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Kip Theno: Welcome tothe Road to Care podcast hosted by SamaCare, where we will talk with keyopinion leaders, physicians, administrators, manufacturers, venturecapitalists, and legislators to get their insights on the state of healthcaretoday and where we see it evolving. SamaCare's prior authorization platform isfree to clinics, ensuring patients get on the right therapy at the right time.
Together, we can simply make things right.
Hey everybody, welcome back to the Road to Care podcast hosted by SamaCare. And our special guest today is Sara Julson RHIT. Sara is an experienced revenue cycle manager focusing on patient financial services. Sara is passionate about serving as a liaison between patients, billing departments, and the payer while enhancing account receivable processes. She's a registered health information technician and certified patient service specialist
Thanks for joining everybody. And Sara, really appreciate your time. I've gotta tell you [00:01:00] this, the pre-show that we had was one of the most fun. It was the longest one I've ever had, and there's a reason for it. I mean, you went into your background and history, Keratoconus, impacted patients, rare disease council, artificial iris.
You're a self-described nerd. I thought that was amazing, just kind of like myself. So we've got a lot to cover today. But Sara, first of all, how are you? And thank you for joining.
Sara Julson: I amdoing wonderful. Thank you so much for having me. I am excited to talk more about some of those passions.
As you said, I am absolutely a medical nerd. I've been in the RCM world for a long time, over twenty years, and I'm currently made my home inthe ophthalmology realm. It has been fascinating and really excited to talk about some of the landscape changes that we've seen in the revenue side of medical care.
Kip Theno: And let's get to that question first from the RCM perspective. But before we [00:02:00] do that, as I always start, just your personal journey into healthcare, Sara. What got you there? Where are you now?And, and just your passions for, uh, for being in this side of the world.
Sara Julson: Absolutely. I have always been interested in medical procedures, in how the overall medical world works.
And for me, when it was time to decide what am I gonna do with my life, there's a point we all hit that, and I really didn't know. So I started focusing and thinking about things that I enjoyed, which really led me back to some medical. Um, I love to help people. I am very passionate in that realm, but I'm not necessarily that hands-on, patient-facing person.
So it melded from a coding degree to more of the more the straight financial part, more of the RCM compared to strict coding. So that's where I started about 22 years ago. I've worked in several specialties. I've worked everything from pain management [00:03:00] to vein clinics. I've worked mental health. And as I mentioned, ophthalmology has really been where I've found that passion, that deep drive to help patients, and that is my current world for what I am looking at.
I'm all about the eyeballs.
Kip Theno: From, from revenue cycle, you know, it's an interesting place to be, right? You've got the clinic, you've got the workflows, the insurances, and then of course the patients, and you're kind of in the middle of this entire circle for, you know, the, the solvency of the clinic to continue patient care.
Just talk to us a little bit about revenue cycle and the challenges and things that you wanna change or maybe better that you've learned in the RCM space.
Sara Julson: Oh, absolutely. You are hitting my medical nerd-ism here with hard, hard blows, so it's great to be able to talk about this.
As I've been in this for about twenty years, we've started tosee some of the most significant changes that healthcare has had probably within the last ten years or so, and maybe even [00:04:00] more towards the last five years. It used to be where medical insurance was what people had, and they went to the doctor, and that was about the end of it.
Rarely did you get a bill or it was going to be a copay. Then you started to see insurance changing and going to more deductible plans orhigher patient responsibility. You saw more of the HSAs and the FSAs, so your financial spending accounts or those health savings accounts. Started to see more of that.
And where we currently are today is probably the highest rate of patient responsibility that I have ever seen. And that's a tough world, especially when you're talking about certain items. Like I mentioned, I'm in the eye world right now. And when you think about it, what would you pay for your vision?
It's unfortunate we have to think in that manner at this time versus, "I'm gonna go to the doctor and get the care that I need." So that's really been one of the areas that I focused in on is: How do I [00:05:00] help eliminate issues for access to care as an example? How do those financial pieces tie to the care that patients are actually getting?
The big phrase that I always say to people is, "I care about their financial health as much as their medical health." Because however much we want to say they could be separate, they really are tied together, where we have to work to find those financial solutions to be able to access the care that our patients needI definitely think that's one of my biggest areas of, uh, change that I think could happen.
I don't know how it would ever happen, but it's been tough to watch people go through their situations and share that they can't afford their medical care. I've had some absolute horror stories in my time of patients that needed care. Their insurance wouldn't cover items, so they needed state aid.
Absolutely, but the only way the state would have that happen--There was an elderly couple I remember who they'd been married for [00:06:00]almost fifty years, and theywound up having to get divorced so that they could afford or they would be in the correct financial category to be able to receive state assistance.
That is just a world that I don't want to see for people, and my goals are working to help people get that access to care, to break down some of those financial burdens. And I really speak to this regarding several different types of procedures or diagnoses where I'm working with groups across our state to ask for additional coverage or working on getting items donated or doing anything we can to really increase the access to care for patients.
Not only is the financial difficult on that end, we also have one more area to really consider that is a hindrance or a tough area to work as the patient: prior authorizations. They are not consistent per different insurance companies, perdifferent procedures. You can't say [00:07:00]that this surgery is going to need an authorization all the time because there's going to be those payers that don't.
Or you can't say that this surgery will never need an authorization because there are payers that will. So there's not only a higher patient financial responsibility, but there's a lot more s- administrative burden than I've ever seen. Those are really those areas that I think impact the RCM world and patient care that have driven that passion for me and the work that I'm doing.
Kip Theno: Uh, Sara, and I, what you said, I mean, it kind of struck a chord, right? What would you pay for your vision? Well, what would you pay for your heart, your brain, your pancreas, right? Diabetes. And they're all connected to, to- Yep ... visual or retinal disease states. And,you know, we can talk about prior authorizations all day long.
That's kind of our world over here at SamaCare, but you're not alone. Every single specialty says the same thing. Why is it so difficult? You know, the role of, say, PBMs as an example, and then the high cost, and [00:08:00]then you have seven payers denying it in an algorithm 46% of the time for the same drug, and then thethree payers 100% of the time have no auth required, right?
And there's no uniformity. I mean, Medicare to Medicare Advantage to commercial plans. And we, we do kind of steer away from politics here on my show, but we will not steer away from legislation. And so let's, let's talk about you, you had mentioned the No Surprises Act as an example.
Sara Julson: Yeah.
Kip Theno: Walk us through what that is.
Is it working? Is there transparency? Do you see it as a benefit? And then, where is it not working?And feel free to drop the gloves, Sara, if you'd like.
Sara Julson: Absolutely. So the No Surprises Act, um, and I'm gonna just kind of preface with I am not providing any legal advice. I am just taking my personal stanceon it and sharing what I have inferred from all the different meetings and different items that I've done.
So definitely not any legal advice. But I do think that the No Surprises Act has [00:09:00] goodareas or good intentions. Letting patients know their financial responsibility ahead of time, especially if they're going to be out of network or if theydon't have care under the No Surprises Act is a requirement. And that I dobelieve is helping people because they can have those early conversations. Ittakes some of the worry out of the situation, because if you're going into adoctor, you wanna be able to sit down and listen to what the doctor is saying to you. Sometimes it'sthat first appointment when you see your doctor, and they might say, "Youneed surgery."
If you don't have insurance, the immediate thought is,"How much is this going to cost?" And the rest of what the doctor is saying may or may not actually resonate with you because you are very concerned about the cost. So where the No Surprises Act has been helpful is being able to share those costs upfront with patients so that they can focus on their medical care with their providers.[00:10:00]
There are areas that are challenging in it, such as making sure that networks are clearly found. Insurance companies have definitely put some challenges in place for networks where this one plan that ends with one number different than all the others, that one's out of network for you, but everybody else is.
You know, everybody else is in network, and you're okay to see them. So while the No Surprises Act is really helpful on the patient side and even on the financial side, being able to have those conversations, there are definitely some challenges in making sure that we are meeting those requirements and that we are accurately able to present information to patients to make sure they have all of the knowledge.
Um, we want them to have the care, so using the good intentions is always my goal. I think it's difficult because networks, as that example, are not easily defined. You might have your surgery [00:11:00]center in network, and your doctor might be out of network or vice versa. Those are difficult conversations to have with patients.
Not that they're impossible, but it's really tough to say,"Hey, you know, your particular insurance company, you can keep seeing the doctor that you've been seeing. You can have surgery with that doctor. However, you're gonna have to pay for the operating room or the facility because they're not in-network."
That to patients becomes not only frustrating, but almost a point of contention on, "Well, what do you mean? No one told me this." So that's where the No Surprises Act is helpful, but it definitely has duality in whether or not it is helping providers open access to care, in my opinion anyway. So a little bit of gloves off stating that the payers are presenting us with additional challenges regarding networks in particular or those authorizations, making sure that everything is in place prior to.
If you have an authorization denied and you've already provided a good [00:12:00] faith estimate because of a network, now what? You're gonna have to go back and present new information. So there's a lot of details that come into play when we're talking about the NoSurprises Act, making sure that patients have all of the financial information ahead of time.
Kip Theno: Yeah, andI, and I think there, would you agree that there probably is gonna, is gonna have to be some kind of forced tipping point with what you've just said?Because the status quo certainly isn't gonna work. It's just making it more difficult. And you, you said something in the pre-show about financial health being just as important as physical health to the patients and patient access.
So we think of arrows in the quiver when we're trying to get better balance with patient access and the insurances and the payers and the costs, data being, I think, a heavy bat right now. And, and that data's kind of hard to find as an island. [00:13:00] But how do you, even from the revenue cycle side, or maybe go into more detail about that financial health that you are concerned with, with your patients, what are you doing specifically and maybe certain types of data that you're using to really start to force this tipping point, even with your peers and some of the councils and things that you work with, with, with the provider, with the payers as an example?
Sara Julson: Absolutely. So some of those areas that I've really been trying to focus in on.My current role, I make sure that every patient that is going to have a patient responsibility for a surgery gets some type of a good faith estimate. We make sure that the full disclaimer from CMS is on our letter on that good faith estimate so that patients know what the No Surprises Act is.
If they feel that something has been incorrect, there's how to file the dispute on there. So I really think that's been one area [00:14:00] that taking it a step farther for us orfor me has been beneficial because it's not only answering those questions of how much is this going to cost for the patients who are either out-of-network, don't have insurance coverage, or have, are underinsured.
So those areas are definitely a benefit. It also opens conversations early. We're able to talk to patients to state we can help you apply for different financing. We can set up an internal payment plan potentially. We can talk through the finances so that the patient can focus on their recovery, so that they can focus on the care for their physical health.
Their financial health, I never want to be the reason why they aren't getting medical care. So it's really taking time to work with each patient, realizing each patient has a different perspective, they have a different situation, and really making sure that we're not [00:15:00] only addressing the legal areas with the No Surprises Act as an example, but we're addressing the financial concerns of the patient early so that care can continue, so that they can continue going through their post-op appointments and following up in that six month, one year, making sure that they are able to be compliant with their treatment plans.
So it really is a worthwhile challenge, but I think some of the tipping points come down to, for us, timeframes. It's tough to get information to people and find that perfect sweet spot window of early enough for them to make financial decisions and have those conversations, but close enough to their appointment so that that appointment is really in their mind, whether it's a clinic appointment, whether it's a surgery appointment.
There's definitely a sweet spot, and in making sure that we're going one step above the No Surprises Act, that has been a challenge [00:16:00] for us, and I think that, in my opinion, could be kind of a tipping point in where do we meet all of the guidelines and where do we need to talk about changing some of those guidelines?
Kip Theno: And yeah, and well, and you mentioned change, but you also mentioned, Sara, treatment plans. Mm-hmm.
Sara Julson: And
Kip Theno: I can kind of think back, I might have some of this wrong, going by some memory here, but retina injections, I think the first ones were in the early 1900s. 1911 theywere, I think injections started as air bubbles for retinal tears, right?
And then they, they did penicillin injections in the eye, and then now we're in the '40s, so you look at the evolution of just science in general, which is amazing. But it also wasn't that long ago that y'all had oneto two, drugs for injections. Then you wake up in a heartbeat and then it's four and six, soon to be eight, right?
For the drugs available, biosimilar step therapy. So how do you, how do we balance all of that? [00:17:00]Not only the, the clinical behavior on the clinical side, the choices, the pathway, the workflows for the clinic, the treatment plans. How are you all navigating that? Because it is gonna continue to change. And then you can tie all that back into how does that financially affect the clinic and the patient?
Sara Julson: Oh, absolutely. I've got a few examples of my passion projects that really fall into the, that realm of what are we doing? How are we working on things? I spend quite a bit of my day-to-day work working with new procedures or new types of medications for patients relating to ophthalmology. There are several procedures out there that are new, and I found it to be a particular challenge because it is on average, I read, uh, 5 to 5.7 years from when a new procedure or drug has been FDA approved before the majority of payers are [00:18:00] recognizing it as, uh, a covered service or are putting out policies.
