Ep. 19: Lisa Rock – Rev Cycle Trends for 2023 | This Week in Surgery Centers
Here’s what to expect on this week’s episode. 🎙️
Your revenue cycle is the lifeline of your surgery center, and if every piece of the workflow is not optimized, you’re likely leaving money on the table.
Lisa Rock is the President of National Medical Billing Services, the ASC industry’s largest revenue cycle company. With over 1,200 clients across 48 states – she knows a thing or two about optimizing financial results and anticipating what’s to come. Here are a few topics we cover as we talk through Rev Cycle Trends for 2023:
💰 Coding Trends
💰 Implants
💰 Commercial Payers
💰 Out-of-Network Landscape
💰 Denials
💰 Managed Care Contracts
Find the full episode on Apple Podcasts, Spotify, or YouTube to hear all the details!
Episode Transcript
0:00
welcome to this week in surgery centers
0:03
if you’re in the ASC industry then
0:06
you’re in the right place every week
0:08
we’ll start the episode off by sharing
0:10
an interesting conversation we had with
0:11
our featured guests and then we’ll close
0:13
the episode by recapping the latest news
0:15
impacting surgery centers we’re excited
0:18
to share with you what we have so let’s
0:20
get started and see what the industry’s
0:22
been up to
0:23
[Music]
0:27
hi everyone happy Valentine’s Day here’s
0:30
what you can expect on today’s episode
0:33
Lisa rock is the president at National
0:35
medical billing and she’s here to talk
0:37
with us about all things related to
0:39
payers and how they impact your revenue
0:41
cycle we’ll specifically dive into payer
0:44
trends that ASCS should be aware of in
0:47
our news recap we’ll cover marketing
0:49
your ASC tips from 55 industry leaders
0:53
on successfully running your surgery
0:55
center
0:56
tips for post-op nausea and vomiting and
1:00
of course end the new segment with a
1:02
positive story about a boy’s classmates
1:04
who made him a prosthetic hand in their
1:06
engineering class
1:08
hope everyone enjoys the episode and
1:10
here’s what’s going on this week in
1:12
surgery centers
1:14
[Music]
1:17
hi Lisa thank you so much for joining us
1:20
on our podcast today you’re welcome how
1:22
are you Erica
1:24
I’m doing good we are so excited to have
1:27
you on I do feel like not much of an
1:29
introduction is needed but just in case
1:32
some of our listeners aren’t familiar
1:33
can you tell us a little bit about
1:35
yourself sure well my name is Lisa rock
1:38
as you as you’ve already mentioned and
1:40
I’m the president of National medical
1:42
billing services we’re a full service
1:45
revenue cycle management company
1:47
awesome
1:50
oh I like that
1:52
um and again I feel like no introduction
1:54
is needed for National medical billing
1:56
but
1:57
um fill us in on a little bit more about
1:59
what it what you guys do and how many
2:01
ASCS you work with your presence all of
2:03
that good stuff okay well we manage the
2:06
red cycle for the entire Outpatient
2:09
Surgical episode of care so that would
2:11
include the facility which is the
2:14
surgery center uh or hopd uh also uh the
2:19
professional side which would be the
2:21
surgeon’s fee uh the uh anesthesia piece
2:24
and then any ancillary services that
2:27
might go along with that such as uh lab
2:30
or DME something like that so just about
2:33
anything that a patient would see
2:37
um clinically in the in in the
2:40
Outpatient Surgical episode of care we
2:42
would be able to handle the billing for
2:44
that okay so today we’re here to talk
2:47
about revenue cycle trends for for 2023
2:50
which is always timely and interesting
2:53
and I feel like our industry Can’t Get
2:55
Enough tips and tricks for how to kind
2:57
of improve their revenue cycle processes
2:59
so we’re just going to Dive Right In
3:03
um first question what are some coding
3:05
trends that you’re seeing
3:07
uh the coding Trends we’re seeing are a
3:11
lot of
3:12
um uh surgeries today are uh are newer
3:16
in technology and technique and there
3:20
really really isn’t a good CPT code uh a
3:25
sign for that service and unfortunately
3:28
the way the current uh structure is set
3:32
up now that procedure would have an
3:35
enlisted code and Medicare doesn’t pay
3:38
for unlisted codes and
3:41
um unlisted codes have a lot of other
3:43
problems as well
3:45
um sometimes the
3:48
um the net revenue is unknown you you
3:51
get paid by a report by some contracts
3:54
and uh if you’re not sure what you’re
3:57
going to get paid and your accountants
4:00
are looking at net revenue at time of
4:02
charge posting except for maybe the
4:05
enlisted codes which are sitting on your
4:07
books as gross it uh it’s a little
4:10
difficult to measure and manage and so
4:14
we’re seeing more and more of these
4:16
unlisted codes today and then
4:19
and I’ll also mention too sometimes
4:22
surgeons want to to get the closest
4:25
thing
4:26
to that code and you just can’t do that
4:30
what we have to figure out is how we can
4:33
get the system to move faster to keep up
4:36
with uh the newer procedures the newer
4:39
technology that that we’re seeing so
4:41
much of today
4:43
um and then one more piece to that I I
4:45
would mention
4:47
um sometimes the enlisted codes require
4:49
pre-authorization and
4:53
um and now we’re going down a whole new
4:55
rabbit hole with that so
4:58
um I would say that uh that’s a trend
5:02
that we’re seeing more and more of
5:04
um last year especially in orthopedic
5:06
surgery
5:08
yeah I feel like the pre-off stuff is
5:11
coming up
5:12
so much more often than it was
5:14
previously and it’s getting harder to
5:18
kind of identify those cases that
5:20
require
5:21
pre-auth would is that correct is
5:24
absolutely correct and uh one of the
5:26
reasons for that is
5:29
um
5:30
we might get what scheduled authorized
5:33
and the surgeon will go in and do even a
5:37
little something different on top of the
5:39
main procedure something different
5:41
altogether and so the auth is
5:45
no good and uh and so that is a real
5:49
problem but this one’s Really Gonna
5:51
shock people
5:53
you can do everything right and you can
5:55
put the auth on the claim form and you
5:58
can send the claim in and lo and behold
6:01
you get a denial that says uh no off
6:04
denied
6:06
so you call and you tell the payer the
6:10
auth number is on the claim form and
6:12
they say oops my bad we’ll go ahead and
6:14
reprocess it and so you’ve just lost
6:17
like two to three weeks of of uh deposit
6:20
uh for that for that surgery and it’s
6:23
happening more and more today
6:26
so you’re right it’s hard to track and
6:29
in fact uh one of the things that we’re
6:33
noticing here is as we try to reduce the
6:37
error rate
6:39
um in coding and payment posting and
6:42
