Key Takeaways
- Clinical excellence and financial sustainability must coexist. Ethical wound care requires balancing evidence-based treatment with reimbursement realities, coverage policies, and operational considerations without compromising patient outcomes.
- Documentation is the strongest defense against denials and audits. Thorough, policy-compliant documentation, close collaboration with billing and coding teams, and timely responses to audits and denials can help protect practices from costly payment recoupments.
- Start with the fundamentals before advancing to higher-cost therapies. Addressing foundational aspects of wound care—including vascular assessment, edema management, nutrition, and offloading—not only improves patient outcomes but also supports appropriate use of advanced therapies and reimbursement success.
Transcript
Please note: This content is a direct transcript, capturing the authentic conversation without edits. Some language may reflect the flow of live discussion rather than polished text.
Jayesh Shah, MD:
Welcome back to WoundConversations where wound care professionals come together to learn, share, and advance the practice of healing. I'm your host, Dr. Jayesh Shah. In today's episode, we are continuing our conversation with Dr. Helen Gelly, this time focusing less on terminology, more on decision-making relevant to the business of wound care. One of the realities clinicians eventually discover is that wound care exists at the intersections of science, ethics, operations, reimbursement and sustainability. Those realities can feel uncomfortable at times, especially for clinicians who simply want to do what's best for patients. Today we'll explore how experienced clinicians navigate that balance thoughtfully, ethically, and practically. WoundConversations is brought to you by WoundSource and WoundCon, helping clinicians stay connected to trusted education, practical insights, and the evolving landscape of wound management. As our returning guest, Dr. Gelly has been involved in wound management and hyperbaric medicine since 1991 and has shared her knowledge and experience through multiple leadership and educational roles.
Last time we touched on key definitions and frameworks. Let's just jump back into the conversation. Helen, welcome back for part two of our discussion.
Helen Gelly, MD:
It's nice to be back. Thank you.
Jayesh Shah, MD:
In our first episode, you shared wound care why with us. To kick things off in the same spirit, but advance the discussion, was there a moment in your career that really drove home the importance of understanding the business and regulatory structure of medicine?
Helen Gelly, MD:
Well, in the late 1990s, CMS arbitrarily reduced physician payment for hyperbaric supervision to zero and reduced hospital payments by about 60%. And for me, even though they reversed those positions, it was really the first wake-up call that we as hyperbaric physicians, as wound care physicians, were not immune to scrutiny and that we needed to be better prepared and more aware of the process in which payment is determined, how policies are developed, how policies are implemented on national level, at the AMA in terms of physician work, which is usually determined at the AMA RUC meetings. So we have had numerous challenges in both arenas and now especially with wound care, as you know, there's been a lot of focus on debridements and cellular tissue products and compression dressings, lymphedema management, and these are not going away. And if we don't know or are not engaged in the process, then our voices won't be heard and we're going to be left behind.
So I think that that's why it's imperative that all of us try and contribute to the conversation when we have these issues.
Jayesh Shah, MD:
Very nicely said. Dr. Gelly, most physicians and providers really just want to do wound care or hyperbarics, take care of the patients, heal the patients, but do you think the reimbursement structure influence clinical decision-making in wound care for better or worse? And if so, why?
Helen Gelly, MD:
Well, the reimbursement structure rarely is for the better lately because physicians have been taking cuts in reimbursement now for the last 15 years, if not longer. But let's just discuss the worst case scenario. So the recent worst case scenario has been with cellular tissue products or CAMPS. Overutilization, potential fraud and abuse have significantly affected the use of these products. So despite the fact that they've helped countless patients when used appropriately now because the use of these products is under microscopic review by most of the insurance plans and especially by CMS, many clinicians are shying away from using them, limiting access to the patients that need them, and I think potentially impacting outcomes. So the decision when you decide whether or not it's appropriate to use the product, now the next question is not just whether or not it's appropriate, it's important to know whether or not you're going to be paid adequately to cover the invoice of the cellular tissue product.
