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I am 87 years old, with a problem of the prostate gland. Before I met Dr. Baum, I went to the bathroom every 30-60 minutes. After Dr. Baum's treatment on my prostate, I go only 5 times per day and only 1 time at night! You turned my life around. I am so very grateful!

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The year 2005 will portend significant decrease in income for nearly every American urologist. Nearly every urologist will be impacted by Medicare's slashing the reimbursement for LHRH agonists. Solo practitioners can anticipate annual losses of income in the thousands of dollars and larger group practices can expect over a $1 million shortfall this year.

Every practicing urologist, including pediatric urologists, will be asking "How can we recoup this lost income?" This article will provide a potpourri of suggestions that I have received from interviewing your peers. These are simple ideas that can either generate more revenue or can increase your bottom line by reducing your overhead expenses.

Perhaps the greatest opportunity to generate more income is using an electronic medical record program to improve your E & M coding. Most urological practices codes look like a classic bell-shaped curve with the majority of charges at Level 3, some level 2 and 4, and a rare Level 1 and 5. Using an EMR you move the curve sharply to the right and bill most level 4 and 5s. This is accomplished through documentation of exactly what you did on each visit by a single mouse click on the computer.

Next, I suggest you review your payers and identify what services and procedures are reimbursed at the highest level. Then find ways, usually marketing and practice promotion, to do more of these procedures. Next identify what procedures are poorly reimbursed and make an effort to do fewer of them. Yair Lotan et al provided an excellent review of this topic in the Journal of Urology, 172,1958-1962,2004. This article emphasized that procedures such as cystoscopies, transrectal ultrasounds, and urodynamic studies are more cost-effective on an hourly basis than radical prostatectomies and cystectomies.

Another procedure that currently offers excellent reimbursement and a favorable compensation on a hourly basis is minimally invasive therapy (MIT) for BPH. A TURP calculates to approximately $150/hour versus $850/hour for one of the MITs such as TUMT, TUNA, and water-induced thermotherapy (WIT).

Show me the Money
While the cost of providing medical services continues to increase each year, the reimbursements received from payors, including the government, remain relatively flat or even decreases. Most urologic practices accept payment schedules and fee schedules without questioning or without negotiating with the payor. We errantly believe that insurer fees are immutable. When I looked at my most common CPT codes, I found reimbursement ranged from 50% - 115% of Medicare reimbursement. The average was 90% of Medicare. There were some plans where I lost money each time I treated one of the plans' patients. I suggest you obtain a fee schedule at 110-115% of Medicare's fee schedule and renegotiate with your insurance plans for these rates which correspond with the practice's work effort and expense (a subject for a future article). By understanding your cost of providing care and your minimum acceptable payment level and present your argument in a clear and organized manner, you can usually negotiate for a higher reimbursement from insurance companies.

Dr. Jake Jacobo, from Orlando, Florida, found that he could increase his revenue by expanding his office hours one Saturday morning a month. He did this the weekend he was on call, which meant a negligible increase in the number of hours he worked, yet added to the bottom line of the practice.

Dr. Ted Benderev, from Mission Viejo, California, augments his incontinence and pelvic prolapse practice by performing vasectomies on Friday mornings. Dr. Benderev calculates that the average hourly insurance reimbursement for in-office vasectomy approaches $1000/hour (2 vasectomies/hour) making it a very profitable procedure. He uses Vasectomy.com to help promote this aspect of his practice.

Dr. Stan Brosman, from Santa Monica, California, suggests making every effort to collect co-pays at the time of service. A well-run practice should achieve nearly 100% of co-pays. Anything less is costing you money by increasing your overhead expenses.

Dr. Brosman recommends decreasing your inventories of medications and supplies. He has found that most companies and vendors will deliver the supplies and medications the same day or certainly within 24 hours. Dr. Brosman also points out that office supplies and inventories of expensive medications can tie up large amounts of cash that could be used in other more productive areas. His office has created a very innovative system to track these supplies and to reward the staff for savings when inventories and supplies are reduced. He found that he could reduce his office expenses by nearly $200/month and was willing to share these savings with his staff.

Another suggestion he makes is to allow patients to participate in the preauthorization process. Instead of tying up office staff to obtain an authorization, his staff encourages the patients to be responsible for this task. Although this has met with resistance from some of the patients, they learn that they can have a faster visit if this information is obtained prior to their visit with the urologist.

Dr. Ray Fay, from San Francisco, California, has increased the efficiency of his practice by training a patient coordinator to perform the intake history on his patients. The coordinator takes a complete history, which includes the chief complaint, the past medical history and reviews of systems and inputs this information into his EMR. As a result when Dr. Fay sees the patient, he reviews the history, performs a physical examination and executes a treatment plan. His message is that doctors should spend their time ONLY doing what doctors are trained to do and what only doctors can do and leave other less productive work to the staff.

Dr. Michael Salvatore, a national coding expert, reminds us once again the importance of collecting co-payments at the time of service. He says collecting co-pays at the time of service will save billing costs as well as insuring payments. He also suggests collecting co-payments for office procedures which can be easily calculated as 20% of the Medicare allowable fees for services you perform in the office, and these fees are placed on the encounter form so the front desk people know the charge when the patient signs out and can collect these fees up front.

In summary, now is the time for all of us to learn to become bean counters. I don't think any of us believed that those LHRH dollars would last forever. It was a wonderful while it lasted and we all enjoyed the ride. Now it's time to learn some practical business principles. We need to focus on increasing reimbursements as well as decreasing overhead costs. It is something we all can do and soon you won't even notice that there's been an erosion of your income.