New Software Captures Tens of Thousands in Lost Surgical Revenue

Sep 13, 2023 at 11:27 am by kbarrettalley

by Jane Ehrhardt


When a practice of 43 sports medicine and orthopedic physicians began using the new Surgical Pathways software, it found over 270 unbilled surgeries in one month. The resulting claims generated $12 million in revenue for the clinic.

“There’s a disconnect between the billing and the clinical side in practices,” says Kevin Bonner, CEO of Systemedx, creators of the program. “They think they got it to billing, but we can find one to three surgeries missed per doctor per month.

“There are a few similar software programs, but they don’t bridge this gap. We’re the first one to marry the billing and clinical sides. And that’s where the big money is. Two-thirds of the missing surgeries have been found among traumas handled after hours. The doctors will just fail to get it all into the system. Surgical Pathways solves much of that using AI-driven billing, task functions, and smart phones.”

Using the app, a surgeon at the hospital can send all of the patient information to the clinic by shooting a photo of the hospital’s information form. That gets encrypted and sent to the main office, allowing staff to manually enter the data. A future update will automatically pull the data from the photo and input it into the system.

Physicians can also use the app for a wide range of access and input including looking up charts, meds, and allergies, manipulating their task list, and viewing their bonus for the month.

Once in the system, Surgical Pathways automatically fills in the CPT codes that are most used by that doctor for that procedure. “All you have to do is okay it or you can massage it a bit,” Bonner says. “The AI can currently guess about 80 percent of the surgeries, but it also learns. It will watch the provider and the billing person as they make adjustments. And the next time, it will recommend that highest percentage of the correct code.”

It works the same way with ICD codes on claims in order to suit the insurer and generate the greatest revenue. For instance, because it knows that insurers pay 100 percent on the first procedure during a surgery and 50 percent on the second, it lists the higher-pay procedure first.

Should a claim be rejected, the AI files an appeal automatically. A staff member only has to approve it. “The AI knows the tricks that insurance companies play to avoid paying,” Bonner says. “And it’s learning all the time.”

The AI also hunts for rogue surgeries. For instance, if the hospital faxes operation notes for a patient, it looks for the procedure on the schedule or in billing. If it can’t find it there, it drops that surgery in the rogue bucket to be investigated so that the surgeon gets paid.

When a surgery is scheduled, a task list specific to that procedure gets automatically generated, which includes everything from cardiac clearance, ordering outside equipment, and generating lab orders to reserving the OR and signing the pre-certification.

The AI portion of the task lists automates, digitalizes, and speeds up a multitude of tasks, beyond just populating and submitting digital forms needed for the procedure. It also pulls info off scans, such as pre-certification authorization numbers, and marks those tasks as completed, identifying the user and time.

Complex tasks get simplified. When a surgeon orders a knee replacement, the AI automatically sends the outside vendor an email alerting them to the order. The vendor clicks on the link to the website to view the specifics. The AI marks the task as completed when the vendor clicks the website link and when they click to accept the order or not. If it’s not accepted, an alert pops up on the task list.

Currently, Surgical Pathways is in beta testing in a few clinics, with ten sales already on the books. “The real world always changes it a little bit so you want to go slow at the beginning,” Bonner says. “We’re on the third install, and now it’s getting smooth.”

At the latest conference unveiling, the AI billing component of the program caused the most excitement. “We think we‘re going to blow away the industry,” Bonner says, adding that Surgical Pathways has been generating an additional average per physician of $50,000 a year from the overlooked surgeries.

But Bonner sees further revenue opportunities by utilizing AI to stay on top of government and insurance regulations. Even something as simple as the AI reminding a physician to ask two additional health questions would qualify the patient visit for an additional $80, which multiplied over a year of visits adds up. “AI is going to revolutionize how we document and bill,” Bonner says. “That lets you focus on seeing patients.”

Sections: Business

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Apr 23, 2024 at 10:42 am by kbarrettalley

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