they are through uh automation we find
6:46
that
6:48
the pairs are kind of in our way with
6:50
that by putting uh technicalities on the
6:54
claim uh the claims adjudication process
6:57
that would kick out a denial in the
7:00
automation process so for example
7:02
uh let’s say you’re building an implant
7:06
and the payer and by the way they’re all
7:08
different in the requirements but let’s
7:10
say you have one payer that requires you
7:12
to circle the dollar amount and the
7:14
patient on the implant invoice with red
7:16
pen I mean you can’t automate that so
7:19
there are numerous things that the
7:22
payers are doing to get in the way of
7:24
automation to reduce the error rate and
7:27
speed up the clean claims adjudication
7:30
process
7:33
that’s a lot that’s a handful you know
7:36
what I’m saying and there are those
7:38
scenarios there really are
7:41
yeah
7:42
okay that that’s all super helpful
7:44
information
7:46
um so moving on to our our second topic
7:49
here what trends are you seeing with
7:51
implants
7:53
so the one that I just mentioned is
7:55
definitely a trend worth the
7:57
technicalities on the implants but
8:01
um with the newer implants that are
8:03
coming uh out your older Managed Care
8:07
contract might not be covering the cost
8:10
of that uh and also your vendor meaning
8:15
your device vendor contracts
8:19
um they might not be covering some of
8:22
the newer implants that are that are
8:24
that are coming out so you need to look
8:27
at two things your Managed Care
8:28
contracts and your vendor contracts and
8:30
uh and make sure that your uh uh
8:33
controlling the new technology through
8:35
above both of those Avenues
8:39
um because it is not uncommon for a very
8:42
expensive meaning a high cost uh implant
8:46
uh case to fall in a bucket by a
8:50
particular pair that doesn’t pay for
8:52
implants and so the more you do those
8:56
cases
8:57
the more you’re losing uh real cash
9:00
because you have to pay that vendor uh
9:04
within 30 days the the device vendor and
9:08
if you negotiate a certain rate for
9:10
Implant and this particular newer
9:13
implant is outside of the scope of that
9:16
contractor paying a higher rate than you
9:18
think so there are two areas to look at
9:22
with the newer implants
9:26
um so so that’s definitely
9:30
um
9:31
that’s definitely one one of one of many
9:34
implanted that I can talk about
9:38
um
9:39
yeah I’m sure another one will come to
9:41
mind when you’re asking me another
9:42
question yeah no and it’s it’s
9:45
interesting that that we’re talking
9:46
about in plants too because I feel like
9:48
that’s coming up more and more on our
9:49
end as well like how can you how can you
9:52
determine the profitability of a case
9:54
when implants are involved and this is
9:57
obviously just one piece of it but
9:59
um yeah it’s definitely such a Hot Topic
10:03
right now well and some of the pairs
10:05
have contracts with uh implant uh
10:09
vendors uh such as ipg so before you’re
10:13
talking about uh the process of handling
10:17
an implant
10:18
being different with the payers in your
10:21
in your facility so you’re asking
10:24
someone to stay on top of all of those
10:26
different procedures by pair and that
10:28
that’s hard to do too
10:31
sure yeah a lot of moving Parts there
10:35
um Switching gears a little bit what are
10:37
you seeing with commercial payers
10:43
um well there’s definitely a move to
10:48
to
10:51
um
10:52
control
10:54
cost in current reimbursement
10:57
methodology so uh we’re seeing something
11:00
like cops for example that
11:03
um that the blues are using and it is a
11:07
reimbursement methodology that mirrors
11:09
uh Medicare hopd and in many instances
11:14
it’s not favorable to the to the ASE and
11:18
it’s very different it’s a very
11:19
different look
11:20
compared to what we’re used to seeing in
11:23
this environment so something that has
11:26
to be looked at
11:28
um
11:29
you know with a magnifying glass really
11:31
like line by line
11:34
um so we’re seeing reimbursement
11:35
methodologies changed we’re seeing
11:37
denial rates
11:39
um for everything you can think of of
11:42
increase uh by a lot medical necessity
11:47
um the auth issue that I talked about
11:50
um and uh it’s it’s difficult now for
11:54
any AR Department any AR Department in
11:57
the country to stay on top of what’s
11:59
happening it’s not difficult to make a
12:02
call
12:03
to an insurance company or check a
12:05
portal or whatever but to figure out
12:07
what’s going on fix it and get that
12:08
claim paid that’s a lot of work and it’s
12:11
very difficult to do today it really is
12:14
yeah and
12:15
how do you think surgery centers can
12:18
continue to build out their
12:20
relationships with payers is it possible
12:23
to have that more one-on-one
12:25
relationship so when you do pick up the
12:28
phone you can get to somebody faster or
12:30
just kind of get more on the PA same
12:33
page as as the payers
12:35
it’s much harder than it used to be so
12:38
yeah
12:39
um we used to be able to take our reps
12:43
to lunch and get to know them and they
12:46
would get to know uh our practice and
12:49
and uh we would develop a good
12:51
relationship with them those those days
12:52
are pretty much over and
12:56
um
12:57
and today
12:59
um
13:00
when when the payer Market is dominated
13:03
by self-funded plans it it means that
13:06
the the payers
13:08
uh don’t really have as much of a say as
13:13
they used to it’s really an employer
13:16
driven market today so now we’re talking
13:19
about how do we develop a relationship
13:22
with the employers and that’s really I
13:25
think the way we should be looking at
13:28
this landscape today is developing a
13:31
relationship with people that actually
13:32
pay the claim and probably 65 to 70
13:35
percent of the time it’s the employer
13:38
groups and these self-funded plans so
13:40
it’s kind of hard to have a conversation
13:42
with one of the big four when they’re
13:44
simply an ASO or administrative Services
13:46
only model and
13:48
um and uh their whole mission right is
13:51
to drive down the rate as much as
13:53
possible
13:55
um so that they can keep that contract
13:57
with the employer group that’s really
14:00
what it’s about the bottom line so it’s
14:03
uh it’s a very different environment
14:04
today
14:08
your larger employer groups are and try
14:10
to work with them directly
14:12
yeah no that’s helpful because I I do
14:15
feel like that’s a conversation we end
14:16
up having sometimes and I’m always
14:18
looking for
14:19
an answer to that question so it’s it’s
14:22
definitely hard to come by
14:25
um what does the out of network
14:27
landscape look like today
14:30
uh
14:31
