title: Surgeon leadership in the coding, billing, and contractual negotiations for fenestrated endovascular aortic aneurysm repair increases medical center contribution margin and physician reimbursement.
abstract: Fenestrated endovascular aneurysm repair (FEVAR) allows endovascular treatment of thoracoabdominal and juxtarenal aneurysms previously outside the indications of use for standard devices. However, because of considerable device costs and increased procedure time, FEVAR is thought to result in financial losses for medical centers and physicians. We hypothesized that surgeon leadership in the coding, billing, and contractual negotiations for FEVAR procedures will increase medical center contribution margin (CM) and physician reimbursement.
  
  
  
  At the UMass Memorial Center for Complex Aortic Disease, a vascular surgeon with experience in medical finances is supported to manage the billing and coding of FEVAR procedures for medical center and physician reimbursement. A comprehensive financial analysis was performed for all FEVAR procedures (2011-2015), independent of insurance status, patient presentation, or type of device used. Medical center CM (actual reimbursement minus direct costs) was determined for each index FEVAR procedure and for all related subsequent procedures, inpatient or outpatient, 3 months before and 1 year subsequent to the index FEVAR procedure. Medical center CM for outpatient clinic visits, radiology examinations, vascular laboratory studies, and cardiology and pulmonary evaluations related to FEVAR were also determined. Surgeon reimbursement for index FEVAR procedure, related adjunct procedures, and assistant surgeon reimbursement were also calculated. All financial analyses were performed and adjudicated by the UMass Department of Finance.
  
  
  
  The index hospitalization for 63 FEVAR procedures incurred $2,776,726 of direct costs and generated $3,027,887 in reimbursement, resulting in a positive CM of $251,160. Subsequent related hospital procedures (n = 26) generated a CM of $144,473. Outpatient clinic visits, radiologic examinations, and vascular laboratory studies generated an additional CM of $96,888. Direct cost analysis revealed that grafts accounted for the largest proportion of costs (55%), followed by supplies (12%), bed (12%), and operating room (10%). Total medical center CM for all FEVAR services was $492,521. Average surgeon reimbursements per FEVAR from 2011 to 2015 increased from $1601 to $2480 while the surgeon payment denial rate declined from 50% to 0%. Surgeon-led negotiations with the Centers for Medicare & Medicaid Services during 2015 resulted in a 27% increase in physician reimbursement for the remainder of 2015 ($2480 vs $3068/case) and a 91% increase in reimbursement from 2011 ($1601 vs $3068). Assistant surgeon reimbursement also increased ($266 vs $764). Concomitant FEVAR-related procedures generated an additional $27,347 in surgeon reimbursement.
  
  
  
  Physician leadership in the coding, billing, and contractual negotiations for FEVAR results in a positive medical center CM and increased physician reimbursement.
authors.affiliation: University of Massachusetts Medical School, Worcester, Mass. Electronic address: francesco.aiello@umassmemorial.org.
authors.forename: Francesco
authors.initials: F
authors.lastname: Aiello
authors.affiliation: University of Massachusetts Medical School, Worcester, Mass.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Durgin
authors.affiliation: University of Massachusetts Medical School, Worcester, Mass.
authors.forename: Vijaya
authors.initials: V
authors.lastname: Daniel
authors.affiliation: University of Massachusetts Medical School, Worcester, Mass.
authors.forename: Louis
authors.initials: L
authors.lastname: Messina
authors.affiliation: University of Massachusetts Medical School, Worcester, Mass.
authors.forename: Danielle
authors.initials: D
authors.lastname: Doucet
authors.affiliation: University of Massachusetts Medical School, Worcester, Mass.
authors.forename: Jessica
authors.initials: J
authors.lastname: Simons
authors.affiliation: University of Massachusetts Medical School, Worcester, Mass.
authors.forename: James
authors.initials: J
authors.lastname: Jenkins
authors.affiliation: University of Massachusetts Medical School, Worcester, Mass.
authors.forename: Andres
authors.initials: A
authors.lastname: Schanzer
mesh_terms: D001014:Aortic Aneurysm / Q000191:economics* / Q000601:surgery*; D001291:Attitude of Health Personnel; D019985:Benchmarking / Q000191:economics; D019917:Blood Vessel Prosthesis Implantation / Q000145:classification / Q000191:economics*; D059019:Clinical Coding; D003164:Competitive Bidding / Q000191:economics; D032982:Contracts / Q000191:economics*; D003362:Cost-Benefit Analysis; D016208:Databases, Factual; D057510:Endovascular Procedures / Q000145:classification / Q000191:economics*; D018588:Fee-for-Service Plans / Q000145:classification / Q000191:economics*; D005102:Health Expenditures; D017722:Hospital Charges; D017721:Hospital Costs; D006801:Humans; D007857:Leadership; D008404:Massachusetts; D017008:Negotiating; D010819:Physician's Role; D017064:Process Assessment, Health Care / Q000145:classification / Q000191:economics; D012189:Retrospective Studies; D066231:Surgeons / Q000191:economics*; D016896:Treatment Outcome