On this episode, hot topic from our Urology, Pharma and Tech Pioneers Group. UPTP for short. Stay tuned.

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Welcome to episode 308 of the Urology Coding and Reimbursement Podcast. I'm your host, Scott Painter, my co-host, Mark Painter, Dr. Ray Painter. And today we wanted to go through a few of the things we heard in our recent meeting, our October meeting of our Urology Pharma and Tech Pioneer Group. And if you're interested in joining, you can go to PRSnetwork.com forward slash join UPTP. So let's get started with this. It's really interesting. When we get together as a group, the group discusses what's happening, and it's kind of the front lines and the pulse of what's happening in urology coding and reimbursement. And we do encourage you to join and share because the more we learn and the more we can share with our urology community, the better off we are. Knowledge has always, as we always say, knowledge is power, and having that information is a great tool for all urology practices. But what we wanted to do is kind of share a few of the things that we picked up on. And Mark, you want to start us off? Let us know some of the things that you saw that you wanted to share with everybody. Or you heard, I guess, not saw.

Fair enough. Because this is, although we do have video, most of the time we're just talking. And just a little clarification on the UPTP. Scott did a pretty good job. I just wanted to fill in a couple holes. But number one, the participants in this group are physician offices. We have a few physicians that join us. We have administrators, billing staff, and they're from around the country. And we call it the UPTP because our main focus is new tech. We like to find out what's happening with new drugs, new technology, what's happening with category three codes. But we open it up and we end up talking about a lot of stuff as we go through this. Where are we having issues? Are we seeing specific problems with specific payers? Now we're very careful not to talk pricing or collusion, those types of things, but we do talk about the mechanics and we talk about some of the office flows that people have set up. So it's really a great open forum for people to discuss things. Some great participants across the board. And it does provide some great opportunities for collaboration. And just we'll give you today some examples of some of the things that we covered. And I'll just start first one with Xyophlex. This is one of the drugs obviously used to address Peron's disease in men. And what we found overall at this point in time is that the pricing and the reimbursement have been, and many of you have experienced this, a bit of a struggle to balance out. And recently we saw another price increase, and of course, it at this point in time the acquisition cost looks like it's floating above the ASP plus six. So it makes everybody stop and figure out how they're going to handle this. We had a couple of folks on the group that indicated they had stopped buy and bill Xiaflex actually long before this particular event, and were looking at alternatives for the patient to acquire the Xyoflex that they would still administer. So it's not that they're wanting to give away or take away the treatment, but it's about finding ways to make that treatment available without having to pay for it for each time you treat your patients. And then we had some other folks that had gone from buying bill back to acquisition through other sources. And so it's about the process really of trying to navigate cost versus reimbursement. And we so that was one of the things we talked about. We also talked about some of the payment problems folks are seeing relative to in Lexo and Zus Duri, not across the board, but with specific payers. So it's a nice collaboration and being able to share that information is really by I think powerful. And everybody that joins every month does seem to enjoy the number one, just the group overall, because it's a good group, and it's pretty rare you get a hangout with a bunch of coding and billing nerds all focused on the same thing you're doing day to day. But it's also good to share. And then one of the other topics we came talked about was PAE. We've got a number of different things that are we're watching for, changes in Anthem policies, whether or not prior authorizations are required with Anthem. Certainly we're starting to see a little bit of Medicare reviewing relative to PAE, UPICs, and RACs and record requests. We don't necessarily have the results, but we are starting to see some claim sampling with PAE. So as we've put out all of our information around PAE, it's one of those things that, as always, you want to document well, follow all of your Medicare bulletins and your guidelines with for Medicare, as well as look at where your private sector payers are. As PAE grows in the overall marketplace as a solution for BPH that is being offered by physicians, it's like everything else, important to remember medical necessity. It's important to remember the patient selection side, and as we always emphasize, documentation. And just so you also, a couple of the other ones that we talked about were PCR and quant UA, what's happening in that particular marketplace, some of the payment problems that we've seen relative to UA, just straight diagnostic dipstick UA. And again, some of the solutions that folks are looking at as far as making sure that they have all the clinical information they need and at the speed they need it, and ultimately trying to figure out how to balance that out with running a financially healthy business. Then finally, we looked a little bit at Alta Viva, ecoin, those types of things, and what's happening around that. Biosimilars, our appeal turnaround times of 90 to 120 days, and then kind of what's happening in the marketplace. It looks like, and we've kind of mentioned this a few times before, the amount of rollouts and what the payers are doing with AI and what they're admitting to or pointing the finger at as far as some of the payment, the claims processing problems where they're actually paying things not according to their own guidelines. So we're seeing a lot right now, and this is it's overwhelming, I think, for a lot of the AR teams that are out there. And again, being able to share all that information is very important, and solutions are a part of the mix as we see some things work and some tests and things that don't.

Yeah, and I think, Mark, also that the one of the nice things, or one of the things that that we appreciate is hearing from the different parts of the country, as you mentioned, and seeing what those trends are from different payers. So having a heads up on if it's a different state, they may be rolling out things Mac by Mac or state by state or commercial plan by commercial plan, and just hearing that information and getting that information just so you can keep an eye on it and make sure that you understand that these things are happening, it really helps out and it's kind of an advanced warning uh for people. And then also I think it's interesting to hear about the different within the different states, uh the different uh policies. For example, New Jersey, I think one of the comments was New Jersey doesn't uh allow uh in-office dispensing. So when looking at the solution of Xiaflex and maybe going through a specialty pharmacy pharmacy or using an IOD uh solution, uh some some states can't do that and others can. Ray. Comments, questions?