uh so a zillion years ago uh when I
14:36
started in this business I was managing
14:38
an ortho group and uh we were actually
14:41
out of network with Medicare
14:43
you believe that I don’t care about that
14:46
very often today so I’ve been I’ve been
14:49
swimming in the out of Network arena for
14:50
a very very long time it’s always been
14:52
hard but today
14:55
um we’re seeing the squeeze uh put on
14:58
the surgery centers in the out of
15:00
network environment so
15:02
um
15:04
there’s language uh if if you’re if your
15:07
facility is participating with a
15:10
commercial payer we’re seeing language
15:11
that if you bring an anesthesia a group
15:15
that’s out of network or if you bring in
15:17
a surgeon that’s out of network or you
15:20
know a lab where you send your pathology
15:23
to uh
15:24
you could see your facility
15:27
reimbursement reduced 10 20 30 even 40
15:30
percent
15:31
um some of the contracts are written if
15:33
you bring it out of network we’re not
15:34
paying anything at all uh so there there
15:39
are
15:40
um
15:41
the the carriers have their ways and and
15:45
you may want to stay out of network and
15:48
in some some instances it makes sense if
15:51
you’re not getting a fair reimbursement
15:53
because if you sign a bad contract I
15:56
mean how long are you going to be in
15:57
business so if if the carrier is not
16:00
willing to work with you it’s a tough
16:02
market and you have to know what you’re
16:03
doing when you’re sitting down with
16:04
these folks
16:06
um
16:07
sometimes staying out of network is very
16:09
difficult first of all
16:11
the work that you have to do on the
16:13
front end
16:14
um understanding what an SPD is looking
16:17
it up understanding
16:19
um how that claim is going to pay many
16:22
times the claim will pay at a Medicare
16:24
rate so if you take an out of network
16:27
charge of let’s say ten thousand dollars
16:30
they can go for a lot more than that
16:33
and you apply a Medicare A Lot amount
16:35
let’s say a thousand dollars
16:38
and now you layer on the out of network
16:41
the patient out of network benefit
16:43
configuration
16:45
um
16:45
which is a heavy patient responsibility
16:49
when it’s out of network you might be
16:51
getting a check for 20 bucks
16:54
so looking at the work that’s involved
16:57
which is an increase in cost from a
17:00
staffing perspective
17:02
a longer time to pay much longer time to
17:06
pay a high rate of underpayments and
17:10
then a lot of work to get what’s due to
17:13
you if what’s due to you as usual and
17:16
customary so I would say
17:19
um you know there’s still a place for
17:21
that but it’s a very difficult
17:25
um it’s a very difficult place to
17:27
navigate
17:30
yeah and with these conversations with
17:34
payers and and implant Trends and out of
17:36
network stuff where it is where does
17:38
kind of data fall into this kind of data
17:40
reporting like what what does the ASC
17:43
need to arm themselves with so they can
17:44
go into these conversations
17:47
you know kind of with a with a good
17:49
fight well I think knowing your data is
17:53
important so I’ll give you an example
17:56
if the average cash per case and that’s
17:59
how we measure a surgery center cash per
18:02
case cash by specialty
18:05
um cash by payer there are a couple of
18:07
different ways but know your Managed
18:09
Care contracts know know what you’re
18:11
supposed to be paid and then know how
18:14
you’re getting paid
18:15
um which are supposed to be the same
18:17
thing by the way but not necessarily but
18:20
it’s net revenue and collections so
18:23
understanding that piece will get you
18:26
away from looking at a secondary
18:30
you can’t stay on top of all of it I
18:33
know that that realistically
18:36
administrators are tough and they want
18:39
every single dollar collected they want
18:40
every single claim paid in their
18:42
entitled to that but the truth is you
18:45
really have to ask yourself do I want 98
18:48
of it to come in
18:50
or am I going to make a mistake while
18:53
I’m looking at the landscape and not
18:56
bring in the 90 percent to focus all of
18:59
my efforts on that two percent so
19:01
so you can’t even make that decision
19:03
unless you understand your numbers and
19:08
um so understanding your numbers means
19:10
that you have to you have to have some
19:13
basis of of benchmarking and there isn’t
19:19
a lot of it out there by the way uh so I
19:22
think using State information can be
19:25
helpful using Fair health information
19:26
can be helpful using your using your own
19:29
historical data can be helpful but
19:32
putting it all together and really
19:35
understanding your numbers
19:37
what’s my gross revenue
19:39
what’s my net collection rate
19:42
uh pardon me my gross collection rate
19:44
what’s my
19:46
um my payer mix and and uh cash for case
19:51
those are important days and AR
19:54
en’t it’s important but not as important
19:56
as it is in a hospital
19:57
because I just mentioned the implant
20:00
thing the implant on a claim can trip up
20:04
a claim almost you know all of the time
20:06
and so I don’t want my days in AR to be
20:10
28 and then not go after that implant so
20:16
understanding your numbers
20:19
first and then developing key
20:21
performance indicators on your numbers
20:24
you can’t throw out kpis they’re going
20:25
to be meaningless unless you understand
20:27
your data
20:29
perfect yep that’s exactly what I was
20:31
looking for I think that’s that’s great
20:33
advice all right and we do this every
20:35
week with our guests what is one thing
20:37
our listeners can do this week to
20:40
improve their surgery Centers Great
20:42
question if I could uh if I could say
20:45
just one thing it would be get copies of
20:48
your Managed Care contracts this is what
20:50
you’re supposed to be paid uh it was one
20:53
of the data elements that we talked
20:54
about what what is your net revenue
20:58
you’re not going to know unless you have
21:00
copies of your contracts and you might
21:02
say Well they’re loaded in your system
21:04
and I’ll say well they can’t all be
21:07
loaded like that correctly and and then
21:09
if there’s a change in the contract was
21:11
that was that
21:13
um fixed in your systems so many times
21:16
it’s not so please get copies of your
21:19
Managed Care contracts read through them
21:20
and see exactly what you’re supposed to
21:22
be paid don’t trust that the payer is
21:24
doing it doing it the right way
21:28
perfect that’s that’s great
21:31
um all right Lisa well I sincerely
21:33
appreciate your time and thank you so
21:35
much for sharing all of your advice with
21:37
our listeners you’re welcome Erica thank
21:39
you
21:41
[Music]
21:43
as always it has been a busy week in
