ALTERNATE PATHS FOR REIMBURSEMENT SUCCESS

In the October newsletter, we discussed how to determine if freelance surgical assisting and insurance billing are viable in your area. But what if your research shows that insurance billing is unlikely to work? Is that the end of your self-employment dreams? It certainly doesn’t have to be! There are still some great options available, and while they might not be the most lucrative, they can still lead to remarkable financial success.

Three Routes to Consider

Contract with your local hospitals

Contract directly with your surgeons

Bill patients for your services

Contract With Your Local Hospitals

You may be wondering, “Why would the hospital want to pay me?” Good question! It’s not about making your dream come true – hospitals don’t care about that. What do they care about? Surgical revenues! They care about their surgeons. That’s where you can potentially have some leverage.

Leverage Surgeon Support

Take a lesson from a friend and mentor of mine, Al Sanchez. In the 1980s, he and two colleagues faced a similar challenge – in their case, hospitals wouldn’t grant them privileges to assist their surgeons. So, they did something ingenious: they went directly to the surgeons and asked them to sign a petition stating they wanted access to this Surgical Assistant service.

What Made This Work?

They didn’t pressure the surgeons. Instead, they asked a simple question, “We understand you already have an assistant you prefer. Can you imagine a time when your favorite assistant isn’t available? Maybe they’re sick or on vacation. Would you value having a qualified substitute ready to step in?” Almost every surgeon signed the petition on the off-chance they could use a substitute.

They also wisely chose to have each surgeon sign their own individual petition rather than having one petition with many signatures at the bottom. This created a visually impactful stack of petitions instead of just a couple of pages when they presented them to the hospital.

Negotiating the Contract

Now that you have the hospital’s attention, how do you negotiate your reimbursements? Always have a number in mind that you really want and then aim high. That way you may get more than you expected or you have some room to negotiate down to the number you were hoping for anyway. Don’t negotiate below your minimum acceptable rate.

Your best success comes from charging by the case, not by the hour. This is a key success principle for a Surgical Assistant business. I’ll outline another key principle at the end of this blog post.

When I was a freelance Surgical Assistant before I started teaching, I was making $105,000 a year assisting on only 10 cases a week (part-time). I got this by billing insurance companies. Even though I didn’t get paid for every case, the average reimbursement was $200. You can make 6-figures easily with a hospital contract like this, which is a solid start. If you want to double your income to $200,000, just double your workload to 20 cases per week! The math is pretty simple.

Here are some payment terms I would suggest for your minimum acceptable rate:

Regular Cases: $50 per hour, $200 minimum per case

Higher Level Cases: $75 per hour, $300 minimum per case

You get to describe what ‘Higher Level Cases’ means. These would be cases or specialties requiring a higher level of knowledge and/or skill of the assistant and usually are associated with higher insurance reimbursements. Here is an example list:

- Neurosurgery
- Cardiothoracic surgery
- Back surgery
- Bariatric surgery
- Pediatric surgery
- Transplant surgery
- Trauma surgery
- Microsurgery
- Robotic surgery

Contract Directly With Your Surgeons

My first foray into the world of freelance surgical assisting was in the mid-1980s when Medicare had just stopped paying surgeons to assist each other on cataract surgeries. I noticed two things:

The surgeons loved my assisting. They quickly became addicted to it. Some would even cancel their cases if I couldn’t be there and reschedule for when I could be there.

I had to hand instruments and assist under the microscope at the same time. Splitting my focus between these two roles was not ideal.

When they had another surgeon to assist, they could focus like a laser on the assisting role. A split focus could pose a risk to the patient. Imagine working under the microscope and holding something on the eye with your forceps. Then it happens. The surgeon asks for the scissors. So, while you are holding something on the eye with one hand, you now must reach back to the Mayo stand for the scissors.

No matter how steady you think you are, under the microscope it looks like an earthquake. And you are working on someone’s eye!

Key Insight #1

A solution came when I realized I could use my days off to work exclusively as an assistant during the Ophthalmologist’s block time in the OR and wouldn’t have to hand the instruments. My surgeons could also count on having me assist on all their cases, offering them an enhanced level of reliability.

I even offered to bill the patient directly so they could get my service for free. Surprisingly, they preferred to pay my bill themselves.