Well it's just nice to be able to have a forum where you can hear what others are doing and to find out and to see that others are having the same problem you are. And sometimes you hear a solution.

Not sometimes, often. And I think it's the other side is sometimes we have not yet found the solution, unfortunately. And that's been frustrating, I think, to a lot of folks. And I mean, this is definitely a marketplace right now where it's hard to practice medicine, I think the way a lot of people would like to practice medicine. You're moving too fast, you don't have access to all the tools. I mean, it's you can see why there's some burnout in the marketplace, a lot of EHR, administrative, all those requirements that are going on, and then so many changes, exciting new technologies, but at the same time, such confusion, such inconsistency, so many changes, and right now, so much activity from the payers that's just hard to keep up with for your AR team. It's a lot of work going on, and those people who really think out there that billing is as easy as slipping a couple of codes in and putting them out the door and not worrying about whether the documentation's there or the ICD 10 code was exactly right, those days are gone. It is it requires follow-up, monitoring. And as we are going to address in our upcoming urology advanced coding and reimbursement seminar, it's the wheel. I mean, it's we introduced the wheel several years ago, which demonstrates how connected the process of scheduling, checking eligibility, insurance, prior authorizations, orders, like and then documentation, coding, communication, understanding what can be done and under what circumstances. It's all connected. And that communication among those among or within a practice is key. And then being able to go outside and see what other folks are doing to grab to gather that information is also very helpful. So it's really bringing that home as everybody's trying to figure out how to adapt in the new environment as AI is starting to really make an impact on every part of the practice.

Yeah, and uh I will uh you mentioned the Urology Advanced Coding and Reimbursement Seminar. I will tell you that our presenters, we've all been meeting on uh and discussing what how is the best way to get this information out to our attendees. And if you would like to attend, we do encourage you to sign up and come and join us in December in Las Vegas or in New Orleans in January. And you can go to PRSnetwork.com and on the homepage you can find a link to sign up and get more information on the seminars. So I think that's gonna be it, it looks really exciting. I think we got a great program and a lot of participation opportunities and get your questions answered. And also, we know that many of you are experiencing things that and you've solved that problem that you can share with others, and that's really the the best part of the the seminar is the community and connections and getting that information.

Right? I have a question for you, Mark. We always use the 80-20 rule that the busy practice wasn't keeping up with all the current rules and maybe not the best documentation. They were all just busy, could collect about 80%, but they would lose about 20. With all the new racks and uh audits and AI, is that percentage going up as to what they are going to be denied? That's a good question.

I would have to say that it feels like yes, but I haven't gone back in and done the study. And the 80-20 rule was generalized, it was a little bit more 90-10, and maybe now it is truly 80-20. We had a period of time where things were really falling into that side of the equation that there was better documentation. I think as we'd been teaching over the years, and folks have gotten a little bit better at using their electronic medical records, and that's and then we saw the change in the EM coding rules. We said we probably saw a drop in the amount of lost revenue that was out there. But I think we're seeing that creep back up. But again, I need to do some data runs and find out where those numbers are at this point in time. It's been a moving target, and quite frankly, we've been so busy in the weeds digging on actually getting things paid and turned around that I haven't had a chance to go back and look at the new numbers. So we will do that shortly. Obviously, that right now we're in the midst of seminar season, and we've got a bunch of stuff with the final rule hopefully coming out pretty soon. So we'll try and juggle that so we'll have all that all together for the UACRS in December to get some good, better numbers, and I can answer that better.

All right. Okay. Well, let's let's wind this episode up. We want to thank ModMed for supporting this episode. If you're in the market for an EHR or a practice management system, you can go to modmed.com forward slash PRS network for specials for our listening audience. All right. Let's get some final thoughts. Mark, final thoughts.

Yeah, so I did want to clarify that the UPTP group is physician practices only. We don't have industry involved in that, but we do have the ability to reach out to industry and see if there is additional assistance that's out there. But it's a it's a good group, and you've heard us emphasize a lot in a lot in all that we do the power of community. And that has been a theme for what we've been doing year over year. And again, we're just gonna keep emphasizing that. Maybe our two mantras are document and talk talk. Communicate. And then you layer on top of that, analyze, decide, plan. There's so many other things, but without the documentation and the communication, the rest of it falls apart. Ray, final thoughts.

We've all heard the old saying, it takes a village to raise a kid. Well, this day and time, it sounds like it takes a village to run a practice.

Indeed. All right. Once again, I'll give you the URL to join UPTP. If you go to PRSnetwork.com forward slash join UPTP, you can fill out the information and join the group. So we look forward to seeing you in the group. All right. That's all we have for today. Thank you all for listening. Take a job, right? Every coding. Thank you for listening to URL De Coding Members to podcast, where we help Euros understand maximize income and efficiency so there's time and everything for 50 years and happy life. You can find these on Spotify under respectable.