21:46
healthcare so let’s jump right in our
21:49
first story comes from the February
21:50
edition of ASC Focus again and it’s all
21:54
about marketing your surgery center
21:56
historically marketing is not something
21:59
that this industry has prioritized you
22:02
know in other Industries a business
22:04
could never survive without some form of
22:07
marketing strategy and I truly believe
22:09
that that reality has been making its
22:12
way to the ASC industry for quite some
22:15
time now
22:16
ASCS can no longer just rely on
22:19
physician referrals to sustain their
22:21
case volume they really need to Market
22:23
themselves with almost the mindset of a
22:26
retailer and consider their patients
22:28
shoppers
22:29
this article has a ton of different tips
22:32
but really focuses on the importance of
22:34
investing in your website integrating
22:37
video and getting more involved on
22:39
social media are really just more
22:41
involved with your community in general
22:43
and if that’s through social media great
22:45
if it’s through another format that
22:48
works too
22:50
by marketing your ASC properly you will
22:53
experience not only an increase in case
22:55
volume and happy patients but also an
22:58
increase in job applications which is
23:01
huge right now an increased interest
23:03
from Physicians and surgeons to perform
23:05
their cases at an ASC uh General
23:08
increase awareness in your community and
23:11
then also this is kind of one of those
23:13
secondary benefits but you’ll also
23:16
experience a major reduction in those
23:18
time-consuming phone calls such as do
23:20
you do this procedure or what surgeons
23:22
work there or What insurances do you
23:24
accept and so much more
23:26
so I highly suggest you check out this
23:28
article from ASC focus and really lean
23:31
into Marketing in 2023 and Beyond
23:35
in our Second Story Becker’s ASC shared
23:39
a cheat sheet with 55 tips from industry
23:42
leaders on how to successfully run an
23:44
ASC so let’s really dive in and go one
23:48
by one
23:49
just kidding I won’t do that to you but
23:51
I did pick out tips from three leaders
23:54
that I really liked so I will share
23:56
those and then we’ll link the full list
23:58
in the episode notes so you can read
24:00
through them all later
24:02
so the first kind of set of tips I
24:04
picked out is from Rebecca Bruce who is
24:06
the senior director at UPMC leader
24:09
Surgery Center and she shared a few
24:11
things
24:13
um the first is to take excellent care
24:15
of Staff as they are the best resource
24:17
to identify savings
24:20
listen and respond to surgeon needs
24:22
identify streamline and standardize your
24:25
processes remember why you all do this
24:28
which is patient care and then this one
24:31
I really like identify fixed
24:34
contributors versus growing contributors
24:36
some staff are content to punch the
24:39
clock and do a great job and others want
24:41
to grow and be part of the performance
24:43
initiatives so think both types and make
24:47
it meaningful to their specific desires
24:50
so those again were from Rebecca Bruce
24:54
uh the second set of tips comes from
24:56
Gary Haynes from Tulane University
24:58
School of Medicine and his angle was
25:02
um all about the anesthesia side of an
25:04
ASC and there are two tips for Reliable
25:07
scheduling keep cases within planned
25:10
hours of operation to avoid overtime
25:12
costs and patient complaints and then
25:15
make sure you find very capable
25:17
anesthesiologists ASC patients are
25:20
increasingly complicated
25:23
um with
25:24
comorbidities Excuse me so you need
25:27
anesthesiologists that can manage that
25:30
and then the last set of tips comes from
25:32
Justin Oppenheimer who is the Chief
25:34
Operating Officer and chief strategy
25:37
officer for hospital for special surgery
25:39
and he shares three tips
25:42
um the first is a surgeon-led structure
25:45
and he says that successful ASCS have an
25:48
Engaged group of surgeon leaders who
25:50
care about every aspect of the business
25:52
so ensuring the right leadership
25:54
structure and the engage surgeons in
25:57
each role is critical
25:59
the second tip that he shared is a
26:03
unified culture every member of the team
26:06
needs to feel connected to the mission
26:07
and goals everyone is a leader and has
26:09
an impact on quality experience
26:12
efficiency and results
26:14
and then the last tip that Justin shared
26:16
um was Data driven operations
26:19
um you can’t improve what you can’t
26:21
measure so having a set of metrics that
26:23
everyone is keyed in on helps to drive
26:25
performance
26:27
so those are just to highlight it’s just
26:29
the tip of the iceberg and again we’ll
26:31
put the link to the entire cheat sheet
26:33
and the episode notes and I I highly
26:34
recommend checking them out our third
26:37
story today is all about post-op nausea
26:40
and vomiting which is a big issue for
26:42
some patients and aside from that being
26:44
a stressful experience for the patient
26:46
it also slows down discharges and
26:49
sometimes causes readmissions so the
26:51
National Library of Medicine released a
26:53
paper recently sharing the results from
26:56
a study that tested the efficacy of post
26:59
ease which is a custom essential oil
27:02
aromatherapy blend and how that
27:05
decreases post-op nausea and vomiting
27:08
so the study had nurses provide the
27:11
post-ease blend
27:13
384 times prior to administering any
27:17
anti-emetic drugs and for 22 percent of
27:20
the patients it worked and there was no
27:22
need for further intervention and the
27:25
blend contained sense of lavender
27:27
peppermint Ginger and lemon
27:30
and because of this the study does
27:31
support the use of aromatherapy to
27:34
reduce post-op nausea and vomiting and
27:36
minimize that antiemetic use so if you
27:39
don’t already this might be something
27:40
you want to keep on hand for patients
27:44
and to end our new segment on a positive
27:47
note three Tennessee High School
27:49
students created a prosthetic hand for
27:51
their new classmate Sergio Peralta was
27:55
born with a hand that wasn’t fully
27:56
formed and it was something he was
27:58
trying to hide from his classmate when
28:00
he switched high schools
28:02
when the engineering teacher found out
28:04
though he told Sergio that some of his
28:06
students might be able to help him and
28:08
three of them jumped at the chance to
28:10
build him a prosthetic hand
28:12
so the students use online models and
28:15
then a 3D printer to come up with a
28:17
prosthetic they hoped would work and it
28:19
did when Sergio caught a baseball for
28:22
the first time he said everyone started
28:24
