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Hospital Impact Model

The EvoEndo Endoscopy System for Sedation-Free TNE adds value to your pediatric GI program. This tool will walk you through steps to generate the estimated benefit for your facility.

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Step 1

Converting a sedated transoral endoscopic procedure to a Sedation-Free TNE with the EvoEndo Endoscopy System presents an incremental revenue opportunity for your facility.

This is an example of what this conversion could look like in practice based on the following assumptions:

  • Total per visit payment for a Sedated Transoral EGD using CPT code 43239 = $3,500.
  • Total per visit payment for a Sedation-Free TNE using CPT code 43198 = $3,000.
  • Going from a sedated upper GI endoscopy to TNE may create a revenue difference. This will be offset by decreased costs associated with TNE.

Benefits

  • Move procedure from high-cost to lower cost-care area.
  • Eliminate costs associated with general anesthesia.
EE Thin Icon _Operating Room Red Opt 2
$3,500
EE Thin Icon _TNE Red
$3,000
EE Thin Icon _Dollar Sign Red
-$500

Step 2

Once the sedated transoral EGD is moved to the TNE procedure room as a Sedation-Free TNE, that empty block is now filled by an additional procedure. You would now collect an additional reimbursement payment for that procedure, resulting in a net revenue gain of $4,200 from this conversion. 

Benefits

  • Free OR procedure block is filled by an additional procedure.
  • Now collecting reimbursement on two procedures instead of one.
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$4,700
EE Thin Icon _Dollar Sign Red
-$500
EE Thin Icon _Hospital Red
$4,200

Step 3

Let’s take things one step further and consider the additional reimbursement revenue opportunities beyond simple sedated to sedation-free conversions in your new TNE Procedure Room.

Sedation-Free TNE is rapidly becoming a new standard of care in Pediatric GI, and as awareness grows in both the patient and physician communities, demand is quickly following. By investing in Sedation-Free TNE now, you position your program to capture a large share of this demand in your market.

Converting a sedated transoral endoscopic procedure to a Sedation-Free TNE also presents an opportunity for your facility to increase procedural capacity by freeing up additional block time in your higher-cost operating rooms and procedural suites:

In this example, if you were able to convert 10 upper GI endoscopies to Sedation-Free TNEs per month blocked at 45 minutes each:

  • You would free up to 450 minutes
  • You now have increased scheduling flexibility for other procedures!

Benefits

  • No large capital investments in equipment, construction, or staffing are required.
  • Reduce procedural wait times, improving patient compliance, satisfaction, and safety.
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Info buttons for explanations.

Reimbursement Inputs

Commercial Facility Reimbursement

Medicaid Facility Reimbursement

Revenue Impact of Converting Existing Patients to TNE:

How does converting existing upper GI endoscopy patients to Sedation-Free TNE add value?

First, define your overall patient payer mix %:

Overall patient payor mix %

Next, the sedated EGD is converted to a sedation-free TNE, creating a difference in revenue according to your reimbursement inputs:

Calculation explanation: This value is your estimated average reimbursement revenue per Diagnostic Upper GI Endoscopic procedure weighted by payer mix according to your inputs. Formula = (Commercial Diagnostic Upper GI Endoscopy Reimbursement x Commercial Overall Payer %) + (Medicaid Diagnostic Upper GI Endoscopy Reimbursement x Medicaid Overall Payer %).
Calculation explanation: This value is your estimated average reimbursement revenue per Diagnostic TNE procedure weighted by payer mix according to your inputs. Formula = (Commercial Diagnostic TNE Reimbursement x Commercial Overall Payer %) + (Medicaid Diagnostic TNE Reimbursement x Medicaid Overall Payer %).
Calculation explanation: This value is your estimated average reimbursement revenue per Diagnostic TNE procedure weighted by payer mix according to your inputs. Formula = (Commercial Diagnostic TNE Reimbursement x Commercial Overall Payer %) + (Medicaid Diagnostic TNE Reimbursement x Medicaid Overall Payer %).

In the final step, the freed OR block is now backfilled with an additional diagnostic or therapeutic procedure, making up for any revenue deficit from the TNE conversion:

7 – Assumes every TNE conversion is replaced by an additional procedure, using a Colonoscopy as a proxy, CPT code 45380. Calculation explanation: This value is your estimated average reimbursement revenue per Additional Diagnostic or Therapeutic procedure weighted by payer mix according to your inputs. Formula = (Commercial Additional Diagnostic or Therapeutic Procedure Reimbursement x Commercial Overall Payer %) + (Medicaid Additional Diagnostic or Therapeutic Reimbursement x Medicaid Overall Payer %).
6 - Assumes that the average reimbursement for a diagnostic TNE will be less than a diagnostic transoral sedated endoscopy using CPT codes 43198 and 43239 respectively. Calculation explanation: This value is the difference between your estimated weighted average reimbursement per procedure between Diagnostic Upper GI Endoscopies and Diagnostic TNEs according to your inputs. Formula = (Weighted average Diagnostic TNE reimbursement) - (Weighted average Diagnostic Upper GI Endoscopy reimbursement).
Calculation explanation: This value is the estimated weighted average reimbursement revenue from each TNE conversion according to your inputs. Formula = (Estimated weighted average reimbursement revenue from Additional Diagnostic or Therapeutic Procedure) – (Difference between weighted average Diagnostic Upper GI Endoscopy reimbursement revenue and weighted average TNE reimbursement revenue).
Revenue Impact from New Patients:

How much reimbursement revenue might you expect from bringing new patients to your practice that otherwise wouldn’t be interested in getting a sedated transoral upper GI endoscopy?