During that 5 years or 5.8 years that I had read, the, what I'd seen was they are just considering everything experimental or investigational for longer periods of time than what they had been in the past. Historically, Ihad seen two, three years where we could get most of the payers on board for new procedures.
It's definitely moved into that five year. And as an example ,one of the areas that I work in and where the financial health comes into play for our patients so much is the artificial iris . That is such a cool technology. I, when I first heard it, I kind of sat there going, "This is way advanced stuff I wouldn't ever expect to happen now."
It feels so futuristic, but it's out there. And the artificial iris was actually FDA approved in [00:19:00] 2018. So 2018 is definitely more than five years ago, and there are very, very few payers who have coverage. Many of their policies are written stating that the artificial iris that's been FDA approved since 2018 is considered investigational or experimental.
To go through the FDA, you have to have your research, you have to have your trials, you have to have enough information to be approved. So there's that point with the insurance companies of investigational and experimental then moves to patient responsibility, and I think that is a big challenge, especially, you know, mentioning artificial iris.
It's really the only type of option that patients with aniridia have to preserve their sight or to regain sight. So it's difficult to say,"Hey, I know that it's medically necessary, but your insurance isn't going to cover it. [00:20:00] It's an expensive item.It's a fairly expensive procedure, and we can help you, but we have to talk finances now."
It's a rock and a hard place. Going back to that first comment of how much would you pay for your vision? Well, we're finding those limits for patients, and it is tough, and it's something that I think we in the medical industry, that the insurance companies need to consider, that new procedures are helping patients and we need to get them moved along faster.
Kip Theno: Thatamazes me. Artificial iris, we-- the future is here, Sara. It's now. It's socool. But I go back to 20-2018, you remember what happened right after that,the, the COVID. And you think of these patients, those patients that were legally blind, as an example, how isolated were they without other options andthings like this that could have helped them through that period?
God forbid we ever go through something like that again. But [00:21:00] What do your peers out there say about the artificial iris? I mean, how is there not this groundswell of here's how many patients there are, this technology could work, here's the benefit long term for the system, for the patient. How do you get that groundswell for something like that?
Sara Julson: It's challenging. Uh, peers are in the same boat as us. There are doctors within ourarea and doctors across the US who do work with and do the do the surgery forartificial iris. We're all saying the same things. Payers are being very slowto adopt the new procedure, and we're really working towards individual casesat this time, or my, my approach has been individual cases with the payers sothat we're really working to have the rationale of here's why this is helpful.
There is nothing elsethat this patient can do. Here's why we need to do this. [00:22:00] And then I know my peers are doing the same. I've talked to some across thecountry, and unfortunately, it is a large administrative area for us to take things case by case and really work the insurance companies to understand the rationale.
It's FDA approved. Wehave all these research studies. How can you state this is still experimental or investigational? In the artificial iris case, we are well over five years. It's gone through all of the testing to get here. So we're-- we as agroup are trying to work on the insurance side to draw more attention to the procedures that are new, that really are solving issues that patients have that we could have never done before.
The challenges for myself and peers across the country are authorizations, getting coverage, and really removing that barrier to care regarding the [00:23:00] experimental items that are considered non-covered, but they have passed FDA approval. So that'san area that is challenging, and we as a whole need to work a little bit harder to have the insurance companies adopt these new procedures sooner.
Kip Theno: It, it's just, it feels a little bit like jumbo shrimp, right? Like an oxymoron. Well, it's FDA approved, but on the other side it's experimental. Like, how is that a binary state? I don't know. It kind of reminds me of the day, Sara, where, where, you know, a, a new data-driven approved device, as an example, to save lives in the cardiac space still had to go through what was called a VAC committee, value analysis.
Well, we've gotta analyze the value. Well, the value is I'm saving this patient's life. Like so we will, we will help scream it to the hills with you, Sara, for sure on this. And then with that, you're also taking some other steps, right? You talked about the Keratoconus patients, you talked about the Rare Disease Council.
Can you elaborate more into those passions of yours?
Sara Julson: oh, [00:24:00] absolutely. Uh, patients with Keratoconushave been one of my passion projects. I started working with what at that timewas a new procedure, ironically, back in 2018, and trying to get care for these patients. Keratoconus is a condition where the eye becomes cone-shaped.
It can progress at any point in time, and their vision canworsen. Once you are diagnosed or once you have Keratoconus, there really is nogoing back. So as you progress, as the shape of your eye worsens, as your visual acuity worsens, there's nothing that can be done for you outside ofdoing one particular procedure called cross-linking or epioxia. The reason I'm saying or is 2018, the cross-linking procedure had been FDA approved.
We started seeing really good coverage for patients some where in the 2020 twenty 2021 [00:25:00] category.And then twenty twenty-two, we started seeing the vast majority of payer having policies that would allow us to obtain coverage for patients. We never say all payers because we know that's not the truth, but we were seeing a largenumber of them.
And what's really cool here is they have developed an improved or a further way to help patients with Keratoconus in a new system that was FDA approved last year. So we're really working to get care for these patients because Keratoconus and the disease state itself do fall into that rare disease category.
So working with groups in the state to try to have rare disease council assist in talking to payers or talking to the state about coverage. I think one of the best examples is the Keratoconus patients, where historically, once we were able to get policies listed and work with payers to get coverage, [00:26:00] one of the payer issues was Medicaid, where Medicaid would cover the procedure for cross-linking, but not the drug required to do the procedure.
And that was a challenge because you had to then tell your patients, "Hey, you're financially qualified for Medicaid. They'll pay for the procedure, but we need a lot of money for the drug." And that is stilla challenge because Medicaid is still not allowing for coverage on the drug inmost cases. There are some payers that we're starting to see some changes, but even as the technology is growing and improving and the machine and the equipment is improving, payers are actually taking a step backwards.
So cross-linking had been predominantly approved by payers. Now with the new plan coming out that started last year called Epioxa, we're seeing that Keratoconus patients are losing their one [00:27:00]opportunity to halt the progression of Keratoconus. Insurance companies are doubling back on their policies saying, "Oh, with this new procedure?
Nope, that's investigational even though there's-- it is a little bit different, but not significantly different than the other procedure.So we're starting that process all over again, and these patients have no options. They cannot wear glasses. Glasses on a cone-shaped eye aren't going to help the visual acuity to the highest level needed, and it's not going to treat the condition of that misshapen eye.
If you think about contact lenses into some of those large scleral lenses, they're on the eye so they can help, but there's a point where they won't be able to help any longer. And the cross-linking procedure Epioxa procedure are really the only options that patients have to halt that progression. If they don't do one of those procedures, or if we can't [00:28:00] obtain coverage, the next choice is to letthem lose further vision, and at some point, they will need to do a transplant, a cornea transplant.
And where that sounds like, "Oh, well, maybe that's gonna help," yes, it does help, but it does not remove the Keratoconus from the patient. And oftentimes, not only is there a risk for rejection of the cornea tissue, but Keratoconus patients can have Keratoconus show up again. It's still with them. It's still part of them.
So they will oftentimes have to go through multiple cornea transplants. Where if we were able to do the cross-linking procedure Epioxa procedure, that will halt their progression, allowing their doctors to work with them on the visual acuity or how well they see. So the Keratoconus patients are really in a rock and a hard place where it used to have more coverage, but now that the technology is advancing, now we're taking a step [00:29:00]back in coverage, and there aren't options.
So I, myself, and some peers in the area are really working to talk to the Rare Disease Council. How can we bring more attention to this, specifically to the Medicaid program, so that we can open that access to care, help people preserve their vision, and be able to honestly still function? We need to be paid for services, whether it's going to be a patient or the insurance company, and I would much rather take the insurance company money than the patient's money because we have insurance for a reason.
So it's, it is a challenge in so many factors of trying to help people and to keep their financial area responsible for them or within something that they can afford, and we're pulling in, we're taking any angle we can because these patients need that care, and they need that assistance. So my passion there is let's get care.
How can we help [00:30:00]them? A few years ago, as an example,I had worked with the maker of the drug and the machine for cross-linking, and just in the practice that I was working, we were able to update coverage and get ninety-seven patients care that had not had any options due to the financial commitments before.
They were Medicaid patients. We were able to work together and get care for them. Where ninety-seven patients might not seem like a huge number, but really each one of those patients is a whole person, so helping ninety-seven whole people is bigger than the number ninety-seven itself to me.
Kip Theno: Wow. Rightand Sara thank you for
all
Kip Theno: of that work. By the way, the Rare Disease Council does have a voice. It occurs to methat I think we should just here's a crazy like a fox idea, let's just replaceall of our state legislators with patients. I guarantee we get a lot more done.
Sara Julson: Oh my gosh. Oh, I would love to see what would happen [00:31:00]there. That would be... Oh, wow.
Kip Theno: Yeah, yeah. Well, this is gonna be live and go out to the masses, so I'm sure I'mgonna get a phone call from somebody.
Anyway, the la- last question, 'cause I- I'm really curious about this. It, it kind of goes back to prior authorizations, you know, where we focus at SamaCare is solving the medical benefits side, right?
Your physician-administered injections and infusions. And, and you had mentioned, um, oculoplastics and some changes there on the surgical side for authorizations. Walk us through that, or what was your kind of levelof importance and diligence there?
Sara Julson: Yeah.That was super exciting for me and my team.
We have used SamaCare on the retina side for a while, and we're continuing to expand our use. One of the areas that we were working on isfinding ways to help our patients who are having oculoplastic surgery. So they're working on the eyelids, they're working on the muscles around the eye.
It's not as cosmetic as it may sound. There [00:32:00] are cosmetic factors or features within, but there are other items such as can the patient open their eyelid all the way? Can they see with, where their eyelid is sitting? Sometimes their eyelid is going all the way down to the middle of their pupil or beyond, so theirvisual field is limited just because of the structure of their eye, and that's where the oculoplastics comes in.
It's interesting because there is a difference, as I said, with a functional or a cosmetic surgery, and insurance companies are trying to makesure that the functional ones are truly functional. Most of the procedures are going to require an authorization for oculoplastics. That's across many payers,and it's not necessarily a bad thing, but it does take time, and there are cases where we can show that there's a functional need.
This patient has their daily living impacted by where their [00:33:00] eyelid is sitting, and the insurance company might come back and say, "It's not bad enough. That's cosmetic right now." So that's an area where we're really taking those challenges to be able to draw more attention to the functional side, be able to go back tothe documentation from the doctors, and work with the insurance companies to see the why behind our request.
We're curating a story of why this patient deserves to have care. And I do say deserves. They are paying for their insurance. They have a need. They deserve to be able to havecare. Um, in that realm, playing with SamaCare has been great because their reporting structure in SamaCare has given me more data than I've ever had.
Um, it's great to be able to start adding other procedures into that process where we know we're going to have a high volume of prior authorizations to be able to track the [00:34:00]denials, track why they're being denied. Which payers are we having the most tissues with? So that we can chip away at those issues to help patients get thatcare that they deserve.
So having options and reporting like that is just speaks to my nerd mind of I want all the data. I wanna see everything that I can, and then let's take that and make it useful. So absolutely. It's, it's a challenge
Kip Theno: Well, h-yeah, thank you, and thank you for the partnership too, and yeah, I mean, you know, evidence-based medicine, right?
But what's that based on? It's all based on data, right? So that's how those decisions should be made going forward. It should be the tip of the sword. Uh, and we're gonna continue to provide that because that is one of our goals is to try and solve, uh, the equation for the patients in all of our specialties and also provide that atomic-level data to expose the deficiencies and inefficiencies in the system, um, which is powerful [00:35:00] because it will make folks sit up a little higher in their seat and hopefully be change agents.
And Sara, this has been so informative, so cool. I'm so glad you joined with us today. I know how valuable your time is, and you gotta get back to patients- ... um, and all of your nerd stuff. But before we do, I have a Easter egg question, and then I will let you go. Um, obviously, you know I'm from Minnesota, my home state.
You can take the boy out of Minnesota, you can't take Minnesota out of the boy. Uh, what is your favorite walleye restaurant or walleye fish fry? Where do you go?
Sara Julson: Oh, goodness. You know what? That is a great one. Um, I'm not a huge fish fan- ...but I can definitely say, and it's gonna sound so Minnesotan on this, the fish fries in your church basements really, they have just something, maybe not thebest flavor in all cases, but there is something that just warms your heart, and you gotta love those church basement fish fries.
There's [00:36:00] something about it. Well,
Kip Theno: a little extra salt, a little extra love. Yep, awesome. Sara, thank you so much for yourtime. Can't wait to get this out to all of our listeners and, and really appreciate you joining on The Road to Care. Thank you, Sara.
Sara Julson: Absolutely. Thanks, Kip. It has been a pleasure.
Thank you for joining The Road to Care podcast hosted by SamaCare, the leader in prior authorization technology and services, where through a script-to-therapy operating system, we enable connectivity with clinics, payers, andmanufacturers focused on optimizing patient care. Tune in next time as together we can make things right.