freaking out and he also added that it
28:27
changed his life
28:29
and that news story officially wraps up
28:31
this week’s podcast thank you as always
28:34
for spending a few minutes of your week
28:35
with us make sure you subscribe or leave
28:38
a review on whichever platform you’re
28:40
listening from I hope you have a great
28:42
day and we’ll see you again next week
28:46
[Music]
welcome to this week in surgery centers
0:03
if you’re in the ASC industry then
0:06
you’re in the right place every week
0:08
we’ll start the episode off by sharing
0:10
an interesting conversation we had with
0:11
our featured guests and then we’ll close
0:13
the episode by recapping the latest news
0:15
impacting surgery centers we’re excited
0:18
to share with you what we have so let’s
0:20
get started and see what the industry’s
0:22
been up to
0:23
[Music]
0:27
hi everyone happy Valentine’s Day here’s
0:30
what you can expect on today’s episode
0:33
Lisa rock is the president at National
0:35
medical billing and she’s here to talk
0:37
with us about all things related to
0:39
payers and how they impact your revenue
0:41
cycle we’ll specifically dive into payer
0:44
trends that ASCS should be aware of in
0:47
our news recap we’ll cover marketing
0:49
your ASC tips from 55 industry leaders
0:53
on successfully running your surgery
0:55
center
0:56
tips for post-op nausea and vomiting and
1:00
of course end the new segment with a
1:02
positive story about a boy’s classmates
1:04
who made him a prosthetic hand in their
1:06
engineering class
1:08
hope everyone enjoys the episode and
1:10
here’s what’s going on this week in
1:12
surgery centers
1:14
[Music]
1:17
hi Lisa thank you so much for joining us
1:20
on our podcast today you’re welcome how
1:22
are you Erica
1:24
I’m doing good we are so excited to have
1:27
you on I do feel like not much of an
1:29
introduction is needed but just in case
1:32
some of our listeners aren’t familiar
1:33
can you tell us a little bit about
1:35
yourself sure well my name is Lisa rock
1:38
as you as you’ve already mentioned and
1:40
I’m the president of National medical
1:42
billing services we’re a full service
1:45
revenue cycle management company
1:47
awesome
1:50
oh I like that
1:52
um and again I feel like no introduction
1:54
is needed for National medical billing
1:56
but
1:57
um fill us in on a little bit more about
1:59
what it what you guys do and how many
2:01
ASCS you work with your presence all of
2:03
that good stuff okay well we manage the
2:06
red cycle for the entire Outpatient
2:09
Surgical episode of care so that would
2:11
include the facility which is the
2:14
surgery center uh or hopd uh also uh the
2:19
professional side which would be the
2:21
surgeon’s fee uh the uh anesthesia piece
2:24
and then any ancillary services that
2:27
might go along with that such as uh lab
2:30
or DME something like that so just about
2:33
anything that a patient would see
2:37
um clinically in the in in the
2:40
Outpatient Surgical episode of care we
2:42
would be able to handle the billing for
2:44
that okay so today we’re here to talk
2:47
about revenue cycle trends for for 2023
2:50
which is always timely and interesting
2:53
and I feel like our industry Can’t Get
2:55
Enough tips and tricks for how to kind
2:57
of improve their revenue cycle processes
2:59
so we’re just going to Dive Right In
3:03
um first question what are some coding
3:05
trends that you’re seeing
3:07
uh the coding Trends we’re seeing are a
3:11
lot of
3:12
um uh surgeries today are uh are newer
3:16
in technology and technique and there
3:20
really really isn’t a good CPT code uh a
3:25
sign for that service and unfortunately
3:28
the way the current uh structure is set
3:32
up now that procedure would have an
3:35
enlisted code and Medicare doesn’t pay
3:38
for unlisted codes and
3:41
um unlisted codes have a lot of other
3:43
problems as well
3:45
um sometimes the
3:48
um the net revenue is unknown you you
3:51
get paid by a report by some contracts
3:54
and uh if you’re not sure what you’re
3:57
going to get paid and your accountants
4:00
are looking at net revenue at time of
4:02
charge posting except for maybe the
4:05
enlisted codes which are sitting on your
4:07
books as gross it uh it’s a little
4:10
difficult to measure and manage and so
4:14
we’re seeing more and more of these
4:16
unlisted codes today and then
4:19
and I’ll also mention too sometimes
4:22
surgeons want to to get the closest
4:25
thing
4:26
to that code and you just can’t do that
4:30
what we have to figure out is how we can
4:33
get the system to move faster to keep up
4:36
with uh the newer procedures the newer
4:39
technology that that we’re seeing so
4:41
much of today
4:43
um and then one more piece to that I I
4:45
would mention
4:47
um sometimes the enlisted codes require
4:49
pre-authorization and
4:53
um and now we’re going down a whole new
4:55
rabbit hole with that so
4:58
um I would say that uh that’s a trend
5:02
that we’re seeing more and more of
5:04
um last year especially in orthopedic
5:06
surgery
5:08
yeah I feel like the pre-off stuff is
5:11
coming up
5:12
so much more often than it was
5:14
previously and it’s getting harder to
5:18
kind of identify those cases that
5:20
require
5:21
pre-auth would is that correct is
5:24
absolutely correct and uh one of the
5:26
reasons for that is
5:29
um
5:30
we might get what scheduled authorized
5:33
and the surgeon will go in and do even a
5:37
little something different on top of the
5:39
main procedure something different
5:41
altogether and so the auth is
5:45
no good and uh and so that is a real
5:49
problem but this one’s Really Gonna
5:51
shock people
5:53
you can do everything right and you can
5:55
put the auth on the claim form and you
5:58
can send the claim in and lo and behold
6:01
you get a denial that says uh no off
6:04
denied
6:06
so you call and you tell the payer the
6:10
auth number is on the claim form and
6:12
they say oops my bad we’ll go ahead and
6:14
reprocess it and so you’ve just lost
6:17
like two to three weeks of of uh deposit
6:20
uh for that for that surgery and it’s
6:23
happening more and more today
6:26
so you’re right it’s hard to track and
6:29
in fact uh one of the things that we’re
6:33
noticing here is as we try to reduce the
6:37
error rate
6:39
um in coding and payment posting and
6:42
they are through uh automation we find
6:46
that
6:48
the pairs are kind of in our way with
6:50
that by putting uh technicalities on the
6:54
claim uh the claims adjudication process
6:57
that would kick out a denial in the
7:00
automation process so for example
7:02
uh let’s say you’re building an implant
7:06
and the payer and by the way they’re all
7:08
different in the requirements but let’s
7:10
say you have one payer that requires you
