Improving Patient Care and Revenue with Ancillary Testing
It's worked for this doctor, who explains his strategy.
By Mark D. Fromer, M.D., New York, N.Y.

While providing the highest level of care starts with listening to our patients, gathering good technical information further enhances the diagnostic process. To provide state-of-the-art care to my patients, I've selectively adopted a series of ancillary tests that augment my knowledge of several disease processes.

The tests that I now perform in my practice are invaluable in the day-to-day care of my patients. And now that the Health Care Financing Administration has more fully sanctioned diagnostic tests under the Medicare Fee Schedule, the ancillary tests support the fiscal health of my practice as well. In this article, I'll explain what I've added and how the strategy of adding ancillary tests has worked for me.

How I got started

In 1989, when I first began practicing as a retinal subspecialist, the first ancillary test I thought to add as a complement to my medical services was fluorescein angiography. Being fellowship trained in retina, the test was an important and necessary service for my patients. Having little in the way of financial resources at the time, the expense of the equipment concerned me. My fears quickly subsided, however, once I realized that if I had the test available on-site, I could readily offer it to my patients and improve the profitability of my growing practice.

In the mid-1990s, I added general ophthalmology care to my practice. Guided by ophthalmic practice management consultant David Steinberger, I began adding the ancillary tests that would also provide value to my cataract and glaucoma patients. (Mr. Steinberger provides additional advice in "A Sensible Strategy,")

For my glaucoma patients, I added disc photography, which allowed me to provide excellent cup-to-disc documentation. Around that time, the Humphrey visual field test became the gold standard for glaucoma care, so I added that, too.

Today, at my three offices in the Manhattan area, I offer these ancillary tests:

• fluorescein angiography
• retinal tomography
• fundus photography
• B-scan ultrasonography
• A-scan ultrasonography
• visual field testing
• visually evoked response testing.

Key benefits

Offering these tests has improved my practice in several ways, including:

• Richer data to analyze. In-house ancillary testing has become an indispensable resource. It gives me an enormous amount of data from which to draw, enhancing my ability to diagnose and treat patients.
• Increased revenue. By adding tests to patient encounters as warranted, I've dramatically improved my practice's revenue stream and profits.
• Improved staff morale and productivity. While technician downtime is a major concern for many practices, it's not a concern in mine. We schedule ancillary procedures during periods when I'm involved in other practice-building activities. And because we schedule most ancillary testing during times when exams aren't scheduled, patient flow is smooth.
  Furthermore, the tests and equipment give our technicians the welcome opportunity to expand their skill sets, and reimbursement amply covers their overhead costs and returns profits to the practice.
• Increased patient loyalty and word-of-mouth referrals. When patients see the highly technical equipment we use in our office, they feel secure in our commitment to cutting edge technology and providing the best care possible. In fact, they routinely compliment my staff and me on the quality of care they receive from us.
  Because I offer a full range of ancillary tests for multiple disease processes, I don't have to send patients elsewhere for care. This has bolstered patient retention and loyalty, and has resulted in a steady and growing stream of new patient referrals.

Ensuring success

Experiencing these benefits requires attention to a few important points. First, it makes sense to buy or lease equipment that meets Medicare's "medical necessity" standard. I started that way, which allowed me to create immediate cash flow to my practice. I put equipment and tests that didn't meet this criterion on hold until revenue from income-producing ancillary testing made it feasible to move forward.

Second, to keep staffing expenses and related overhead in check, and to get comfortable with the equipment and service you're performing, consider initially performing the tests yourself. That has worked well for me. For example, when I first added fluorescein angiography, I gained invaluable experience and confidence with the equipment.

With the advent of digital angiography, I was able to view the images in the photography suite, which made the testing even more valuable. Plus, the testing became simpler to execute, so I quickly became proficient in angiography. As the practice continued to grow, I added a trained angiographer, who also served as my technical assistant. I then added B-scan ultrasonography, which was a natural extension for evaluating my retina patients.

As I added to my practice's testing capability, I added more technical staff members. I also made it a requirement that everyone be cross-trained in all equipment and tests. Today, my technicians continuously cross-train to ensure that they're proficient and performing at top levels with all tests and equipment.

Choosing the right tests to offer is also crucial to success. If you're interested in getting started in ancillary testing, I strongly advise adding tests that complement the medical needs of your particular patient base. That determination isn't difficult to make. If you know how many patients in your practice require what types of care, you can determine which tests provide the best fit. For example, practices with a strong population of glaucoma patients would benefit from visual field testing, optic nerve and nerve fiber layer imaging, and disc photography rather than angiography.

In my case, prior to adding the Heidelberg Retinal Tomography (HRT) unit to my stable of ancillary testing services, I looked at the cost of the instrument and the potential benefit of this test to my patients. I also evaluated the number of visual fields that I was performing. This data gave me a solid estimate of how many HRTs I might perform. From that information, I was able to determine the economic return I'd achieve by bringing the equipment and test in-house. (When new software becomes available, we'll be able to evaluate retinal thickness in our diabetic patients.)

Of course, no matter what test you're considering, the buying and leasing costs of equipment and technical staff salaries shouldn't exceed projected revenue.

If you're not in a position to buy or lease new equipment, you could start your ancillary testing program by bringing a photographer into your office. Photographers charge for the technical component of the imaging, but you can bill Medicare for the professional component, which covers the entire procedure.

Strengthening your position in more ways than one

In short, ancillary testing positions your practice more favorably in the eyes of patients and referral sources. And it makes you better at the business of medicine by allowing you to be fairly compensated for doing what you do best, providing excellent patient care. 

Dr. Fromer is a retinal subspecialist who also maintains a general ophthalmology practice in Manhattan. You can send mail to him at 115 East 61st Street, Suite 7F, New York, N.Y. 10021; call him at (212) 832-9228; or send a fax to (212) 751-9482.
David Steinberger is an ophthalmic practice management consultant based in Manhattan. You may reach him by phone at (917) 841-3665.