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Kip Theno: Welcome tothe Road to Care podcast hosted by SamaCare, where we will talk with keyopinion leaders, physicians, administrators, manufacturers, venturecapitalists, and legislators to get their insights on the state of healthcaretoday and where we see it evolving. SamaCare's prior authorization platform isfree to clinics, ensuring patients get on the right therapy at the right time.
Together, we can simply make things right.
Hey everybody, welcome back to the Road to Care podcast hosted by SamaCare. And our special guest today is Sara Julson RHIT. Sara is an experienced revenue cycle manager focusing on patient financial services. Sara is passionate about serving as a liaison between patients, billing departments, and the payer while enhancing account receivable processes. She's a registered health information technician and certified patient service specialist
Thanks for joining everybody. And Sara, really appreciate your time. I've gotta tell you [00:01:00] this, the pre-show that we had was one of the most fun. It was the longest one I've ever had, and there's a reason for it. I mean, you went into your background and history, Keratoconus, impacted patients, rare disease council, artificial iris.
You're a self-described nerd. I thought that was amazing, just kind of like myself. So we've got a lot to cover today. But Sara, first of all, how are you? And thank you for joining.
Sara Julson: I amdoing wonderful. Thank you so much for having me. I am excited to talk more about some of those passions.
As you said, I am absolutely a medical nerd. I've been in the RCM world for a long time, over twenty years, and I'm currently made my home inthe ophthalmology realm. It has been fascinating and really excited to talk about some of the landscape changes that we've seen in the revenue side of medical care.
Kip Theno: And let's get to that question first from the RCM perspective. But before we [00:02:00] do that, as I always start, just your personal journey into healthcare, Sara. What got you there? Where are you now?And, and just your passions for, uh, for being in this side of the world.
Sara Julson: Absolutely. I have always been interested in medical procedures, in how the overall medical world works.
And for me, when it was time to decide what am I gonna do with my life, there's a point we all hit that, and I really didn't know. So I started focusing and thinking about things that I enjoyed, which really led me back to some medical. Um, I love to help people. I am very passionate in that realm, but I'm not necessarily that hands-on, patient-facing person.
So it melded from a coding degree to more of the more the straight financial part, more of the RCM compared to strict coding. So that's where I started about 22 years ago. I've worked in several specialties. I've worked everything from pain management [00:03:00] to vein clinics. I've worked mental health. And as I mentioned, ophthalmology has really been where I've found that passion, that deep drive to help patients, and that is my current world for what I am looking at.
I'm all about the eyeballs.
Kip Theno: From, from revenue cycle, you know, it's an interesting place to be, right? You've got the clinic, you've got the workflows, the insurances, and then of course the patients, and you're kind of in the middle of this entire circle for, you know, the, the solvency of the clinic to continue patient care.
Just talk to us a little bit about revenue cycle and the challenges and things that you wanna change or maybe better that you've learned in the RCM space.
Sara Julson: Oh, absolutely. You are hitting my medical nerd-ism here with hard, hard blows, so it's great to be able to talk about this.
As I've been in this for about twenty years, we've started tosee some of the most significant changes that healthcare has had probably within the last ten years or so, and maybe even [00:04:00] more towards the last five years. It used to be where medical insurance was what people had, and they went to the doctor, and that was about the end of it.
Rarely did you get a bill or it was going to be a copay. Then you started to see insurance changing and going to more deductible plans orhigher patient responsibility. You saw more of the HSAs and the FSAs, so your financial spending accounts or those health savings accounts. Started to see more of that.
And where we currently are today is probably the highest rate of patient responsibility that I have ever seen. And that's a tough world, especially when you're talking about certain items. Like I mentioned, I'm in the eye world right now. And when you think about it, what would you pay for your vision?
It's unfortunate we have to think in that manner at this time versus, "I'm gonna go to the doctor and get the care that I need." So that's really been one of the areas that I focused in on is: How do I [00:05:00] help eliminate issues for access to care as an example? How do those financial pieces tie to the care that patients are actually getting?
The big phrase that I always say to people is, "I care about their financial health as much as their medical health." Because however much we want to say they could be separate, they really are tied together, where we have to work to find those financial solutions to be able to access the care that our patients needI definitely think that's one of my biggest areas of, uh, change that I think could happen.
I don't know how it would ever happen, but it's been tough to watch people go through their situations and share that they can't afford their medical care. I've had some absolute horror stories in my time of patients that needed care. Their insurance wouldn't cover items, so they needed state aid.
Absolutely, but the only way the state would have that happen--There was an elderly couple I remember who they'd been married for [00:06:00]almost fifty years, and theywound up having to get divorced so that they could afford or they would be in the correct financial category to be able to receive state assistance.
That is just a world that I don't want to see for people, and my goals are working to help people get that access to care, to break down some of those financial burdens. And I really speak to this regarding several different types of procedures or diagnoses where I'm working with groups across our state to ask for additional coverage or working on getting items donated or doing anything we can to really increase the access to care for patients.
Not only is the financial difficult on that end, we also have one more area to really consider that is a hindrance or a tough area to work as the patient: prior authorizations. They are not consistent per different insurance companies, perdifferent procedures. You can't say [00:07:00]that this surgery is going to need an authorization all the time because there's going to be those payers that don't.
Or you can't say that this surgery will never need an authorization because there are payers that will. So there's not only a higher patient financial responsibility, but there's a lot more s- administrative burden than I've ever seen. Those are really those areas that I think impact the RCM world and patient care that have driven that passion for me and the work that I'm doing.
Kip Theno: Uh, Sara, and I, what you said, I mean, it kind of struck a chord, right? What would you pay for your vision? Well, what would you pay for your heart, your brain, your pancreas, right? Diabetes. And they're all connected to, to- Yep ... visual or retinal disease states. And,you know, we can talk about prior authorizations all day long.
That's kind of our world over here at SamaCare, but you're not alone. Every single specialty says the same thing. Why is it so difficult? You know, the role of, say, PBMs as an example, and then the high cost, and [00:08:00]then you have seven payers denying it in an algorithm 46% of the time for the same drug, and then thethree payers 100% of the time have no auth required, right?
And there's no uniformity. I mean, Medicare to Medicare Advantage to commercial plans. And we, we do kind of steer away from politics here on my show, but we will not steer away from legislation. And so let's, let's talk about you, you had mentioned the No Surprises Act as an example.
Sara Julson: Yeah.
Kip Theno: Walk us through what that is.
Is it working? Is there transparency? Do you see it as a benefit? And then, where is it not working?And feel free to drop the gloves, Sara, if you'd like.
Sara Julson: Absolutely. So the No Surprises Act, um, and I'm gonna just kind of preface with I am not providing any legal advice. I am just taking my personal stanceon it and sharing what I have inferred from all the different meetings and different items that I've done.
So definitely not any legal advice. But I do think that the No Surprises Act has [00:09:00] goodareas or good intentions. Letting patients know their financial responsibility ahead of time, especially if they're going to be out of network or if theydon't have care under the No Surprises Act is a requirement. And that I dobelieve is helping people because they can have those early conversations. Ittakes some of the worry out of the situation, because if you're going into adoctor, you wanna be able to sit down and listen to what the doctor is saying to you. Sometimes it'sthat first appointment when you see your doctor, and they might say, "Youneed surgery."
If you don't have insurance, the immediate thought is,"How much is this going to cost?" And the rest of what the doctor is saying may or may not actually resonate with you because you are very concerned about the cost. So where the No Surprises Act has been helpful is being able to share those costs upfront with patients so that they can focus on their medical care with their providers.[00:10:00]
There are areas that are challenging in it, such as making sure that networks are clearly found. Insurance companies have definitely put some challenges in place for networks where this one plan that ends with one number different than all the others, that one's out of network for you, but everybody else is.
You know, everybody else is in network, and you're okay to see them. So while the No Surprises Act is really helpful on the patient side and even on the financial side, being able to have those conversations, there are definitely some challenges in making sure that we are meeting those requirements and that we are accurately able to present information to patients to make sure they have all of the knowledge.
Um, we want them to have the care, so using the good intentions is always my goal. I think it's difficult because networks, as that example, are not easily defined. You might have your surgery [00:11:00]center in network, and your doctor might be out of network or vice versa. Those are difficult conversations to have with patients.
Not that they're impossible, but it's really tough to say,"Hey, you know, your particular insurance company, you can keep seeing the doctor that you've been seeing. You can have surgery with that doctor. However, you're gonna have to pay for the operating room or the facility because they're not in-network."
That to patients becomes not only frustrating, but almost a point of contention on, "Well, what do you mean? No one told me this." So that's where the No Surprises Act is helpful, but it definitely has duality in whether or not it is helping providers open access to care, in my opinion anyway. So a little bit of gloves off stating that the payers are presenting us with additional challenges regarding networks in particular or those authorizations, making sure that everything is in place prior to.
If you have an authorization denied and you've already provided a good [00:12:00] faith estimate because of a network, now what? You're gonna have to go back and present new information. So there's a lot of details that come into play when we're talking about the NoSurprises Act, making sure that patients have all of the financial information ahead of time.
Kip Theno: Yeah, andI, and I think there, would you agree that there probably is gonna, is gonna have to be some kind of forced tipping point with what you've just said?Because the status quo certainly isn't gonna work. It's just making it more difficult. And you, you said something in the pre-show about financial health being just as important as physical health to the patients and patient access.
So we think of arrows in the quiver when we're trying to get better balance with patient access and the insurances and the payers and the costs, data being, I think, a heavy bat right now. And, and that data's kind of hard to find as an island. [00:13:00] But how do you, even from the revenue cycle side, or maybe go into more detail about that financial health that you are concerned with, with your patients, what are you doing specifically and maybe certain types of data that you're using to really start to force this tipping point, even with your peers and some of the councils and things that you work with, with, with the provider, with the payers as an example?
Sara Julson: Absolutely. So some of those areas that I've really been trying to focus in on.My current role, I make sure that every patient that is going to have a patient responsibility for a surgery gets some type of a good faith estimate. We make sure that the full disclaimer from CMS is on our letter on that good faith estimate so that patients know what the No Surprises Act is.
If they feel that something has been incorrect, there's how to file the dispute on there. So I really think that's been one area [00:14:00] that taking it a step farther for us orfor me has been beneficial because it's not only answering those questions of how much is this going to cost for the patients who are either out-of-network, don't have insurance coverage, or have, are underinsured.
So those areas are definitely a benefit. It also opens conversations early. We're able to talk to patients to state we can help you apply for different financing. We can set up an internal payment plan potentially. We can talk through the finances so that the patient can focus on their recovery, so that they can focus on the care for their physical health.
Their financial health, I never want to be the reason why they aren't getting medical care. So it's really taking time to work with each patient, realizing each patient has a different perspective, they have a different situation, and really making sure that we're not [00:15:00] only addressing the legal areas with the No Surprises Act as an example, but we're addressing the financial concerns of the patient early so that care can continue, so that they can continue going through their post-op appointments and following up in that six month, one year, making sure that they are able to be compliant with their treatment plans.
So it really is a worthwhile challenge, but I think some of the tipping points come down to, for us, timeframes. It's tough to get information to people and find that perfect sweet spot window of early enough for them to make financial decisions and have those conversations, but close enough to their appointment so that that appointment is really in their mind, whether it's a clinic appointment, whether it's a surgery appointment.
There's definitely a sweet spot, and in making sure that we're going one step above the No Surprises Act, that has been a challenge [00:16:00] for us, and I think that, in my opinion, could be kind of a tipping point in where do we meet all of the guidelines and where do we need to talk about changing some of those guidelines?
Kip Theno: And yeah, and well, and you mentioned change, but you also mentioned, Sara, treatment plans. Mm-hmm.
Sara Julson: And
Kip Theno: I can kind of think back, I might have some of this wrong, going by some memory here, but retina injections, I think the first ones were in the early 1900s. 1911 theywere, I think injections started as air bubbles for retinal tears, right?
And then they, they did penicillin injections in the eye, and then now we're in the '40s, so you look at the evolution of just science in general, which is amazing. But it also wasn't that long ago that y'all had oneto two, drugs for injections. Then you wake up in a heartbeat and then it's four and six, soon to be eight, right?
For the drugs available, biosimilar step therapy. So how do you, how do we balance all of that? [00:17:00]Not only the, the clinical behavior on the clinical side, the choices, the pathway, the workflows for the clinic, the treatment plans. How are you all navigating that? Because it is gonna continue to change. And then you can tie all that back into how does that financially affect the clinic and the patient?
Sara Julson: Oh, absolutely. I've got a few examples of my passion projects that really fall into the, that realm of what are we doing? How are we working on things? I spend quite a bit of my day-to-day work working with new procedures or new types of medications for patients relating to ophthalmology. There are several procedures out there that are new, and I found it to be a particular challenge because it is on average, I read, uh, 5 to 5.7 years from when a new procedure or drug has been FDA approved before the majority of payers are [00:18:00] recognizing it as, uh, a covered service or are putting out policies.