7:12
to circle the dollar amount and the
7:14
patient on the implant invoice with red
7:16
pen I mean you can’t automate that so
7:19
there are numerous things that the
7:22
payers are doing to get in the way of
7:24
automation to reduce the error rate and
7:27
speed up the clean claims adjudication
7:30
process
7:33
that’s a lot that’s a handful you know
7:36
what I’m saying and there are those
7:38
scenarios there really are
7:41
yeah
7:42
okay that that’s all super helpful
7:44
information
7:46
um so moving on to our our second topic
7:49
here what trends are you seeing with
7:51
implants
7:53
so the one that I just mentioned is
7:55
definitely a trend worth the
7:57
technicalities on the implants but
8:01
um with the newer implants that are
8:03
coming uh out your older Managed Care
8:07
contract might not be covering the cost
8:10
of that uh and also your vendor meaning
8:15
your device vendor contracts
8:19
um they might not be covering some of
8:22
the newer implants that are that are
8:24
that are coming out so you need to look
8:27
at two things your Managed Care
8:28
contracts and your vendor contracts and
8:30
uh and make sure that your uh uh
8:33
controlling the new technology through
8:35
above both of those Avenues
8:39
um because it is not uncommon for a very
8:42
expensive meaning a high cost uh implant
8:46
uh case to fall in a bucket by a
8:50
particular pair that doesn’t pay for
8:52
implants and so the more you do those
8:56
cases
8:57
the more you’re losing uh real cash
9:00
because you have to pay that vendor uh
9:04
within 30 days the the device vendor and
9:08
if you negotiate a certain rate for
9:10
Implant and this particular newer
9:13
implant is outside of the scope of that
9:16
contractor paying a higher rate than you
9:18
think so there are two areas to look at
9:22
with the newer implants
9:26
um so so that’s definitely
9:30
um
9:31
that’s definitely one one of one of many
9:34
implanted that I can talk about
9:38
um
9:39
yeah I’m sure another one will come to
9:41
mind when you’re asking me another
9:42
question yeah no and it’s it’s
9:45
interesting that that we’re talking
9:46
about in plants too because I feel like
9:48
that’s coming up more and more on our
9:49
end as well like how can you how can you
9:52
determine the profitability of a case
9:54
when implants are involved and this is
9:57
obviously just one piece of it but
9:59
um yeah it’s definitely such a Hot Topic
10:03
right now well and some of the pairs
10:05
have contracts with uh implant uh
10:09
vendors uh such as ipg so before you’re
10:13
talking about uh the process of handling
10:17
an implant
10:18
being different with the payers in your
10:21
in your facility so you’re asking
10:24
someone to stay on top of all of those
10:26
different procedures by pair and that
10:28
that’s hard to do too
10:31
sure yeah a lot of moving Parts there
10:35
um Switching gears a little bit what are
10:37
you seeing with commercial payers
10:43
um well there’s definitely a move to
10:48
to
10:51
um
10:52
control
10:54
cost in current reimbursement
10:57
methodology so uh we’re seeing something
11:00
like cops for example that
11:03
um that the blues are using and it is a
11:07
reimbursement methodology that mirrors
11:09
uh Medicare hopd and in many instances
11:14
it’s not favorable to the to the ASE and
11:18
it’s very different it’s a very
11:19
different look
11:20
compared to what we’re used to seeing in
11:23
this environment so something that has
11:26
to be looked at
11:28
um
11:29
you know with a magnifying glass really
11:31
like line by line
11:34
um so we’re seeing reimbursement
11:35
methodologies changed we’re seeing
11:37
denial rates
11:39
um for everything you can think of of
11:42
increase uh by a lot medical necessity
11:47
um the auth issue that I talked about
11:50
um and uh it’s it’s difficult now for
11:54
any AR Department any AR Department in
11:57
the country to stay on top of what’s
11:59
happening it’s not difficult to make a
12:02
call
12:03
to an insurance company or check a
12:05
portal or whatever but to figure out
12:07
what’s going on fix it and get that
12:08
claim paid that’s a lot of work and it’s
12:11
very difficult to do today it really is
12:14
yeah and
12:15
how do you think surgery centers can
12:18
continue to build out their
12:20
relationships with payers is it possible
12:23
to have that more one-on-one
12:25
relationship so when you do pick up the
12:28
phone you can get to somebody faster or
12:30
just kind of get more on the PA same
12:33
page as as the payers
12:35
it’s much harder than it used to be so
12:38
yeah
12:39
um we used to be able to take our reps
12:43
to lunch and get to know them and they
12:46
would get to know uh our practice and
12:49
and uh we would develop a good
12:51
relationship with them those those days
12:52
are pretty much over and
12:56
um
12:57
and today
12:59
um
13:00
when when the payer Market is dominated
13:03
by self-funded plans it it means that
13:06
the the payers
13:08
uh don’t really have as much of a say as
13:13
they used to it’s really an employer
13:16
driven market today so now we’re talking
13:19
about how do we develop a relationship
13:22
with the employers and that’s really I
13:25
think the way we should be looking at
13:28
this landscape today is developing a
13:31
relationship with people that actually
13:32
pay the claim and probably 65 to 70
13:35
percent of the time it’s the employer
13:38
groups and these self-funded plans so
13:40
it’s kind of hard to have a conversation
13:42
with one of the big four when they’re
13:44
simply an ASO or administrative Services
13:46
only model and
13:48
um and uh their whole mission right is
13:51
to drive down the rate as much as
13:53
possible
13:55
um so that they can keep that contract
13:57
with the employer group that’s really
14:00
what it’s about the bottom line so it’s
14:03
uh it’s a very different environment
14:04
today
14:08
your larger employer groups are and try
14:10
to work with them directly
14:12
yeah no that’s helpful because I I do
14:15
feel like that’s a conversation we end
14:16
up having sometimes and I’m always
14:18
looking for
14:19
an answer to that question so it’s it’s
14:22
definitely hard to come by
14:25
um what does the out of network
14:27
landscape look like today
14:30
uh
14:31
uh so a zillion years ago uh when I
14:36
started in this business I was managing
14:38
an ortho group and uh we were actually
14:41
out of network with Medicare
14:43
you believe that I don’t care about that
14:46
very often today so I’ve been I’ve been
14:49
swimming in the out of Network arena for
14:50
a very very long time it’s always been
14:52
hard but today
14:55
um we’re seeing the squeeze uh put on
14:58
the surgery centers in the out of
15:00
