Gary Keeling: Billing for a Perioperative Medicine Clinic

Gary Keeling, Vice President of Anesthesia Services at Coronis Health, a veteran CPA, shares how perioperative medicine clinics can transform anesthesia finances by structuring them as separate entities with their own tax IDs, CPT/EM billing, and financial statements. Using real hospital examples, he shows how modest per-case EM revenue, reduced cancellations, and better OR utilization can generate hundreds of thousands in new revenue and significantly reduce anesthesia subsidies while using largely existing staff and resources.

Explore the full episode here: https://www.medaxion.com/gary-keeling-billing-for-a-perioperative-medicine-clinic

Jeff McLaren introduces the speakers and panelists whose discussions were recorded live at the 2026 Anesthesia Economics Summit.

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Transcript

SPEAKER_00 0:05

Uh Bob

Dynamic CPA

SPEAKER_00 0:06

and I go way back, right? And he said, We're gonna put you on right after the afternoon break. And I said, Well, that's a that's a tough spot to pick. And he said, Well, you need to become dynamic, right? And I said, Well, I'm a CPA by trade. I've been doing this for 29 years, and a dynamic speaker and a CPA don't have too many qualities that cross each other. So I called Bob back and I said, Hey, I have an idea. He

Periop Finances

SPEAKER_00 0:30

said, Talk about the finances of a perioperative uh medicine clinic. And I said, Remember the movie Jerry McGuire, Tom Cruise, and Cuba Gooding Jr. I said, remember when they were saying, Show me the money, they were yelling at each other over the phone. I said, Bob, it'll be great. I'll put that on my screen, and everyone will think that's hilarious. He said, No, everyone will think that's cheesy. So he told me to come up with something else to talk about. So this is only a funny story to the people in this room. So I've been doing this for 29 years. So last September I get a call from a CEO out in the Pacific Northwest. He said, We own 17 ASCs, and we're tired of getting private practice groups, we're tired of locums, we're gonna employ them all. I said, Oh, okay. He said, Can you help us out? I said, sure. He said, we want at least a 5% profit margin on those on that service. And I said, after I dropped the phone, I picked it back up, and I said, You'll be lucky if you lose 15 to 25 percent on that service. There's no chance on earth you're gonna make a profit. And then we heard Dr. Hicks talk this morning, and the average subsidy is between 30 and 70 percent. So the whole issue is people don't really understand anesthesia all that well. So this was gonna be together. So Dr. Steele had to leave early, he had some things change in his life. He put together 25 white papers. If anyone wants this as we leave, you know, he wanted to stay here and answer questions, but he couldn't. So they're on the table if anybody wants one.

Separate Entity

SPEAKER_00 2:01

So we talked about the upside to having a parapet of medicine clinic, and he mentioned setting it up as a separate entity. That's absolutely the case. Separate tax ID underneath the hospital umbrella. It makes it easier for billing and tracking, right? So anesthesia boeing, base and time units, uh, parapet medicine clinic, you're building billing CPT codes, EMs, etc. And it you don't have the denials from the insurance companies when they see the anesthesiologist is also doing an EM. So breaking it into separate organizations is the way to go. Uh I heard Clint Stort speaking early this morning, he's the CFO, and for CFOs nowadays, I mean that's a tough job, right? Costs are going through the moon, revenues aren't following along, so they're really playing a balancing act just to kind of keep the health system's head above water, and this makes it easier to track. As part of that, you get separate financial statements, right? There's different margins, different structure, there's RVUs that that would fall into a perioperative medicine clinic. You can look at what the return on investment was. You know, if there's additional profit, that is in essence is reducing the subsidy paid to the anesthesia

Billing Rules

SPEAKER_00 3:10

group. So there's a lot of advantage of uh keeping them both separate. So the billing gets a little complicated, but once once you figure it out, you're good to go. Uh the global service surgical package, there's rules you can't bring patients back. Some are 10 days, some are 90 days. And if it's necessary to do that, you just have to append appropriate modifiers in order to get them paid. Uh you