During that 5 years or 5.8 years that I had read, the, what I'd seen was they are just considering everything experimental or investigational for longer periods of time than what they had been in the past. Historically, Ihad seen two, three years where we could get most of the payers on board for new procedures.
It's definitely moved into that five year. And as an example ,one of the areas that I work in and where the financial health comes into play for our patients so much is the artificial iris . That is such a cool technology. I, when I first heard it, I kind of sat there going, "This is way advanced stuff I wouldn't ever expect to happen now."
It feels so futuristic, but it's out there. And the artificial iris was actually FDA approved in [00:19:00] 2018. So 2018 is definitely more than five years ago, and there are very, very few payers who have coverage. Many of their policies are written stating that the artificial iris that's been FDA approved since 2018 is considered investigational or experimental.
To go through the FDA, you have to have your research, you have to have your trials, you have to have enough information to be approved. So there's that point with the insurance companies of investigational and experimental then moves to patient responsibility, and I think that is a big challenge, especially, you know, mentioning artificial iris.
It's really the only type of option that patients with aniridia have to preserve their sight or to regain sight. So it's difficult to say,"Hey, I know that it's medically necessary, but your insurance isn't going to cover it. [00:20:00] It's an expensive item.It's a fairly expensive procedure, and we can help you, but we have to talk finances now."
It's a rock and a hard place. Going back to that first comment of how much would you pay for your vision? Well, we're finding those limits for patients, and it is tough, and it's something that I think we in the medical industry, that the insurance companies need to consider, that new procedures are helping patients and we need to get them moved along faster.
Kip Theno: Thatamazes me. Artificial iris, we-- the future is here, Sara. It's now. It's socool. But I go back to 20-2018, you remember what happened right after that,the, the COVID. And you think of these patients, those patients that were legally blind, as an example, how isolated were they without other options andthings like this that could have helped them through that period?
God forbid we ever go through something like that again. But [00:21:00] What do your peers out there say about the artificial iris? I mean, how is there not this groundswell of here's how many patients there are, this technology could work, here's the benefit long term for the system, for the patient. How do you get that groundswell for something like that?
Sara Julson: It's challenging. Uh, peers are in the same boat as us. There are doctors within ourarea and doctors across the US who do work with and do the do the surgery forartificial iris. We're all saying the same things. Payers are being very slowto adopt the new procedure, and we're really working towards individual casesat this time, or my, my approach has been individual cases with the payers sothat we're really working to have the rationale of here's why this is helpful.
There is nothing elsethat this patient can do. Here's why we need to do this. [00:22:00] And then I know my peers are doing the same. I've talked to some across thecountry, and unfortunately, it is a large administrative area for us to take things case by case and really work the insurance companies to understand the rationale.
It's FDA approved. Wehave all these research studies. How can you state this is still experimental or investigational? In the artificial iris case, we are well over five years. It's gone through all of the testing to get here. So we're-- we as agroup are trying to work on the insurance side to draw more attention to the procedures that are new, that really are solving issues that patients have that we could have never done before.
The challenges for myself and peers across the country are authorizations, getting coverage, and really removing that barrier to care regarding the [00:23:00] experimental items that are considered non-covered, but they have passed FDA approval. So that'san area that is challenging, and we as a whole need to work a little bit harder to have the insurance companies adopt these new procedures sooner.
Kip Theno: It, it's just, it feels a little bit like jumbo shrimp, right? Like an oxymoron. Well, it's FDA approved, but on the other side it's experimental. Like, how is that a binary state? I don't know. It kind of reminds me of the day, Sara, where, where, you know, a, a new data-driven approved device, as an example, to save lives in the cardiac space still had to go through what was called a VAC committee, value analysis.
Well, we've gotta analyze the value. Well, the value is I'm saving this patient's life. Like so we will, we will help scream it to the hills with you, Sara, for sure on this. And then with that, you're also taking some other steps, right? You talked about the Keratoconus patients, you talked about the Rare Disease Council.
Can you elaborate more into those passions of yours?
Sara Julson: oh, [00:24:00] absolutely. Uh, patients with Keratoconushave been one of my passion projects. I started working with what at that timewas a new procedure, ironically, back in 2018, and trying to get care for these patients. Keratoconus is a condition where the eye becomes cone-shaped.
It can progress at any point in time, and their vision canworsen. Once you are diagnosed or once you have Keratoconus, there really is nogoing back. So as you progress, as the shape of your eye worsens, as your visual acuity worsens, there's nothing that can be done for you outside ofdoing one particular procedure called cross-linking or epioxia. The reason I'm saying or is 2018, the cross-linking procedure had been FDA approved.
We started seeing really good coverage for patients some where in the 2020 twenty 2021 [00:25:00] category.And then twenty twenty-two, we started seeing the vast majority of payer having policies that would allow us to obtain coverage for patients. We never say all payers because we know that's not the truth, but we were seeing a largenumber of them.
And what's really cool here is they have developed an improved or a further way to help patients with Keratoconus in a new system that was FDA approved last year. So we're really working to get care for these patients because Keratoconus and the disease state itself do fall into that rare disease category.
So working with groups in the state to try to have rare disease council assist in talking to payers or talking to the state about coverage. I think one of the best examples is the Keratoconus patients, where historically, once we were able to get policies listed and work with payers to get coverage, [00:26:00] one of the payer issues was Medicaid, where Medicaid would cover the procedure for cross-linking, but not the drug required to do the procedure.
And that was a challenge because you had to then tell your patients, "Hey, you're financially qualified for Medicaid. They'll pay for the procedure, but we need a lot of money for the drug." And that is stilla challenge because Medicaid is still not allowing for coverage on the drug inmost cases. There are some payers that we're starting to see some changes, but even as the technology is growing and improving and the machine and the equipment is improving, payers are actually taking a step backwards.
So cross-linking had been predominantly approved by payers. Now with the new plan coming out that started last year called Epioxa, we're seeing that Keratoconus patients are losing their one [00:27:00]opportunity to halt the progression of Keratoconus. Insurance companies are doubling back on their policies saying, "Oh, with this new procedure?
Nope, that's investigational even though there's-- it is a little bit different, but not significantly different than the other procedure.So we're starting that process all over again, and these patients have no options. They cannot wear glasses. Glasses on a cone-shaped eye aren't going to help the visual acuity to the highest level needed, and it's not going to treat the condition of that misshapen eye.
If you think about contact lenses into some of those large scleral lenses, they're on the eye so they can help, but there's a point where they won't be able to help any longer. And the cross-linking procedure Epioxa procedure are really the only options that patients have to halt that progression. If they don't do one of those procedures, or if we can't [00:28:00] obtain coverage, the next choice is to letthem lose further vision, and at some point, they will need to do a transplant, a cornea transplant.
And where that sounds like, "Oh, well, maybe that's gonna help," yes, it does help, but it does not remove the Keratoconus from the patient. And oftentimes, not only is there a risk for rejection of the cornea tissue, but Keratoconus patients can have Keratoconus show up again. It's still with them. It's still part of them.
So they will oftentimes have to go through multiple cornea transplants. Where if we were able to do the cross-linking procedure Epioxa procedure, that will halt their progression, allowing their doctors to work with them on the visual acuity or how well they see. So the Keratoconus patients are really in a rock and a hard place where it used to have more coverage, but now that the technology is advancing, now we're taking a step [00:29:00]back in coverage, and there aren't options.
So I, myself, and some peers in the area are really working to talk to the Rare Disease Council. How can we bring more attention to this, specifically to the Medicaid program, so that we can open that access to care, help people preserve their vision, and be able to honestly still function? We need to be paid for services, whether it's going to be a patient or the insurance company, and I would much rather take the insurance company money than the patient's money because we have insurance for a reason.
So it's, it is a challenge in so many factors of trying to help people and to keep their financial area responsible for them or within something that they can afford, and we're pulling in, we're taking any angle we can because these patients need that care, and they need that assistance. So my passion there is let's get care.
How can we help [00:30:00]them? A few years ago, as an example,I had worked with the maker of the drug and the machine for cross-linking, and just in the practice that I was working, we were able to update coverage and get ninety-seven patients care that had not had any options due to the financial commitments before.
They were Medicaid patients. We were able to work together and get care for them. Where ninety-seven patients might not seem like a huge number, but really each one of those patients is a whole person, so helping ninety-seven whole people is bigger than the number ninety-seven itself to me.
Kip Theno: Wow. Rightand Sara thank you for
all
Kip Theno: of that work. By the way, the Rare Disease Council does have a voice. It occurs to methat I think we should just here's a crazy like a fox idea, let's just replaceall of our state legislators with patients. I guarantee we get a lot more done.
Sara Julson: Oh my gosh. Oh, I would love to see what would happen [00:31:00]there. That would be... Oh, wow.
Kip Theno: Yeah, yeah. Well, this is gonna be live and go out to the masses, so I'm sure I'mgonna get a phone call from somebody.
Anyway, the la- last question, 'cause I- I'm really curious about this. It, it kind of goes back to prior authorizations, you know, where we focus at SamaCare is solving the medical benefits side, right?
Your physician-administered injections and infusions. And, and you had mentioned, um, oculoplastics and some changes there on the surgical side for authorizations. Walk us through that, or what was your kind of levelof importance and diligence there?
Sara Julson: Yeah.That was super exciting for me and my team.
We have used SamaCare on the retina side for a while, and we're continuing to expand our use. One of the areas that we were working on isfinding ways to help our patients who are having oculoplastic surgery. So they're working on the eyelids, they're working on the muscles around the eye.
It's not as cosmetic as it may sound. There [00:32:00] are cosmetic factors or features within, but there are other items such as can the patient open their eyelid all the way? Can they see with, where their eyelid is sitting? Sometimes their eyelid is going all the way down to the middle of their pupil or beyond, so theirvisual field is limited just because of the structure of their eye, and that's where the oculoplastics comes in.
It's interesting because there is a difference, as I said, with a functional or a cosmetic surgery, and insurance companies are trying to makesure that the functional ones are truly functional. Most of the procedures are going to require an authorization for oculoplastics. That's across many payers,and it's not necessarily a bad thing, but it does take time, and there are cases where we can show that there's a functional need.
This patient has their daily living impacted by where their [00:33:00] eyelid is sitting, and the insurance company might come back and say, "It's not bad enough. That's cosmetic right now." So that's an area where we're really taking those challenges to be able to draw more attention to the functional side, be able to go back tothe documentation from the doctors, and work with the insurance companies to see the why behind our request.
We're curating a story of why this patient deserves to have care. And I do say deserves. They are paying for their insurance. They have a need. They deserve to be able to havecare. Um, in that realm, playing with SamaCare has been great because their reporting structure in SamaCare has given me more data than I've ever had.
Um, it's great to be able to start adding other procedures into that process where we know we're going to have a high volume of prior authorizations to be able to track the [00:34:00]denials, track why they're being denied. Which payers are we having the most tissues with? So that we can chip away at those issues to help patients get thatcare that they deserve.
So having options and reporting like that is just speaks to my nerd mind of I want all the data. I wanna see everything that I can, and then let's take that and make it useful. So absolutely. It's, it's a challenge
Kip Theno: Well, h-yeah, thank you, and thank you for the partnership too, and yeah, I mean, you know, evidence-based medicine, right?
But what's that based on? It's all based on data, right? So that's how those decisions should be made going forward. It should be the tip of the sword. Uh, and we're gonna continue to provide that because that is one of our goals is to try and solve, uh, the equation for the patients in all of our specialties and also provide that atomic-level data to expose the deficiencies and inefficiencies in the system, um, which is powerful [00:35:00] because it will make folks sit up a little higher in their seat and hopefully be change agents.
And Sara, this has been so informative, so cool. I'm so glad you joined with us today. I know how valuable your time is, and you gotta get back to patients- ... um, and all of your nerd stuff. But before we do, I have a Easter egg question, and then I will let you go. Um, obviously, you know I'm from Minnesota, my home state.
You can take the boy out of Minnesota, you can't take Minnesota out of the boy. Uh, what is your favorite walleye restaurant or walleye fish fry? Where do you go?
Sara Julson: Oh, goodness. You know what? That is a great one. Um, I'm not a huge fish fan- ...but I can definitely say, and it's gonna sound so Minnesotan on this, the fish fries in your church basements really, they have just something, maybe not thebest flavor in all cases, but there is something that just warms your heart, and you gotta love those church basement fish fries.
There's [00:36:00] something about it. Well,
Kip Theno: a little extra salt, a little extra love. Yep, awesome. Sara, thank you so much for yourtime. Can't wait to get this out to all of our listeners and, and really appreciate you joining on The Road to Care. Thank you, Sara.
Sara Julson: Absolutely. Thanks, Kip. It has been a pleasure.
Thank you for joining The Road to Care podcast hosted by SamaCare, the leader in prior authorization technology and services, where through a script-to-therapy operating system, we enable connectivity with clinics, payers, andmanufacturers focused on optimizing patient care. Tune in next time as together we can make things right.