network environment so
15:02
um
15:04
there’s language uh if if you’re if your
15:07
facility is participating with a
15:10
commercial payer we’re seeing language
15:11
that if you bring an anesthesia a group
15:15
that’s out of network or if you bring in
15:17
a surgeon that’s out of network or you
15:20
know a lab where you send your pathology
15:23
to uh
15:24
you could see your facility
15:27
reimbursement reduced 10 20 30 even 40
15:30
percent
15:31
um some of the contracts are written if
15:33
you bring it out of network we’re not
15:34
paying anything at all uh so there there
15:39
are
15:40
um
15:41
the the carriers have their ways and and
15:45
you may want to stay out of network and
15:48
in some some instances it makes sense if
15:51
you’re not getting a fair reimbursement
15:53
because if you sign a bad contract I
15:56
mean how long are you going to be in
15:57
business so if if the carrier is not
16:00
willing to work with you it’s a tough
16:02
market and you have to know what you’re
16:03
doing when you’re sitting down with
16:04
these folks
16:06
um
16:07
sometimes staying out of network is very
16:09
difficult first of all
16:11
the work that you have to do on the
16:13
front end
16:14
um understanding what an SPD is looking
16:17
it up understanding
16:19
um how that claim is going to pay many
16:22
times the claim will pay at a Medicare
16:24
rate so if you take an out of network
16:27
charge of let’s say ten thousand dollars
16:30
they can go for a lot more than that
16:33
and you apply a Medicare A Lot amount
16:35
let’s say a thousand dollars
16:38
and now you layer on the out of network
16:41
the patient out of network benefit
16:43
configuration
16:45
um
16:45
which is a heavy patient responsibility
16:49
when it’s out of network you might be
16:51
getting a check for 20 bucks
16:54
so looking at the work that’s involved
16:57
which is an increase in cost from a
17:00
staffing perspective
17:02
a longer time to pay much longer time to
17:06
pay a high rate of underpayments and
17:10
then a lot of work to get what’s due to
17:13
you if what’s due to you as usual and
17:16
customary so I would say
17:19
um you know there’s still a place for
17:21
that but it’s a very difficult
17:25
um it’s a very difficult place to
17:27
navigate
17:30
yeah and with these conversations with
17:34
payers and and implant Trends and out of
17:36
network stuff where it is where does
17:38
kind of data fall into this kind of data
17:40
reporting like what what does the ASC
17:43
need to arm themselves with so they can
17:44
go into these conversations
17:47
you know kind of with a with a good
17:49
fight well I think knowing your data is
17:53
important so I’ll give you an example
17:56
if the average cash per case and that’s
17:59
how we measure a surgery center cash per
18:02
case cash by specialty
18:05
um cash by payer there are a couple of
18:07
different ways but know your Managed
18:09
Care contracts know know what you’re
18:11
supposed to be paid and then know how
18:14
you’re getting paid
18:15
um which are supposed to be the same
18:17
thing by the way but not necessarily but
18:20
it’s net revenue and collections so
18:23
understanding that piece will get you
18:26
away from looking at a secondary
18:30
you can’t stay on top of all of it I
18:33
know that that realistically
18:36
administrators are tough and they want
18:39
every single dollar collected they want
18:40
every single claim paid in their
18:42
entitled to that but the truth is you
18:45
really have to ask yourself do I want 98
18:48
of it to come in
18:50
or am I going to make a mistake while
18:53
I’m looking at the landscape and not
18:56
bring in the 90 percent to focus all of
18:59
my efforts on that two percent so
19:01
so you can’t even make that decision
19:03
unless you understand your numbers and
19:08
um so understanding your numbers means
19:10
that you have to you have to have some
19:13
basis of of benchmarking and there isn’t
19:19
a lot of it out there by the way uh so I
19:22
think using State information can be
19:25
helpful using Fair health information
19:26
can be helpful using your using your own
19:29
historical data can be helpful but
19:32
putting it all together and really
19:35
understanding your numbers
19:37
what’s my gross revenue
19:39
what’s my net collection rate
19:42
uh pardon me my gross collection rate
19:44
what’s my
19:46
um my payer mix and and uh cash for case
19:51
those are important days and AR
19:54
en’t it’s important but not as important
19:56
as it is in a hospital
19:57
because I just mentioned the implant
20:00
thing the implant on a claim can trip up
20:04
a claim almost you know all of the time
20:06
and so I don’t want my days in AR to be
20:10
28 and then not go after that implant so
20:16
understanding your numbers
20:19
first and then developing key
20:21
performance indicators on your numbers
20:24
you can’t throw out kpis they’re going
20:25
to be meaningless unless you understand
20:27
your data
20:29
perfect yep that’s exactly what I was
20:31
looking for I think that’s that’s great
20:33
advice all right and we do this every
20:35
week with our guests what is one thing
20:37
our listeners can do this week to
20:40
improve their surgery Centers Great
20:42
question if I could uh if I could say
20:45
just one thing it would be get copies of
20:48
your Managed Care contracts this is what
20:50
you’re supposed to be paid uh it was one
20:53
of the data elements that we talked
20:54
about what what is your net revenue
20:58
you’re not going to know unless you have
21:00
copies of your contracts and you might
21:02
say Well they’re loaded in your system
21:04
and I’ll say well they can’t all be
21:07
loaded like that correctly and and then
21:09
if there’s a change in the contract was
21:11
that was that
21:13
um fixed in your systems so many times
21:16
it’s not so please get copies of your
21:19
Managed Care contracts read through them
21:20
and see exactly what you’re supposed to
21:22
be paid don’t trust that the payer is
21:24
doing it doing it the right way
21:28
perfect that’s that’s great
21:31
um all right Lisa well I sincerely
21:33
appreciate your time and thank you so
21:35
much for sharing all of your advice with
21:37
our listeners you’re welcome Erica thank
21:39
you
21:41
[Music]
21:43
as always it has been a busy week in
21:46
healthcare so let’s jump right in our
21:49
first story comes from the February
21:50
edition of ASC Focus again and it’s all
21:54
about marketing your surgery center
21:56
historically marketing is not something
21:59
that this industry has prioritized you
22:02
know in other Industries a business
22:04
could never survive without some form of
22:07
marketing strategy and I truly believe
22:09
that that reality has been making its