The takeaway? It surprised me that the surgeons wanted to pay my $200 per case themselves. Your surgeons may also happily pay you if they want you to assist badly enough. Focus now on building that kind of surgeon loyalty.

Bill Your Patients

Billing the patient is actually what you do when you bill the insurance company. But what if the insurance ultimately denies payment? You have the option to collect your fee from the patient or guardian.

It’s helpful to have a policy that is friendly to patients and surgeons alike. Set a limit on how much you’ll collect. I recommend $400. Your customary fee for their surgery may be thousands of dollars. But when the patient sees they only have to pay $400, they are likely to feel relieved. And the surgeon will feel good about it as well because they’ll have a happy patient and not one who complains about the bill.

The No Surprises Act (NSA)

The NSA, enacted in 2022, is a federal law designed to protect patients from unexpected medical bills, particularly in situations where they receive care from out-of-network providers at in-network facilities (No Surprises). Here’s how it affects self-employed Surgical Assistants:

Protections Against Surprise Billing

Patients are shielded from surprise medical bills for emergency services, non-emergency services at in-network hospitals, and air ambulance services. If you’re assisting in these cases, the patient cannot be billed more than their in-network cost-sharing amount, even if you’re out-of-network.

Patient Notification and Consent

For non-emergency services, if you’re an out-of-network assistant, you can still charge the patient directly, but you must provide notice and obtain their written consent at least 72 hours before the service. If the patient does not consent, you must accept their insurance payment as final, without additional billing.

If the insurance company denies payment completely, you have the right to bill the patient directly, as they are ultimately responsible for covering the cost of your services. However, you must have informed the patient in advance about this possibility under the NSA.

Balance Billing Ban

Balance billing (charging the patient the difference between your fee and what the insurance covers) is prohibited in situations where the patient has no control over selecting their provider (e.g., during surgery at an in-network hospital). This applies to many cases where Surgical Assistants are brought in without the patient’s direct involvement in the selection.

Billing Transparency

You must give patients clear, advanced notice of any potential out-of-pocket costs and provide them with a “Good Faith Estimate” if they are uninsured or paying out of pocket.

Impact on Self-Employed Surgical Assistants

If you’re out-of-network as is the case with most Surgical Assistants, the No Surprises Act may limit how much you can charge the patient. You’ll need to navigate in-network contracts or adjust your payment expectations for patients receiving care at in-network facilities.

Make sure to comply with the law’s consent and notification requirements, especially for non-emergency procedures. This includes providing detailed cost estimates and obtaining proper documentation.

Be prepared to give patients accurate cost estimates and make sure all agreements are in writing to avoid disputes later on.

You can succeed despite these new limitations. But you have to deal with new issues that you didn’t have to before the advent of the NSA. Your medical biller may help you with specifics related to the market you work in. Mederi Services in particular is more than willing to share their expertise and help keep you on the safe side of this law.

Key Insight #2

Michael Gerber, the author of “The E-Myth,” refers to one of the biggest reasons for business failure, such as in a surgical assisting business – the owner has suffered an “entrepreneurial seizure.” They assume that because they are good at assisting in surgery, they would also be good at the business of assisting in surgery. Michael Gerber calls this a “fatal assumption,” and it’s the reason most small businesses fail (Kidd) .

“Lack of experience can lead to costly mistakes: Running a business requires a lot of skills, from marketing and sales to finance and management. If you don’t have a solid background in these areas, you might end up making costly mistakes that could hurt your bottom line or even sink your business” (Kumar).

So, if you haven’t run any kind of business long enough to hone your business skills and your gut (business acumen), there are still some things you can do to increase your chances of success:

Trial by fire – just never give up. Fail as many times as you need to, learning from every failure, and ultimately succeed through shear persistence. This is a costly and time-consuming method and not everybody has the stomach for it. Or you could…

Find a partner who has successful business experience in your field and who has developed a high level of business acumen. That partner will help you avoid pitfalls and follow a proven fast track to success. This kind of partnership is priceless.

Unlike any other school, ACE Surgical Assisting can fill your need for a business expert. You will have to make a small upfront investment and ACE will need to own a small portion of the business.

If you want details about an ACE Partnership, send an email request to dan.bump@acesatraining.com. We look forward to hearing from you soon.