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Kip Theno: Welcome tothe Road to Care podcast hosted by SamaCare, where we will talk with keyopinion leaders, physicians, administrators, manufacturers, venturecapitalists, and legislators to get their insights on the state of healthcaretoday and where we see it evolving. SamaCare's prior authorization platform isfree to clinics, ensuring patients get on the right therapy at the right time.
Together, we can simply make things right.
Hey everybody, welcome back to the Road to Care podcast hosted by SamaCare. And our special guest today is Sara Julson RHIT. Sara is an experienced revenue cycle manager focusing on patient financial services. Sara is passionate about serving as a liaison between patients, billing departments, and the payer while enhancing account receivable processes. She's a registered health information technician and certified patient service specialist
Thanks for joining everybody. And Sara, really appreciate your time. I've gotta tell you [00:01:00] this, the pre-show that we had was one of the most fun. It was the longest one I've ever had, and there's a reason for it. I mean, you went into your background and history, Keratoconus, impacted patients, rare disease council, artificial iris.
You're a self-described nerd. I thought that was amazing, just kind of like myself. So we've got a lot to cover today. But Sara, first of all, how are you? And thank you for joining.
Sara Julson: I amdoing wonderful. Thank you so much for having me. I am excited to talk more about some of those passions.
As you said, I am absolutely a medical nerd. I've been in the RCM world for a long time, over twenty years, and I'm currently made my home inthe ophthalmology realm. It has been fascinating and really excited to talk about some of the landscape changes that we've seen in the revenue side of medical care.
Kip Theno: And let's get to that question first from the RCM perspective. But before we [00:02:00] do that, as I always start, just your personal journey into healthcare, Sara. What got you there? Where are you now?And, and just your passions for, uh, for being in this side of the world.
Sara Julson: Absolutely. I have always been interested in medical procedures, in how the overall medical world works.
And for me, when it was time to decide what am I gonna do with my life, there's a point we all hit that, and I really didn't know. So I started focusing and thinking about things that I enjoyed, which really led me back to some medical. Um, I love to help people. I am very passionate in that realm, but I'm not necessarily that hands-on, patient-facing person.
So it melded from a coding degree to more of the more the straight financial part, more of the RCM compared to strict coding. So that's where I started about 22 years ago. I've worked in several specialties. I've worked everything from pain management [00:03:00] to vein clinics. I've worked mental health. And as I mentioned, ophthalmology has really been where I've found that passion, that deep drive to help patients, and that is my current world for what I am looking at.
I'm all about the eyeballs.
Kip Theno: From, from revenue cycle, you know, it's an interesting place to be, right? You've got the clinic, you've got the workflows, the insurances, and then of course the patients, and you're kind of in the middle of this entire circle for, you know, the, the solvency of the clinic to continue patient care.
Just talk to us a little bit about revenue cycle and the challenges and things that you wanna change or maybe better that you've learned in the RCM space.
Sara Julson: Oh, absolutely. You are hitting my medical nerd-ism here with hard, hard blows, so it's great to be able to talk about this.
As I've been in this for about twenty years, we've started tosee some of the most significant changes that healthcare has had probably within the last ten years or so, and maybe even [00:04:00] more towards the last five years. It used to be where medical insurance was what people had, and they went to the doctor, and that was about the end of it.
Rarely did you get a bill or it was going to be a copay. Then you started to see insurance changing and going to more deductible plans orhigher patient responsibility. You saw more of the HSAs and the FSAs, so your financial spending accounts or those health savings accounts. Started to see more of that.
And where we currently are today is probably the highest rate of patient responsibility that I have ever seen. And that's a tough world, especially when you're talking about certain items. Like I mentioned, I'm in the eye world right now. And when you think about it, what would you pay for your vision?
It's unfortunate we have to think in that manner at this time versus, "I'm gonna go to the doctor and get the care that I need." So that's really been one of the areas that I focused in on is: How do I [00:05:00] help eliminate issues for access to care as an example? How do those financial pieces tie to the care that patients are actually getting?
The big phrase that I always say to people is, "I care about their financial health as much as their medical health." Because however much we want to say they could be separate, they really are tied together, where we have to work to find those financial solutions to be able to access the care that our patients needI definitely think that's one of my biggest areas of, uh, change that I think could happen.
I don't know how it would ever happen, but it's been tough to watch people go through their situations and share that they can't afford their medical care. I've had some absolute horror stories in my time of patients that needed care. Their insurance wouldn't cover items, so they needed state aid.
Absolutely, but the only way the state would have that happen--There was an elderly couple I remember who they'd been married for [00:06:00]almost fifty years, and theywound up having to get divorced so that they could afford or they would be in the correct financial category to be able to receive state assistance.
That is just a world that I don't want to see for people, and my goals are working to help people get that access to care, to break down some of those financial burdens. And I really speak to this regarding several different types of procedures or diagnoses where I'm working with groups across our state to ask for additional coverage or working on getting items donated or doing anything we can to really increase the access to care for patients.
Not only is the financial difficult on that end, we also have one more area to really consider that is a hindrance or a tough area to work as the patient: prior authorizations. They are not consistent per different insurance companies, perdifferent procedures. You can't say [00:07:00]that this surgery is going to need an authorization all the time because there's going to be those payers that don't.
Or you can't say that this surgery will never need an authorization because there are payers that will. So there's not only a higher patient financial responsibility, but there's a lot more s- administrative burden than I've ever seen. Those are really those areas that I think impact the RCM world and patient care that have driven that passion for me and the work that I'm doing.
Kip Theno: Uh, Sara, and I, what you said, I mean, it kind of struck a chord, right? What would you pay for your vision? Well, what would you pay for your heart, your brain, your pancreas, right? Diabetes. And they're all connected to, to- Yep ... visual or retinal disease states. And,you know, we can talk about prior authorizations all day long.
That's kind of our world over here at SamaCare, but you're not alone. Every single specialty says the same thing. Why is it so difficult? You know, the role of, say, PBMs as an example, and then the high cost, and [00:08:00]then you have seven payers denying it in an algorithm 46% of the time for the same drug, and then thethree payers 100% of the time have no auth required, right?
And there's no uniformity. I mean, Medicare to Medicare Advantage to commercial plans. And we, we do kind of steer away from politics here on my show, but we will not steer away from legislation. And so let's, let's talk about you, you had mentioned the No Surprises Act as an example.
Sara Julson: Yeah.
Kip Theno: Walk us through what that is.
Is it working? Is there transparency? Do you see it as a benefit? And then, where is it not working?And feel free to drop the gloves, Sara, if you'd like.
Sara Julson: Absolutely. So the No Surprises Act, um, and I'm gonna just kind of preface with I am not providing any legal advice. I am just taking my personal stanceon it and sharing what I have inferred from all the different meetings and different items that I've done.
So definitely not any legal advice. But I do think that the No Surprises Act has [00:09:00] goodareas or good intentions. Letting patients know their financial responsibility ahead of time, especially if they're going to be out of network or if theydon't have care under the No Surprises Act is a requirement. And that I dobelieve is helping people because they can have those early conversations. Ittakes some of the worry out of the situation, because if you're going into adoctor, you wanna be able to sit down and listen to what the doctor is saying to you. Sometimes it'sthat first appointment when you see your doctor, and they might say, "Youneed surgery."
If you don't have insurance, the immediate thought is,"How much is this going to cost?" And the rest of what the doctor is saying may or may not actually resonate with you because you are very concerned about the cost. So where the No Surprises Act has been helpful is being able to share those costs upfront with patients so that they can focus on their medical care with their providers.[00:10:00]
There are areas that are challenging in it, such as making sure that networks are clearly found. Insurance companies have definitely put some challenges in place for networks where this one plan that ends with one number different than all the others, that one's out of network for you, but everybody else is.
You know, everybody else is in network, and you're okay to see them. So while the No Surprises Act is really helpful on the patient side and even on the financial side, being able to have those conversations, there are definitely some challenges in making sure that we are meeting those requirements and that we are accurately able to present information to patients to make sure they have all of the knowledge.
Um, we want them to have the care, so using the good intentions is always my goal. I think it's difficult because networks, as that example, are not easily defined. You might have your surgery [00:11:00]center in network, and your doctor might be out of network or vice versa. Those are difficult conversations to have with patients.
Not that they're impossible, but it's really tough to say,"Hey, you know, your particular insurance company, you can keep seeing the doctor that you've been seeing. You can have surgery with that doctor. However, you're gonna have to pay for the operating room or the facility because they're not in-network."
That to patients becomes not only frustrating, but almost a point of contention on, "Well, what do you mean? No one told me this." So that's where the No Surprises Act is helpful, but it definitely has duality in whether or not it is helping providers open access to care, in my opinion anyway. So a little bit of gloves off stating that the payers are presenting us with additional challenges regarding networks in particular or those authorizations, making sure that everything is in place prior to.
If you have an authorization denied and you've already provided a good [00:12:00] faith estimate because of a network, now what? You're gonna have to go back and present new information. So there's a lot of details that come into play when we're talking about the NoSurprises Act, making sure that patients have all of the financial information ahead of time.
Kip Theno: Yeah, andI, and I think there, would you agree that there probably is gonna, is gonna have to be some kind of forced tipping point with what you've just said?Because the status quo certainly isn't gonna work. It's just making it more difficult. And you, you said something in the pre-show about financial health being just as important as physical health to the patients and patient access.
So we think of arrows in the quiver when we're trying to get better balance with patient access and the insurances and the payers and the costs, data being, I think, a heavy bat right now. And, and that data's kind of hard to find as an island. [00:13:00] But how do you, even from the revenue cycle side, or maybe go into more detail about that financial health that you are concerned with, with your patients, what are you doing specifically and maybe certain types of data that you're using to really start to force this tipping point, even with your peers and some of the councils and things that you work with, with, with the provider, with the payers as an example?
Sara Julson: Absolutely. So some of those areas that I've really been trying to focus in on.My current role, I make sure that every patient that is going to have a patient responsibility for a surgery gets some type of a good faith estimate. We make sure that the full disclaimer from CMS is on our letter on that good faith estimate so that patients know what the No Surprises Act is.
If they feel that something has been incorrect, there's how to file the dispute on there. So I really think that's been one area [00:14:00] that taking it a step farther for us orfor me has been beneficial because it's not only answering those questions of how much is this going to cost for the patients who are either out-of-network, don't have insurance coverage, or have, are underinsured.
So those areas are definitely a benefit. It also opens conversations early. We're able to talk to patients to state we can help you apply for different financing. We can set up an internal payment plan potentially. We can talk through the finances so that the patient can focus on their recovery, so that they can focus on the care for their physical health.
Their financial health, I never want to be the reason why they aren't getting medical care. So it's really taking time to work with each patient, realizing each patient has a different perspective, they have a different situation, and really making sure that we're not [00:15:00] only addressing the legal areas with the No Surprises Act as an example, but we're addressing the financial concerns of the patient early so that care can continue, so that they can continue going through their post-op appointments and following up in that six month, one year, making sure that they are able to be compliant with their treatment plans.
So it really is a worthwhile challenge, but I think some of the tipping points come down to, for us, timeframes. It's tough to get information to people and find that perfect sweet spot window of early enough for them to make financial decisions and have those conversations, but close enough to their appointment so that that appointment is really in their mind, whether it's a clinic appointment, whether it's a surgery appointment.
There's definitely a sweet spot, and in making sure that we're going one step above the No Surprises Act, that has been a challenge [00:16:00] for us, and I think that, in my opinion, could be kind of a tipping point in where do we meet all of the guidelines and where do we need to talk about changing some of those guidelines?
Kip Theno: And yeah, and well, and you mentioned change, but you also mentioned, Sara, treatment plans. Mm-hmm.
Sara Julson: And
Kip Theno: I can kind of think back, I might have some of this wrong, going by some memory here, but retina injections, I think the first ones were in the early 1900s. 1911 theywere, I think injections started as air bubbles for retinal tears, right?
And then they, they did penicillin injections in the eye, and then now we're in the '40s, so you look at the evolution of just science in general, which is amazing. But it also wasn't that long ago that y'all had oneto two, drugs for injections. Then you wake up in a heartbeat and then it's four and six, soon to be eight, right?
For the drugs available, biosimilar step therapy. So how do you, how do we balance all of that? [00:17:00]Not only the, the clinical behavior on the clinical side, the choices, the pathway, the workflows for the clinic, the treatment plans. How are you all navigating that? Because it is gonna continue to change. And then you can tie all that back into how does that financially affect the clinic and the patient?
Sara Julson: Oh, absolutely. I've got a few examples of my passion projects that really fall into the, that realm of what are we doing? How are we working on things? I spend quite a bit of my day-to-day work working with new procedures or new types of medications for patients relating to ophthalmology. There are several procedures out there that are new, and I found it to be a particular challenge because it is on average, I read, uh, 5 to 5.7 years from when a new procedure or drug has been FDA approved before the majority of payers are [00:18:00] recognizing it as, uh, a covered service or are putting out policies.