Profit Model

SPEAKER_00 3:35

same CPT codes, it's it's very straightforward, but you just need to know the rules. So, show the money here, right? This is the Cornelius Vanderbilt uh profit mod model. Remember, he started Standard Oil? His opinion was I'd rather make a dollar off a million people than a million dollars off one person, right? So these numbers aren't very exciting, right? You Medicare is gonna pay 150 bucks for every one of these patients, commercial care is gonna pay 180 bucks, right? So nobody gets too excited about this, but if you're already doing the work, there's a there's a part of this that people don't realize, right? So you're getting improved patient care. That first and foremost, always. You're gonna get a reduction in canceled cases, you're gonna get better OR utilization. So there's a financial value to this. I've been doing this a long time, and the ASA was promoting this years ago, and I would work with anesthesia groups, and they would go meet with hospital CFOs and they drag me along, and they would come up to this nebulous number, right? We're gonna do all this really cool stuff for you, hospital, and you're gonna make like three million bucks and then kick us back some money. And the CFOs would look and be like, How are you gonna measure that, right?

EM Revenue

SPEAKER_00 4:45

So there's a part of it that improves uh utilization, patient care, but you're gonna generate about $150 to $180 per case. So, as an example, 20,000 anesthesia cases, you're gonna throw off about $700,000 of EM revenue, which is true. CPT's out the door, money coming back in, right? The why this is valuable, because as Dr. Steele said, and everyone in this room knows, is a lot of your health systems are already employing these people, right? So they're already in the budget, they're already in the costs.

Case Example

SPEAKER_00 5:18

And here's an example. This is a true client, is they had about 20,000 cases, they're gonna generate about 850,000 in in billing revenue, plus we had to estimate uh reduced leakage, improve case mix index, reduction cancel cases. We think the upside is gonna be around 2.6 million dollars, right? And this is the example. So this isn't a crazy. We're gonna take questions at the end, if that's okay. Uh this isn't like a crazy hospital that's in like Beverly Hills, right? People always use those examples. Everyone has insurance, everyone has great insurance, everyone has cash pay. This is a normal hospital, right? So they had about 20,000 cases. Uh there's the there's a case mix. Uh orthopedic, they had a big orthopedic practice, but everything else was was pretty normal. The the the the cases that get utilized, or the CPTs that get utilized from one of these uh perioperative clinics is typically between 18 and 30 percent of the patients that come through, you can generate a bill for their time. So uh their payer mix was 49% Medicare, 5% Medicaid, 46% commercial. So pretty normal hospital, maybe even a little worse on the payer mix side.

Cost Structure

SPEAKER_00 6:28

Here's the the final numbers, right? So we're gonna generate 842,000 bucks. The way it works is there was a uh anesthesiologist that was close to retirement, so he's now the part-time medical director of the perioperative clinic. We we're assuming his costs are around 280, right? Halftime uh MD. They're using APRN, it's about 180,000, that's with benefits fully loaded. But those costs are already baked into the budget, right? So the new revenue's coming in, but the costs are are gonna stay the same. You're gonna add some more costs on there, you're now gonna have to pay for the collection of those, so let's say 5% in order to do the billing, and then you're gonna have to hire a scheduling person or one and a half scheduling people to schedule the perioperative clinic. But if you look at that, it drops 716 to the bottom line because you're using costs that you're already uh incurring, and the and most of this is work you're already doing. So you're just basically restructuring this, and that's where Dr. Steele wanted to stay and kind of get into the details of that. But you're restructuring the service, which now makes it profitable.

Starting Clinic

SPEAKER_00 7:34

My last slide, then I'm gonna hand it off to my colleague over there, Bellinger Moody, who is our compliance expert that has been doing this. But if you want to start a practice, right, let's say you're gonna do 12 patients a day, 260 days a year, it's about 3,000 patients. You're gonna need one APRN for that, you're gonna need one scheduling person to do that work. So if you start it, you're gonna see a profit of about $300,000. As the clinic grows, then you would add incremental cost to bring more and more people in. So what we're seeing, and we're all saying the same thing, right, is that hospitals are struggling with the financials and they're struggling with anesthesia costs, and they can't understand why, right? And like I said, there's a huge shortage. So every dollar counts. This is a way that if you're private practice, you can reduce your subsidy from the hospital, and if you're employed, you're just gonna improve the bottom line. So, that being said, this is all links into the team's program.