22:12
way to the ASC industry for quite some
22:15
time now
22:16
ASCS can no longer just rely on
22:19
physician referrals to sustain their
22:21
case volume they really need to Market
22:23
themselves with almost the mindset of a
22:26
retailer and consider their patients
22:28
shoppers
22:29
this article has a ton of different tips
22:32
but really focuses on the importance of
22:34
investing in your website integrating
22:37
video and getting more involved on
22:39
social media are really just more
22:41
involved with your community in general
22:43
and if that’s through social media great
22:45
if it’s through another format that
22:48
works too
22:50
by marketing your ASC properly you will
22:53
experience not only an increase in case
22:55
volume and happy patients but also an
22:58
increase in job applications which is
23:01
huge right now an increased interest
23:03
from Physicians and surgeons to perform
23:05
their cases at an ASC uh General
23:08
increase awareness in your community and
23:11
then also this is kind of one of those
23:13
secondary benefits but you’ll also
23:16
experience a major reduction in those
23:18
time-consuming phone calls such as do
23:20
you do this procedure or what surgeons
23:22
work there or What insurances do you
23:24
accept and so much more
23:26
so I highly suggest you check out this
23:28
article from ASC focus and really lean
23:31
into Marketing in 2023 and Beyond
23:35
in our Second Story Becker’s ASC shared
23:39
a cheat sheet with 55 tips from industry
23:42
leaders on how to successfully run an
23:44
ASC so let’s really dive in and go one
23:48
by one
23:49
just kidding I won’t do that to you but
23:51
I did pick out tips from three leaders
23:54
that I really liked so I will share
23:56
those and then we’ll link the full list
23:58
in the episode notes so you can read
24:00
through them all later
24:02
so the first kind of set of tips I
24:04
picked out is from Rebecca Bruce who is
24:06
the senior director at UPMC leader
24:09
Surgery Center and she shared a few
24:11
things
24:13
um the first is to take excellent care
24:15
of Staff as they are the best resource
24:17
to identify savings
24:20
listen and respond to surgeon needs
24:22
identify streamline and standardize your
24:25
processes remember why you all do this
24:28
which is patient care and then this one
24:31
I really like identify fixed
24:34
contributors versus growing contributors
24:36
some staff are content to punch the
24:39
clock and do a great job and others want
24:41
to grow and be part of the performance
24:43
initiatives so think both types and make
24:47
it meaningful to their specific desires
24:50
so those again were from Rebecca Bruce
24:54
uh the second set of tips comes from
24:56
Gary Haynes from Tulane University
24:58
School of Medicine and his angle was
25:02
um all about the anesthesia side of an
25:04
ASC and there are two tips for Reliable
25:07
scheduling keep cases within planned
25:10
hours of operation to avoid overtime
25:12
costs and patient complaints and then
25:15
make sure you find very capable
25:17
anesthesiologists ASC patients are
25:20
increasingly complicated
25:23
um with
25:24
comorbidities Excuse me so you need
25:27
anesthesiologists that can manage that
25:30
and then the last set of tips comes from
25:32
Justin Oppenheimer who is the Chief
25:34
Operating Officer and chief strategy
25:37
officer for hospital for special surgery
25:39
and he shares three tips
25:42
um the first is a surgeon-led structure
25:45
and he says that successful ASCS have an
25:48
Engaged group of surgeon leaders who
25:50
care about every aspect of the business
25:52
so ensuring the right leadership
25:54
structure and the engage surgeons in
25:57
each role is critical
25:59
the second tip that he shared is a
26:03
unified culture every member of the team
26:06
needs to feel connected to the mission
26:07
and goals everyone is a leader and has
26:09
an impact on quality experience
26:12
efficiency and results
26:14
and then the last tip that Justin shared
26:16
um was Data driven operations
26:19
um you can’t improve what you can’t
26:21
measure so having a set of metrics that
26:23
everyone is keyed in on helps to drive
26:25
performance
26:27
so those are just to highlight it’s just
26:29
the tip of the iceberg and again we’ll
26:31
put the link to the entire cheat sheet
26:33
and the episode notes and I I highly
26:34
recommend checking them out our third
26:37
story today is all about post-op nausea
26:40
and vomiting which is a big issue for
26:42
some patients and aside from that being
26:44
a stressful experience for the patient
26:46
it also slows down discharges and
26:49
sometimes causes readmissions so the
26:51
National Library of Medicine released a
26:53
paper recently sharing the results from
26:56
a study that tested the efficacy of post
26:59
ease which is a custom essential oil
27:02
aromatherapy blend and how that
27:05
decreases post-op nausea and vomiting
27:08
so the study had nurses provide the
27:11
post-ease blend
27:13
384 times prior to administering any
27:17
anti-emetic drugs and for 22 percent of
27:20
the patients it worked and there was no
27:22
need for further intervention and the
27:25
blend contained sense of lavender
27:27
peppermint Ginger and lemon
27:30
and because of this the study does
27:31
support the use of aromatherapy to
27:34
reduce post-op nausea and vomiting and
27:36
minimize that antiemetic use so if you
27:39
don’t already this might be something
27:40
you want to keep on hand for patients
27:44
and to end our new segment on a positive
27:47
note three Tennessee High School
27:49
students created a prosthetic hand for
27:51
their new classmate Sergio Peralta was
27:55
born with a hand that wasn’t fully
27:56
formed and it was something he was
27:58
trying to hide from his classmate when
28:00
he switched high schools
28:02
when the engineering teacher found out
28:04
though he told Sergio that some of his
28:06
students might be able to help him and
28:08
three of them jumped at the chance to
28:10
build him a prosthetic hand
28:12
so the students use online models and
28:15
then a 3D printer to come up with a
28:17
prosthetic they hoped would work and it
28:19
did when Sergio caught a baseball for
28:22
the first time he said everyone started
28:24
freaking out and he also added that it
28:27
changed his life
28:29
and that news story officially wraps up
28:31
this week’s podcast thank you as always
28:34
for spending a few minutes of your week
28:35
with us make sure you subscribe or leave
28:38
a review on whichever platform you’re
28:40
listening from I hope you have a great
28:42
day and we’ll see you again next week
28:46
[Music]
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