During that 5 years or 5.8 years that I had read, the, what I'd seen was they are just considering everything experimental or investigational for longer periods of time than what they had been in the past. Historically, Ihad seen two, three years where we could get most of the payers on board for new procedures.
It's definitely moved into that five year. And as an example ,one of the areas that I work in and where the financial health comes into play for our patients so much is the artificial iris . That is such a cool technology. I, when I first heard it, I kind of sat there going, "This is way advanced stuff I wouldn't ever expect to happen now."
It feels so futuristic, but it's out there. And the artificial iris was actually FDA approved in [00:19:00] 2018. So 2018 is definitely more than five years ago, and there are very, very few payers who have coverage. Many of their policies are written stating that the artificial iris that's been FDA approved since 2018 is considered investigational or experimental.
To go through the FDA, you have to have your research, you have to have your trials, you have to have enough information to be approved. So there's that point with the insurance companies of investigational and experimental then moves to patient responsibility, and I think that is a big challenge, especially, you know, mentioning artificial iris.
It's really the only type of option that patients with aniridia have to preserve their sight or to regain sight. So it's difficult to say,"Hey, I know that it's medically necessary, but your insurance isn't going to cover it. [00:20:00] It's an expensive item.It's a fairly expensive procedure, and we can help you, but we have to talk finances now."
It's a rock and a hard place. Going back to that first comment of how much would you pay for your vision? Well, we're finding those limits for patients, and it is tough, and it's something that I think we in the medical industry, that the insurance companies need to consider, that new procedures are helping patients and we need to get them moved along faster.
Kip Theno: Thatamazes me. Artificial iris, we-- the future is here, Sara. It's now. It's socool. But I go back to 20-2018, you remember what happened right after that,the, the COVID. And you think of these patients, those patients that were legally blind, as an example, how isolated were they without other options andthings like this that could have helped them through that period?
God forbid we ever go through something like that again. But [00:21:00] What do your peers out there say about the artificial iris? I mean, how is there not this groundswell of here's how many patients there are, this technology could work, here's the benefit long term for the system, for the patient. How do you get that groundswell for something like that?
Sara Julson: It's challenging. Uh, peers are in the same boat as us. There are doctors within ourarea and doctors across the US who do work with and do the do the surgery forartificial iris. We're all saying the same things. Payers are being very slowto adopt the new procedure, and we're really working towards individual casesat this time, or my, my approach has been individual cases with the payers sothat we're really working to have the rationale of here's why this is helpful.
There is nothing elsethat this patient can do. Here's why we need to do this. [00:22:00] And then I know my peers are doing the same. I've talked to some across thecountry, and unfortunately, it is a large administrative area for us to take things case by case and really work the insurance companies to understand the rationale.
It's FDA approved. Wehave all these research studies. How can you state this is still experimental or investigational? In the artificial iris case, we are well over five years. It's gone through all of the testing to get here. So we're-- we as agroup are trying to work on the insurance side to draw more attention to the procedures that are new, that really are solving issues that patients have that we could have never done before.
The challenges for myself and peers across the country are authorizations, getting coverage, and really removing that barrier to care regarding the [00:23:00] experimental items that are considered non-covered, but they have passed FDA approval. So that'san area that is challenging, and we as a whole need to work a little bit harder to have the insurance companies adopt these new procedures sooner.
Kip Theno: It, it's just, it feels a little bit like jumbo shrimp, right? Like an oxymoron. Well, it's FDA approved, but on the other side it's experimental. Like, how is that a binary state? I don't know. It kind of reminds me of the day, Sara, where, where, you know, a, a new data-driven approved device, as an example, to save lives in the cardiac space still had to go through what was called a VAC committee, value analysis.
Well, we've gotta analyze the value. Well, the value is I'm saving this patient's life. Like so we will, we will help scream it to the hills with you, Sara, for sure on this. And then with that, you're also taking some other steps, right? You talked about the Keratoconus patients, you talked about the Rare Disease Council.
Can you elaborate more into those passions of yours?
Sara Julson: oh, [00:24:00] absolutely. Uh, patients with Keratoconushave been one of my passion projects. I started working with what at that timewas a new procedure, ironically, back in 2018, and trying to get care for these patients. Keratoconus is a condition where the eye becomes cone-shaped.
It can progress at any point in time, and their vision canworsen. Once you are diagnosed or once you have Keratoconus, there really is nogoing back. So as you progress, as the shape of your eye worsens, as your visual acuity worsens, there's nothing that can be done for you outside ofdoing one particular procedure called cross-linking or epioxia. The reason I'm saying or is 2018, the cross-linking procedure had been FDA approved.
We started seeing really good coverage for patients some where in the 2020 twenty 2021 [00:25:00] category.And then twenty twenty-two, we started seeing the vast majority of payer having policies that would allow us to obtain coverage for patients. We never say all payers because we know that's not the truth, but we were seeing a largenumber of them.
And what's really cool here is they have developed an improved or a further way to help patients with Keratoconus in a new system that was FDA approved last year. So we're really working to get care for these patients because Keratoconus and the disease state itself do fall into that rare disease category.
So working with groups in the state to try to have rare disease council assist in talking to payers or talking to the state about coverage. I think one of the best examples is the Keratoconus patients, where historically, once we were able to get policies listed and work with payers to get coverage, [00:26:00] one of the payer issues was Medicaid, where Medicaid would cover the procedure for cross-linking, but not the drug required to do the procedure.
And that was a challenge because you had to then tell your patients, "Hey, you're financially qualified for Medicaid. They'll pay for the procedure, but we need a lot of money for the drug." And that is stilla challenge because Medicaid is still not allowing for coverage on the drug inmost cases. There are some payers that we're starting to see some changes, but even as the technology is growing and improving and the machine and the equipment is improving, payers are actually taking a step backwards.
So cross-linking had been predominantly approved by payers. Now with the new plan coming out that started last year called Epioxa, we're seeing that Keratoconus patients are losing their one [00:27:00]opportunity to halt the progression of Keratoconus. Insurance companies are doubling back on their policies saying, "Oh, with this new procedure?
Nope, that's investigational even though there's-- it is a little bit different, but not significantly different than the other procedure.So we're starting that process all over again, and these patients have no options. They cannot wear glasses. Glasses on a cone-shaped eye aren't going to help the visual acuity to the highest level needed, and it's not going to treat the condition of that misshapen eye.
If you think about contact lenses into some of those large scleral lenses, they're on the eye so they can help, but there's a point where they won't be able to help any longer. And the cross-linking procedure Epioxa procedure are really the only options that patients have to halt that progression. If they don't do one of those procedures, or if we can't [00:28:00] obtain coverage, the next choice is to letthem lose further vision, and at some point, they will need to do a transplant, a cornea transplant.
And where that sounds like, "Oh, well, maybe that's gonna help," yes, it does help, but it does not remove the Keratoconus from the patient. And oftentimes, not only is there a risk for rejection of the cornea tissue, but Keratoconus patients can have Keratoconus show up again. It's still with them. It's still part of them.
So they will oftentimes have to go through multiple cornea transplants. Where if we were able to do the cross-linking procedure Epioxa procedure, that will halt their progression, allowing their doctors to work with them on the visual acuity or how well they see. So the Keratoconus patients are really in a rock and a hard place where it used to have more coverage, but now that the technology is advancing, now we're taking a step [00:29:00]back in coverage, and there aren't options.
So I, myself, and some peers in the area are really working to talk to the Rare Disease Council. How can we bring more attention to this, specifically to the Medicaid program, so that we can open that access to care, help people preserve their vision, and be able to honestly still function? We need to be paid for services, whether it's going to be a patient or the insurance company, and I would much rather take the insurance company money than the patient's money because we have insurance for a reason.
So it's, it is a challenge in so many factors of trying to help people and to keep their financial area responsible for them or within something that they can afford, and we're pulling in, we're taking any angle we can because these patients need that care, and they need that assistance. So my passion there is let's get care.
How can we help [00:30:00]them? A few years ago, as an example,I had worked with the maker of the drug and the machine for cross-linking, and just in the practice that I was working, we were able to update coverage and get ninety-seven patients care that had not had any options due to the financial commitments before.
They were Medicaid patients. We were able to work together and get care for them. Where ninety-seven patients might not seem like a huge number, but really each one of those patients is a whole person, so helping ninety-seven whole people is bigger than the number ninety-seven itself to me.
Kip Theno: Wow. Rightand Sara thank you for
all
Kip Theno: of that work. By the way, the Rare Disease Council does have a voice. It occurs to methat I think we should just here's a crazy like a fox idea, let's just replaceall of our state legislators with patients. I guarantee we get a lot more done.
Sara Julson: Oh my gosh. Oh, I would love to see what would happen [00:31:00]there. That would be... Oh, wow.
Kip Theno: Yeah, yeah. Well, this is gonna be live and go out to the masses, so I'm sure I'mgonna get a phone call from somebody.
Anyway, the la- last question, 'cause I- I'm really curious about this. It, it kind of goes back to prior authorizations, you know, where we focus at SamaCare is solving the medical benefits side, right?
Your physician-administered injections and infusions. And, and you had mentioned, um, oculoplastics and some changes there on the surgical side for authorizations. Walk us through that, or what was your kind of levelof importance and diligence there?
Sara Julson: Yeah.That was super exciting for me and my team.
We have used SamaCare on the retina side for a while, and we're continuing to expand our use. One of the areas that we were working on isfinding ways to help our patients who are having oculoplastic surgery. So they're working on the eyelids, they're working on the muscles around the eye.
It's not as cosmetic as it may sound. There [00:32:00] are cosmetic factors or features within, but there are other items such as can the patient open their eyelid all the way? Can they see with, where their eyelid is sitting? Sometimes their eyelid is going all the way down to the middle of their pupil or beyond, so theirvisual field is limited just because of the structure of their eye, and that's where the oculoplastics comes in.
It's interesting because there is a difference, as I said, with a functional or a cosmetic surgery, and insurance companies are trying to makesure that the functional ones are truly functional. Most of the procedures are going to require an authorization for oculoplastics. That's across many payers,and it's not necessarily a bad thing, but it does take time, and there are cases where we can show that there's a functional need.
This patient has their daily living impacted by where their [00:33:00] eyelid is sitting, and the insurance company might come back and say, "It's not bad enough. That's cosmetic right now." So that's an area where we're really taking those challenges to be able to draw more attention to the functional side, be able to go back tothe documentation from the doctors, and work with the insurance companies to see the why behind our request.
We're curating a story of why this patient deserves to have care. And I do say deserves. They are paying for their insurance. They have a need. They deserve to be able to havecare. Um, in that realm, playing with SamaCare has been great because their reporting structure in SamaCare has given me more data than I've ever had.
Um, it's great to be able to start adding other procedures into that process where we know we're going to have a high volume of prior authorizations to be able to track the [00:34:00]denials, track why they're being denied. Which payers are we having the most tissues with? So that we can chip away at those issues to help patients get thatcare that they deserve.
So having options and reporting like that is just speaks to my nerd mind of I want all the data. I wanna see everything that I can, and then let's take that and make it useful. So absolutely. It's, it's a challenge
Kip Theno: Well, h-yeah, thank you, and thank you for the partnership too, and yeah, I mean, you know, evidence-based medicine, right?
But what's that based on? It's all based on data, right? So that's how those decisions should be made going forward. It should be the tip of the sword. Uh, and we're gonna continue to provide that because that is one of our goals is to try and solve, uh, the equation for the patients in all of our specialties and also provide that atomic-level data to expose the deficiencies and inefficiencies in the system, um, which is powerful [00:35:00] because it will make folks sit up a little higher in their seat and hopefully be change agents.
And Sara, this has been so informative, so cool. I'm so glad you joined with us today. I know how valuable your time is, and you gotta get back to patients- ... um, and all of your nerd stuff. But before we do, I have a Easter egg question, and then I will let you go. Um, obviously, you know I'm from Minnesota, my home state.
You can take the boy out of Minnesota, you can't take Minnesota out of the boy. Uh, what is your favorite walleye restaurant or walleye fish fry? Where do you go?
Sara Julson: Oh, goodness. You know what? That is a great one. Um, I'm not a huge fish fan- ...but I can definitely say, and it's gonna sound so Minnesotan on this, the fish fries in your church basements really, they have just something, maybe not thebest flavor in all cases, but there is something that just warms your heart, and you gotta love those church basement fish fries.
There's [00:36:00] something about it. Well,
Kip Theno: a little extra salt, a little extra love. Yep, awesome. Sara, thank you so much for yourtime. Can't wait to get this out to all of our listeners and, and really appreciate you joining on The Road to Care. Thank you, Sara.
Sara Julson: Absolutely. Thanks, Kip. It has been a pleasure.
Thank you for joining The Road to Care podcast hosted by SamaCare, the leader in prior authorization technology and services, where through a script-to-therapy operating system, we enable connectivity with clinics, payers, andmanufacturers focused on optimizing patient care. Tune in next time as together we can make things right.
