to provide some guidance and maybe some labor to help prepare those things because obviously they want you to keep using their drugs. Some groups have had some ability to set up time payments and things along those lines. But generally speaking, the invoice is the invoice once that is done. And certainly there are manufacturers that have put together protocols and procedures and checks list checklists. And they may have services that help do prior offs and figure out how to get additional money in place to get grants to cover those when the if they ship to the patient. But it's not about getting a refund, it's about finding another way to get that revenue back or to get revenue from another source that really is where they help.

It makes sense.

This podcast episode is supported by Eurogen, manufacturer of Zesturi. Zesturi, mitomycin for intervesical solution, is indicated for the treatment of adult patients with recurrent low-grade intermediate risk non-muscle invasive bladder cancer. Please visit zesturi.com for more information.

The final uh question I have to have is when you're looking at bringing a new therapy on board, and let's just use our case study. So if you want to bring Zazduri into your office, can you just walk us through the basic things you're looking at and how you would approach it? Because a lot of these, I I think a lot of people are, you know, maybe sitting on the sidelines and waiting and trying to hear what others are doing. But if you think that's a therapy is good for your patient, and I know Zusduri has its own unique treatment for a specific type of bladder cancer, and you think that's beneficial. How what would you do or how would you go about bringing that into your practice?

So we're at a point with Zusduri that things are a little bit different. Obviously, we're past the initial phase of the enlisted drug code and the whack pricing. We're now to a point where we have a J code, the J9282. We've got an established ASP, and we've got IFU or instructions for use that you know have a specific indication from the FDA. So when you look at all of those, Medicare is pretty much a slam dunk with the traditional Medicare. We need to make sure that they meet the requirements, that it's recurrent, intermediate risk, non-muscle invasive bladder cancer, and that ultimately we're in the right stage of treatment for that. If that's there, you've met those qualifications, then Medicare at this point in time should be relatively automatic. Now we did have a cut one of the Macs out there that misloaded an NDC number, so payments were a little bit slow, but generally coverage is. Is good within Medicare. So at that point in time, you're looking at indications and to see if there are any NC NC or LCAs. Which they're not, or there are not any. They're just general about following the labeling. If you're going off label, that's where you need to slow down and take a look for Medicare. So we'll just stick on label use at this point in time. Now, when you look at expanding this to your other payers, you want to check your contracts. Are you based on Medicare? Do you have a pathway to follow those Medicare payment guidelines with a commercial payer? And then you want to, at least for the first two, if you can do a predetermination to see what your pricing or your reimbursement's going to be, that's the next step I would take with the first couple that I do for a particular payer. If the pricing isn't going to work, then you might need to go back to your contracting to make sure that those adjustments are made ahead of time. If you can't do a predetermination and really see what the for a particular payer, then I would start off with one patient, try it out, see what the reimbursement is, look for the expected payment. Hopefully, somebody else in the market has already submitted it so the payer has the processing set up. If a another group in your market has not tried that with that payer, it may be a little bit slower. But follow it all the way through with one or two. And with some of these drugs that require multiple treatments. So you start a patient on a pathway and they've got a few doses to get, you might want to stick with one. Go through that process, make sure it works all the way through and you get your reimbursement before you start adding other patients. So essentially, probe and then launch. And then, of course, the other thing you've got is do you have neighbors, friends? Have you found out in the UPTP network that things are flowing smoothly? So don't ignore your network of urologists who are doing the same thing to get information on how payers are doing things. They may not give you the exact pricing, but if the drugs being processed and paid and at a reasonable rate, that's where you get some information to go ahead and start jumping into some of those other commercial payers.

Ready? Any comments, questions? No. All right. Okay. Well, let's wrap this episode up here. We want to thank ModMed and Eurogen for supporting this episode. If you're in the market for an EHR or practice management system, you can go to modmed.com forward slash P for specials for our listening audience. And for Zazdur support and tools, you can go to Zazduri.com. All right. Let's get some final thoughts. Mark, any final thoughts today?