First, define your TNE patient payer mix %*:

TNE patient payor mix %

Next, we take the TNE reimbursement inputs from above and apply this payer mix to get your average reimbursement per TNE:

8 - Assumes that your new TNE patient population might have a different payer mix than your overall payer mix and can be calculated separately. Calculation explanation: This value is your estimated average reimbursement revenue per Additional TNE procedure weighted by payer mix according to your inputs. Formula = (Commercial Diagnostic TNE Reimbursement x Commercial TNE Payer %) + (Medicaid Diagnostic TNE Reimbursement x Medicaid TNE Payer %).

The final step is to determine how many of these additional patients will agree to a Sedation-Free TNE. This is dependent on various factors and can vary widely from facility to facility, but this model assumes that your additional patient opportunity equals 1% of your total upper GI endoscopy volume:

8 - Assumes that your new TNE patient population might have a different payer mix than your overall payer mix and can be calculated separately. Calculation explanation: This value is your estimated average reimbursement revenue per Additional TNE procedure weighted by payer mix according to your inputs. Formula = (Commercial Diagnostic TNE Reimbursement x Commercial TNE Payer %) + (Medicaid Diagnostic TNE Reimbursement x Medicaid TNE Payer %).
9 – Assumes TNE demand from new patients is 1% of total upper GI endoscopy volume. Calculation explanation: This value is the estimated number of monthly additional TNE procedures that your facility may perform outside of TNE conversions. Formula = (Estimated Monthly Sedated Upper GI Endoscopies) x 1%.
Calculation explanation: This value is the monthly estimated reimbursement revenue for Additional TNE procedures weighted by payer mix according to your inputs. Formula = (Estimated weighted average reimbursement revenue from Additional TNE procedures) x (1% of your total estimated Sedated Upper GI Endoscopy Volume).
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Results Summary

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Reimbursement Assumptions:
  1. The default value for Commercial Facility Reimbursement, Diagnostic Transoral Upper GI Endoscopy under sedation is based on per-visit payment averages from commercial payors obtained from Optum Health in Pediatric (ages 5-18) Hospital Outpatient Departments for claim year 2022 for CPT code 43239.
  2. The default value for Commercial Facility Reimbursement, Diagnostic Transnasal Esophagoscopy without sedation is based on per-visit payment averages from commercial payors obtained from Optum Health in Pediatric (ages 5-18) Hospital Outpatient Departments for claim year 2022 for CPT code 43198.
  3. The default value for Commercial Facility Reimbursement, Additional Diagnostic or Therapeutic Procedure, uses Colonoscopy reimbursement information as an example is estimated by calculating the difference between the known commercial health plan average reimbursement payment from Optum Health data and published Medicare reimbursement for CPT 43239, which equals 4.5x. That multiple is then applied to the published Medicare average reimbursement value of $1,054 for a diagnostic Colonoscopy, CPT code 45380.
  4. The default values for Medicaid Facility Reimbursement, Upper GI Endoscopy under sedation and Diagnostic Transnasal Esophagoscopy without sedation are based on published Medicaid data reporting that CPT codes 43239 and 43198 are reimbursed at the same rate. To account for inter-state variability, one of three example scenarios is used: Option 1 = $1,487, reference state is CO; Option 2 = $867, reference state is NY; Option 3 = $655, reference state is MS. 
  5. The default value for Medicaid Facility Reimbursement, Additional Diagnostic or Therapeutic Procedures is estimated by calculating the difference between the known commercial health plan average reimbursement payment from Optum Health data and published Medicare reimbursement for CPT 43239 for the three given scenarios and applying that differential which equals to the estimated commercial reimbursement for a diagnostic Colonoscopy, CPT code 45380. This results in the following: Option 1 = $1,833 ($4,700 x 0.39); Option 2 = $1,081 ($4,700 x 0.23); Option 3 = $799 ($4,700 x 0.17).
General Assumptions: 
  1. Assumes that the average reimbursement for a diagnostic TNE will be less than a diagnostic transoral sedated endoscopy using CPT codes 43198 and 43239 respectively.
  2. Assumes every TNE conversion is replaced by an additional procedure, using a Colonoscopy as a proxy, CPT code 45380.
  3. Assumes that your new TNE patient population might have a different payer mix than your overall payer mix and can be calculated separately.
  4. Assumes TNE demand from new patients is 1% of total upper GI endoscopy volume. and uses weighted by user-selected TNE Payer mix.
  5. Assumes every TNE conversion is replaced by another procedure on a 1:1 basis.
  6. Assumes every sedated to TNE conversion frees up 45 minutes of block time.
  7. Annual TNE Conversion revenue is calculated using customer inputs and assumes 15% year over year growth.
  8. Annual New Patient Revenue is calculated using customer inputs and assumes 30% year over year growth
  9. Assumes TNE demand from new patients is 1% of total upper GI endoscopy volume. and uses weighted by user-selected TNE Payer mix.
  10. Assumes every TNE conversion is replaced by another procedure on a 1:1 basis.
  11. Assumes every sedated to TNE conversion frees up 45 minutes of block time.
  12. Annual TNE Conversion revenue is calculated using customer inputs and assumes 15% year over year growth.
  13. Annual New Patient Revenue is calculated using customer inputs and assumes 30% year over year growth