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Kip Theno: Welcome tothe Road to Care podcast hosted by SamaCare, where we will talk with keyopinion leaders, physicians, administrators, manufacturers, venturecapitalists, and legislators to get their insights on the state of healthcaretoday and where we see it evolving. SamaCare's prior authorization platform isfree to clinics, ensuring patients get on the right therapy at the right time.
Together, we can simply make things right.
Hey everybody, welcome back to the Road to Care podcast hosted by SamaCare. And our special guest today is Sara Julson RHIT. Sara is an experienced revenue cycle manager focusing on patient financial services. Sara is passionate about serving as a liaison between patients, billing departments, and the payer while enhancing account receivable processes. She's a registered health information technician and certified patient service specialist
Thanks for joining everybody. And Sara, really appreciate your time. I've gotta tell you [00:01:00] this, the pre-show that we had was one of the most fun. It was the longest one I've ever had, and there's a reason for it. I mean, you went into your background and history, Keratoconus, impacted patients, rare disease council, artificial iris.
You're a self-described nerd. I thought that was amazing, just kind of like myself. So we've got a lot to cover today. But Sara, first of all, how are you? And thank you for joining.
Sara Julson: I amdoing wonderful. Thank you so much for having me. I am excited to talk more about some of those passions.
As you said, I am absolutely a medical nerd. I've been in the RCM world for a long time, over twenty years, and I'm currently made my home inthe ophthalmology realm. It has been fascinating and really excited to talk about some of the landscape changes that we've seen in the revenue side of medical care.
Kip Theno: And let's get to that question first from the RCM perspective. But before we [00:02:00] do that, as I always start, just your personal journey into healthcare, Sara. What got you there? Where are you now?And, and just your passions for, uh, for being in this side of the world.
Sara Julson: Absolutely. I have always been interested in medical procedures, in how the overall medical world works.
And for me, when it was time to decide what am I gonna do with my life, there's a point we all hit that, and I really didn't know. So I started focusing and thinking about things that I enjoyed, which really led me back to some medical. Um, I love to help people. I am very passionate in that realm, but I'm not necessarily that hands-on, patient-facing person.
So it melded from a coding degree to more of the more the straight financial part, more of the RCM compared to strict coding. So that's where I started about 22 years ago. I've worked in several specialties. I've worked everything from pain management [00:03:00] to vein clinics. I've worked mental health. And as I mentioned, ophthalmology has really been where I've found that passion, that deep drive to help patients, and that is my current world for what I am looking at.
I'm all about the eyeballs.
Kip Theno: From, from revenue cycle, you know, it's an interesting place to be, right? You've got the clinic, you've got the workflows, the insurances, and then of course the patients, and you're kind of in the middle of this entire circle for, you know, the, the solvency of the clinic to continue patient care.
Just talk to us a little bit about revenue cycle and the challenges and things that you wanna change or maybe better that you've learned in the RCM space.
Sara Julson: Oh, absolutely. You are hitting my medical nerd-ism here with hard, hard blows, so it's great to be able to talk about this.
As I've been in this for about twenty years, we've started tosee some of the most significant changes that healthcare has had probably within the last ten years or so, and maybe even [00:04:00] more towards the last five years. It used to be where medical insurance was what people had, and they went to the doctor, and that was about the end of it.
Rarely did you get a bill or it was going to be a copay. Then you started to see insurance changing and going to more deductible plans orhigher patient responsibility. You saw more of the HSAs and the FSAs, so your financial spending accounts or those health savings accounts. Started to see more of that.
And where we currently are today is probably the highest rate of patient responsibility that I have ever seen. And that's a tough world, especially when you're talking about certain items. Like I mentioned, I'm in the eye world right now. And when you think about it, what would you pay for your vision?
It's unfortunate we have to think in that manner at this time versus, "I'm gonna go to the doctor and get the care that I need." So that's really been one of the areas that I focused in on is: How do I [00:05:00] help eliminate issues for access to care as an example? How do those financial pieces tie to the care that patients are actually getting?
The big phrase that I always say to people is, "I care about their financial health as much as their medical health." Because however much we want to say they could be separate, they really are tied together, where we have to work to find those financial solutions to be able to access the care that our patients needI definitely think that's one of my biggest areas of, uh, change that I think could happen.
I don't know how it would ever happen, but it's been tough to watch people go through their situations and share that they can't afford their medical care. I've had some absolute horror stories in my time of patients that needed care. Their insurance wouldn't cover items, so they needed state aid.
Absolutely, but the only way the state would have that happen--There was an elderly couple I remember who they'd been married for [00:06:00]almost fifty years, and theywound up having to get divorced so that they could afford or they would be in the correct financial category to be able to receive state assistance.
That is just a world that I don't want to see for people, and my goals are working to help people get that access to care, to break down some of those financial burdens. And I really speak to this regarding several different types of procedures or diagnoses where I'm working with groups across our state to ask for additional coverage or working on getting items donated or doing anything we can to really increase the access to care for patients.
Not only is the financial difficult on that end, we also have one more area to really consider that is a hindrance or a tough area to work as the patient: prior authorizations. They are not consistent per different insurance companies, perdifferent procedures. You can't say [00:07:00]that this surgery is going to need an authorization all the time because there's going to be those payers that don't.
Or you can't say that this surgery will never need an authorization because there are payers that will. So there's not only a higher patient financial responsibility, but there's a lot more s- administrative burden than I've ever seen. Those are really those areas that I think impact the RCM world and patient care that have driven that passion for me and the work that I'm doing.
Kip Theno: Uh, Sara, and I, what you said, I mean, it kind of struck a chord, right? What would you pay for your vision? Well, what would you pay for your heart, your brain, your pancreas, right? Diabetes. And they're all connected to, to- Yep ... visual or retinal disease states. And,you know, we can talk about prior authorizations all day long.
That's kind of our world over here at SamaCare, but you're not alone. Every single specialty says the same thing. Why is it so difficult? You know, the role of, say, PBMs as an example, and then the high cost, and [00:08:00]then you have seven payers denying it in an algorithm 46% of the time for the same drug, and then thethree payers 100% of the time have no auth required, right?
And there's no uniformity. I mean, Medicare to Medicare Advantage to commercial plans. And we, we do kind of steer away from politics here on my show, but we will not steer away from legislation. And so let's, let's talk about you, you had mentioned the No Surprises Act as an example.
Sara Julson: Yeah.
Kip Theno: Walk us through what that is.
Is it working? Is there transparency? Do you see it as a benefit? And then, where is it not working?And feel free to drop the gloves, Sara, if you'd like.
Sara Julson: Absolutely. So the No Surprises Act, um, and I'm gonna just kind of preface with I am not providing any legal advice. I am just taking my personal stanceon it and sharing what I have inferred from all the different meetings and different items that I've done.
So definitely not any legal advice. But I do think that the No Surprises Act has [00:09:00] goodareas or good intentions. Letting patients know their financial responsibility ahead of time, especially if they're going to be out of network or if theydon't have care under the No Surprises Act is a requirement. And that I dobelieve is helping people because they can have those early conversations. Ittakes some of the worry out of the situation, because if you're going into adoctor, you wanna be able to sit down and listen to what the doctor is saying to you. Sometimes it'sthat first appointment when you see your doctor, and they might say, "Youneed surgery."
If you don't have insurance, the immediate thought is,"How much is this going to cost?" And the rest of what the doctor is saying may or may not actually resonate with you because you are very concerned about the cost. So where the No Surprises Act has been helpful is being able to share those costs upfront with patients so that they can focus on their medical care with their providers.[00:10:00]
There are areas that are challenging in it, such as making sure that networks are clearly found. Insurance companies have definitely put some challenges in place for networks where this one plan that ends with one number different than all the others, that one's out of network for you, but everybody else is.
You know, everybody else is in network, and you're okay to see them. So while the No Surprises Act is really helpful on the patient side and even on the financial side, being able to have those conversations, there are definitely some challenges in making sure that we are meeting those requirements and that we are accurately able to present information to patients to make sure they have all of the knowledge.
Um, we want them to have the care, so using the good intentions is always my goal. I think it's difficult because networks, as that example, are not easily defined. You might have your surgery [00:11:00]center in network, and your doctor might be out of network or vice versa. Those are difficult conversations to have with patients.
Not that they're impossible, but it's really tough to say,"Hey, you know, your particular insurance company, you can keep seeing the doctor that you've been seeing. You can have surgery with that doctor. However, you're gonna have to pay for the operating room or the facility because they're not in-network."
That to patients becomes not only frustrating, but almost a point of contention on, "Well, what do you mean? No one told me this." So that's where the No Surprises Act is helpful, but it definitely has duality in whether or not it is helping providers open access to care, in my opinion anyway. So a little bit of gloves off stating that the payers are presenting us with additional challenges regarding networks in particular or those authorizations, making sure that everything is in place prior to.
If you have an authorization denied and you've already provided a good [00:12:00] faith estimate because of a network, now what? You're gonna have to go back and present new information. So there's a lot of details that come into play when we're talking about the NoSurprises Act, making sure that patients have all of the financial information ahead of time.
Kip Theno: Yeah, andI, and I think there, would you agree that there probably is gonna, is gonna have to be some kind of forced tipping point with what you've just said?Because the status quo certainly isn't gonna work. It's just making it more difficult. And you, you said something in the pre-show about financial health being just as important as physical health to the patients and patient access.
So we think of arrows in the quiver when we're trying to get better balance with patient access and the insurances and the payers and the costs, data being, I think, a heavy bat right now. And, and that data's kind of hard to find as an island. [00:13:00] But how do you, even from the revenue cycle side, or maybe go into more detail about that financial health that you are concerned with, with your patients, what are you doing specifically and maybe certain types of data that you're using to really start to force this tipping point, even with your peers and some of the councils and things that you work with, with, with the provider, with the payers as an example?
Sara Julson: Absolutely. So some of those areas that I've really been trying to focus in on.My current role, I make sure that every patient that is going to have a patient responsibility for a surgery gets some type of a good faith estimate. We make sure that the full disclaimer from CMS is on our letter on that good faith estimate so that patients know what the No Surprises Act is.
If they feel that something has been incorrect, there's how to file the dispute on there. So I really think that's been one area [00:14:00] that taking it a step farther for us orfor me has been beneficial because it's not only answering those questions of how much is this going to cost for the patients who are either out-of-network, don't have insurance coverage, or have, are underinsured.
So those areas are definitely a benefit. It also opens conversations early. We're able to talk to patients to state we can help you apply for different financing. We can set up an internal payment plan potentially. We can talk through the finances so that the patient can focus on their recovery, so that they can focus on the care for their physical health.
Their financial health, I never want to be the reason why they aren't getting medical care. So it's really taking time to work with each patient, realizing each patient has a different perspective, they have a different situation, and really making sure that we're not [00:15:00] only addressing the legal areas with the No Surprises Act as an example, but we're addressing the financial concerns of the patient early so that care can continue, so that they can continue going through their post-op appointments and following up in that six month, one year, making sure that they are able to be compliant with their treatment plans.
So it really is a worthwhile challenge, but I think some of the tipping points come down to, for us, timeframes. It's tough to get information to people and find that perfect sweet spot window of early enough for them to make financial decisions and have those conversations, but close enough to their appointment so that that appointment is really in their mind, whether it's a clinic appointment, whether it's a surgery appointment.
There's definitely a sweet spot, and in making sure that we're going one step above the No Surprises Act, that has been a challenge [00:16:00] for us, and I think that, in my opinion, could be kind of a tipping point in where do we meet all of the guidelines and where do we need to talk about changing some of those guidelines?
Kip Theno: And yeah, and well, and you mentioned change, but you also mentioned, Sara, treatment plans. Mm-hmm.
Sara Julson: And
Kip Theno: I can kind of think back, I might have some of this wrong, going by some memory here, but retina injections, I think the first ones were in the early 1900s. 1911 theywere, I think injections started as air bubbles for retinal tears, right?
And then they, they did penicillin injections in the eye, and then now we're in the '40s, so you look at the evolution of just science in general, which is amazing. But it also wasn't that long ago that y'all had oneto two, drugs for injections. Then you wake up in a heartbeat and then it's four and six, soon to be eight, right?
For the drugs available, biosimilar step therapy. So how do you, how do we balance all of that? [00:17:00]Not only the, the clinical behavior on the clinical side, the choices, the pathway, the workflows for the clinic, the treatment plans. How are you all navigating that? Because it is gonna continue to change. And then you can tie all that back into how does that financially affect the clinic and the patient?
Sara Julson: Oh, absolutely. I've got a few examples of my passion projects that really fall into the, that realm of what are we doing? How are we working on things? I spend quite a bit of my day-to-day work working with new procedures or new types of medications for patients relating to ophthalmology. There are several procedures out there that are new, and I found it to be a particular challenge because it is on average, I read, uh, 5 to 5.7 years from when a new procedure or drug has been FDA approved before the majority of payers are [00:18:00] recognizing it as, uh, a covered service or are putting out policies.