So we've kind of covered a little bit and we've touched on a little bit of a lot today. And, you know, in summation, I think that, you know, from the clinical side of the equation, understand your drugs, how they're utilized, and build your documentation to support it. Because it is both pre and post that you need to make sure that you are going to get and keep that money. So build your protocols, build your orders, build your electronic medical record, build your communication, and build your support infrastructure so that you are confident that one, you're going to get paid, and two, you're going to keep that money. And then the second piece of this, double check things as you go through that. Again, we're getting a lot of lookbacks at this point in time. UPICs, medical record requests, rack audits, they are burying your revenue cycle management team in a truckload of work. And the more you can streamline that by building all of this up front so that your team can grab the records and push them out the door because they're confident that those all the I's have been dotted and the T's have been crossed, the better off you're going to be. So leverage all of that across the board. I mean, it this is one of those areas where the wheel of fortune, as Ray dubbed it, the circle of life with revenue cycle management, whatever you want to call it, everybody has to play their part. And that's true more and more. The amount, the focus now on fraud and abuse and the takebacks and the re-reviews and the waste in the marketplace is being turned up to 11, to borrow a phrase from Spinal Tap. It is really something that we have not seen before. We're seeing rack audits for services provided earlier this year at this point in time. We've never seen that before. So it's it is really turned up. And without that solid clinical support, we're not going to win rack audits. We're not going to win record reviews. And having everything else in place is not going to miss or overcome the miss on the clinical side of it. So make sure the clinical is there. Make sure the administrative is there. And then the last thing I will say is monitor your EOBs. Look at everything. Some of these takebacks are coming in under the wire with weird denial patterns. Look at the payment levels. Make sure you're collecting from your patients or you're getting your secondaries in place. All of that is very important. We're working on thin margins here, and a well-oiled machine really is a piece of it. And I would say, yes, leverage AI, but boy, you got to babysit it. I mean, it's a tool. Anything that doesn't fit into the right bucket as it's getting trained is not going to be covered. So monitor, train, protocols, build your product, build your build your templates. All of that is absolutely required under in today's market.

Great.

Final thoughts?

Two things. One, I want to emphasize that Mark and his team has been and are being very successful because they, and Mark, you can correct me if I misstate anything, but they build protocols and they monitor those and they update them. We're fortunate that we have a lot of data input from practices around the country and from things like UP group, but it's important to have good protocols. It's important to be sure you have staff that knows how to use them. But the last but not least is you have to monitor to be sure everything's working correctly. And that's I think the reason that PRS has been very successful in the RCM arena is we double check in the beginning and double check at the end. Now the second thing is, you know, AI is being used by the other by the payers, and that's what's rack no putty intending, but racking up all the audits because they can do it much easier and they can identify particular or potential profit.

Yeah, and I think, you know, I also want to add that knowledge is power, as we have said over the years, and information is power. And one of the things that we are we've put together is our PRS coding and reimbursement hub. So on that hub is information on categories like kidney stones or bladder cancer. So we have the category information on what you need to know in order to get reimbursed at the proper rate. But we also have partnered with industry to bring information about products and how specifically, as we talked about Zuzduri, how specifically these products are reimbursed when we have individual web pages on the hub with those products that you can go read about and understand that information before you bring them into your office, before you bring these new technologies, because the new technologies are there to help the patients. And we want to try and make the reimbursement hurdles as small as possible. And that's what the hub is all is set up to do and make sure that the practices out there that you do put in the protocols and the procedures with the right information. And we have guides, our code matrix guides that we have set up, and they're free, free to download. You can go on to the prsnetwork.com forward slash urology hub. There's a lot of great information, and we're adding more and more information every week. So we encourage you to get that knowledge, get that information, and put it into your practice and get the technology and add more tools to your clinical toolbox with the technology out there. All right, that's all we have for today.

Thank you all for listening. Okay.

Happy coding.

Thank you for listening to EuroDecoding Remembers the podcast, where we help Eurofits and their staff maximize income and efficiency so there's time and energy for taking care and a happy life. So thanks to our interview today. You can find out on Spotify under a record label YouTube.