During that 5 years or 5.8 years that I had read, the, what I'd seen was they are just considering everything experimental or investigational for longer periods of time than what they had been in the past. Historically, Ihad seen two, three years where we could get most of the payers on board for new procedures.
It's definitely moved into that five year. And as an example ,one of the areas that I work in and where the financial health comes into play for our patients so much is the artificial iris . That is such a cool technology. I, when I first heard it, I kind of sat there going, "This is way advanced stuff I wouldn't ever expect to happen now."
It feels so futuristic, but it's out there. And the artificial iris was actually FDA approved in [00:19:00] 2018. So 2018 is definitely more than five years ago, and there are very, very few payers who have coverage. Many of their policies are written stating that the artificial iris that's been FDA approved since 2018 is considered investigational or experimental.
To go through the FDA, you have to have your research, you have to have your trials, you have to have enough information to be approved. So there's that point with the insurance companies of investigational and experimental then moves to patient responsibility, and I think that is a big challenge, especially, you know, mentioning artificial iris.
It's really the only type of option that patients with aniridia have to preserve their sight or to regain sight. So it's difficult to say,"Hey, I know that it's medically necessary, but your insurance isn't going to cover it. [00:20:00] It's an expensive item.It's a fairly expensive procedure, and we can help you, but we have to talk finances now."
It's a rock and a hard place. Going back to that first comment of how much would you pay for your vision? Well, we're finding those limits for patients, and it is tough, and it's something that I think we in the medical industry, that the insurance companies need to consider, that new procedures are helping patients and we need to get them moved along faster.
Kip Theno: Thatamazes me. Artificial iris, we-- the future is here, Sara. It's now. It's socool. But I go back to 20-2018, you remember what happened right after that,the, the COVID. And you think of these patients, those patients that were legally blind, as an example, how isolated were they without other options andthings like this that could have helped them through that period?
God forbid we ever go through something like that again. But [00:21:00] What do your peers out there say about the artificial iris? I mean, how is there not this groundswell of here's how many patients there are, this technology could work, here's the benefit long term for the system, for the patient. How do you get that groundswell for something like that?
Sara Julson: It's challenging. Uh, peers are in the same boat as us. There are doctors within ourarea and doctors across the US who do work with and do the do the surgery forartificial iris. We're all saying the same things. Payers are being very slowto adopt the new procedure, and we're really working towards individual casesat this time, or my, my approach has been individual cases with the payers sothat we're really working to have the rationale of here's why this is helpful.
There is nothing elsethat this patient can do. Here's why we need to do this. [00:22:00] And then I know my peers are doing the same. I've talked to some across thecountry, and unfortunately, it is a large administrative area for us to take things case by case and really work the insurance companies to understand the rationale.
It's FDA approved. Wehave all these research studies. How can you state this is still experimental or investigational? In the artificial iris case, we are well over five years. It's gone through all of the testing to get here. So we're-- we as agroup are trying to work on the insurance side to draw more attention to the procedures that are new, that really are solving issues that patients have that we could have never done before.
The challenges for myself and peers across the country are authorizations, getting coverage, and really removing that barrier to care regarding the [00:23:00] experimental items that are considered non-covered, but they have passed FDA approval. So that'san area that is challenging, and we as a whole need to work a little bit harder to have the insurance companies adopt these new procedures sooner.
Kip Theno: It, it's just, it feels a little bit like jumbo shrimp, right? Like an oxymoron. Well, it's FDA approved, but on the other side it's experimental. Like, how is that a binary state? I don't know. It kind of reminds me of the day, Sara, where, where, you know, a, a new data-driven approved device, as an example, to save lives in the cardiac space still had to go through what was called a VAC committee, value analysis.
Well, we've gotta analyze the value. Well, the value is I'm saving this patient's life. Like so we will, we will help scream it to the hills with you, Sara, for sure on this. And then with that, you're also taking some other steps, right? You talked about the Keratoconus patients, you talked about the Rare Disease Council.
Can you elaborate more into those passions of yours?
Sara Julson: oh, [00:24:00] absolutely. Uh, patients with Keratoconushave been one of my passion projects. I started working with what at that timewas a new procedure, ironically, back in 2018, and trying to get care for these patients. Keratoconus is a condition where the eye becomes cone-shaped.
It can progress at any point in time, and their vision canworsen. Once you are diagnosed or once you have Keratoconus, there really is nogoing back. So as you progress, as the shape of your eye worsens, as your visual acuity worsens, there's nothing that can be done for you outside ofdoing one particular procedure called cross-linking or epioxia. The reason I'm saying or is 2018, the cross-linking procedure had been FDA approved.
We started seeing really good coverage for patients some where in the 2020 twenty 2021 [00:25:00] category.And then twenty twenty-two, we started seeing the vast majority of payer having policies that would allow us to obtain coverage for patients. We never say all payers because we know that's not the truth, but we were seeing a largenumber of them.
And what's really cool here is they have developed an improved or a further way to help patients with Keratoconus in a new system that was FDA approved last year. So we're really working to get care for these patients because Keratoconus and the disease state itself do fall into that rare disease category.
So working with groups in the state to try to have rare disease council assist in talking to payers or talking to the state about coverage. I think one of the best examples is the Keratoconus patients, where historically, once we were able to get policies listed and work with payers to get coverage, [00:26:00] one of the payer issues was Medicaid, where Medicaid would cover the procedure for cross-linking, but not the drug required to do the procedure.
And that was a challenge because you had to then tell your patients, "Hey, you're financially qualified for Medicaid. They'll pay for the procedure, but we need a lot of money for the drug." And that is stilla challenge because Medicaid is still not allowing for coverage on the drug inmost cases. There are some payers that we're starting to see some changes, but even as the technology is growing and improving and the machine and the equipment is improving, payers are actually taking a step backwards.
So cross-linking had been predominantly approved by payers. Now with the new plan coming out that started last year called Epioxa, we're seeing that Keratoconus patients are losing their one [00:27:00]opportunity to halt the progression of Keratoconus. Insurance companies are doubling back on their policies saying, "Oh, with this new procedure?
Nope, that's investigational even though there's-- it is a little bit different, but not significantly different than the other procedure.So we're starting that process all over again, and these patients have no options. They cannot wear glasses. Glasses on a cone-shaped eye aren't going to help the visual acuity to the highest level needed, and it's not going to treat the condition of that misshapen eye.
If you think about contact lenses into some of those large scleral lenses, they're on the eye so they can help, but there's a point where they won't be able to help any longer. And the cross-linking procedure Epioxa procedure are really the only options that patients have to halt that progression. If they don't do one of those procedures, or if we can't [00:28:00] obtain coverage, the next choice is to letthem lose further vision, and at some point, they will need to do a transplant, a cornea transplant.
And where that sounds like, "Oh, well, maybe that's gonna help," yes, it does help, but it does not remove the Keratoconus from the patient. And oftentimes, not only is there a risk for rejection of the cornea tissue, but Keratoconus patients can have Keratoconus show up again. It's still with them. It's still part of them.
So they will oftentimes have to go through multiple cornea transplants. Where if we were able to do the cross-linking procedure Epioxa procedure, that will halt their progression, allowing their doctors to work with them on the visual acuity or how well they see. So the Keratoconus patients are really in a rock and a hard place where it used to have more coverage, but now that the technology is advancing, now we're taking a step [00:29:00]back in coverage, and there aren't options.
So I, myself, and some peers in the area are really working to talk to the Rare Disease Council. How can we bring more attention to this, specifically to the Medicaid program, so that we can open that access to care, help people preserve their vision, and be able to honestly still function? We need to be paid for services, whether it's going to be a patient or the insurance company, and I would much rather take the insurance company money than the patient's money because we have insurance for a reason.
So it's, it is a challenge in so many factors of trying to help people and to keep their financial area responsible for them or within something that they can afford, and we're pulling in, we're taking any angle we can because these patients need that care, and they need that assistance. So my passion there is let's get care.
How can we help [00:30:00]them? A few years ago, as an example,I had worked with the maker of the drug and the machine for cross-linking, and just in the practice that I was working, we were able to update coverage and get ninety-seven patients care that had not had any options due to the financial commitments before.
They were Medicaid patients. We were able to work together and get care for them. Where ninety-seven patients might not seem like a huge number, but really each one of those patients is a whole person, so helping ninety-seven whole people is bigger than the number ninety-seven itself to me.
Kip Theno: Wow. Rightand Sara thank you for
all
Kip Theno: of that work. By the way, the Rare Disease Council does have a voice. It occurs to methat I think we should just here's a crazy like a fox idea, let's just replaceall of our state legislators with patients. I guarantee we get a lot more done.
Sara Julson: Oh my gosh. Oh, I would love to see what would happen [00:31:00]there. That would be... Oh, wow.
Kip Theno: Yeah, yeah. Well, this is gonna be live and go out to the masses, so I'm sure I'mgonna get a phone call from somebody.
Anyway, the la- last question, 'cause I- I'm really curious about this. It, it kind of goes back to prior authorizations, you know, where we focus at SamaCare is solving the medical benefits side, right?
Your physician-administered injections and infusions. And, and you had mentioned, um, oculoplastics and some changes there on the surgical side for authorizations. Walk us through that, or what was your kind of levelof importance and diligence there?
Sara Julson: Yeah.That was super exciting for me and my team.
We have used SamaCare on the retina side for a while, and we're continuing to expand our use. One of the areas that we were working on isfinding ways to help our patients who are having oculoplastic surgery. So they're working on the eyelids, they're working on the muscles around the eye.
It's not as cosmetic as it may sound. There [00:32:00] are cosmetic factors or features within, but there are other items such as can the patient open their eyelid all the way? Can they see with, where their eyelid is sitting? Sometimes their eyelid is going all the way down to the middle of their pupil or beyond, so theirvisual field is limited just because of the structure of their eye, and that's where the oculoplastics comes in.
It's interesting because there is a difference, as I said, with a functional or a cosmetic surgery, and insurance companies are trying to makesure that the functional ones are truly functional. Most of the procedures are going to require an authorization for oculoplastics. That's across many payers,and it's not necessarily a bad thing, but it does take time, and there are cases where we can show that there's a functional need.
This patient has their daily living impacted by where their [00:33:00] eyelid is sitting, and the insurance company might come back and say, "It's not bad enough. That's cosmetic right now." So that's an area where we're really taking those challenges to be able to draw more attention to the functional side, be able to go back tothe documentation from the doctors, and work with the insurance companies to see the why behind our request.
We're curating a story of why this patient deserves to have care. And I do say deserves. They are paying for their insurance. They have a need. They deserve to be able to havecare. Um, in that realm, playing with SamaCare has been great because their reporting structure in SamaCare has given me more data than I've ever had.
Um, it's great to be able to start adding other procedures into that process where we know we're going to have a high volume of prior authorizations to be able to track the [00:34:00]denials, track why they're being denied. Which payers are we having the most tissues with? So that we can chip away at those issues to help patients get thatcare that they deserve.
So having options and reporting like that is just speaks to my nerd mind of I want all the data. I wanna see everything that I can, and then let's take that and make it useful. So absolutely. It's, it's a challenge
Kip Theno: Well, h-yeah, thank you, and thank you for the partnership too, and yeah, I mean, you know, evidence-based medicine, right?
But what's that based on? It's all based on data, right? So that's how those decisions should be made going forward. It should be the tip of the sword. Uh, and we're gonna continue to provide that because that is one of our goals is to try and solve, uh, the equation for the patients in all of our specialties and also provide that atomic-level data to expose the deficiencies and inefficiencies in the system, um, which is powerful [00:35:00] because it will make folks sit up a little higher in their seat and hopefully be change agents.
And Sara, this has been so informative, so cool. I'm so glad you joined with us today. I know how valuable your time is, and you gotta get back to patients- ... um, and all of your nerd stuff. But before we do, I have a Easter egg question, and then I will let you go. Um, obviously, you know I'm from Minnesota, my home state.
You can take the boy out of Minnesota, you can't take Minnesota out of the boy. Uh, what is your favorite walleye restaurant or walleye fish fry? Where do you go?
Sara Julson: Oh, goodness. You know what? That is a great one. Um, I'm not a huge fish fan- ...but I can definitely say, and it's gonna sound so Minnesotan on this, the fish fries in your church basements really, they have just something, maybe not thebest flavor in all cases, but there is something that just warms your heart, and you gotta love those church basement fish fries.
There's [00:36:00] something about it. Well,
Kip Theno: a little extra salt, a little extra love. Yep, awesome. Sara, thank you so much for yourtime. Can't wait to get this out to all of our listeners and, and really appreciate you joining on The Road to Care. Thank you, Sara.
Sara Julson: Absolutely. Thanks, Kip. It has been a pleasure.
Thank you for joining The Road to Care podcast hosted by SamaCare, the leader in prior authorization technology and services, where through a script-to-therapy operating system, we enable connectivity with clinics, payers, andmanufacturers focused on optimizing patient care. Tune in next time as together we can make things right.
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