So these decisions are being driven by financial considerations, not only in the product choice, but also in the patient selection.
Jayesh Shah, MD:
Okay. So is it realistic to separate clinical care entirely from financial realities?
Helen Gelly, MD:
It is impossible.
Jayesh Shah, MD:
That's a good word. Yeah. I think clinicians experience the most tension because of all the things that you described. What is your opinion about that?
Helen Gelly, MD:
Well, I think that the thing that is the underlying constant irritation is the request for documentation and medical records prior to or after payment. And additionally, now many of the carriers are routinely down coding E&M charges. I think we all need to be aware of that. And that these changes in payment can be quite surreptitious. They don't necessarily say that they're paying you at a lower code, they just pay you less. And so your billing and coding people need to be very, very careful that they track what you billed and what you collect. And in addition, there has been an increase in audits in all aspects of wound care debridements, in hyperbaric oxygen therapy or treatment. And so you have to maintain vigilance in knowing what the policies are, but also being very careful that you watch what is being denied. And if you do get an audit, you need to be aware of the timeframe because it's not forever.
You have to respond sometimes in 30 days, sometimes in 45 days. And if you don't respond or you ignore the request, they're going to take their money back. So we have to look at audits like a notice from the IRS. You have to sit up and take and pay attention because otherwise they will just start taking money out of your future payments.
Jayesh Shah, MD:
So it's really hard when you provide a service, you're already given your time, you're already sometimes even paid for the supplies, and they may take everything back. Is that true?
Helen Gelly, MD:
It is true. But your best defense is a good offense and the good offense is how you do your documentation. And you have to be aware of what the policies are and then comply with whatever the requirements are in terms of documentation and what makes financial sense. So for example, people need to understand that in cellular tissue products, because they're being charged as a line item, they will be influenced by something called the geographic index. So if you are in Alabama, you get paid less for the same service for the same product than if you lived in California. But unfortunately, the company is charging you the same amount no matter where you are. So you have to be very careful that where you're practicing and that geographic index doesn't put you in the red in some of these products and some of not only CTPs or camps, but also with compression dressings, et cetera.
Jayesh Shah, MD:
All right. Can you tell us, Helen, how coverage policies may shape treatment pathways or product selection?
Helen Gelly, MD:
Well, if the coverage policy changes, for example, in the most recent one that is impacted wound care is cellular tissue products where CMS maxed out or stated that the $127 and change per square centimeter of product no matter what the company is charging. So that automatically has limited what's available to you without losing your shirt. Likewise in the hospitals, they're not going to lose money no matter how good the product is, they're not going to lose money consistently unless there's an overwhelming reason why the patient should get this. And so if you can find another product in the same category that's less expensive that would work as well, then we're going to change the way we practice in order to accommodate these new policies, the coverage policies or payment policies.
Jayesh Shah, MD:
When you're in medical school, you always think about the science and how things are evidence-based and how that should really decide what your patient should get. And now you come in the real world and now you're thinking coverage policies. Probably that's causing the burnout on all these physicians and providers. Tell me what is the risk of reimbursement as a primary driver?
Helen Gelly, MD:
The main risk would be overutilization and using inappropriate clinical options. So the only thing you see is that it's financially advantageous. Then you're putting yourself at risk for the government, OIG, the Department of Justice to come back and say, show me why this was necessary. That's the driver.
Jayesh Shah, MD:
So I think it looks like what you're saying, if you do a sound clinical medicine and follow the right thing, you probably will stay out of trouble. It's agreed or if your decision starts becoming more based on financial issues, then you can get into trouble. But how can reimbursement structures also create positive accountability?
Helen Gelly, MD:
Well, I think what it drives you to do more precise evaluations and choices for both the procedure and the product that you're utilizing, it needs to match the patient's needs and shouldn't really reflect a high pressure sales pitch. So if you are sure that a specific product or a specific procedure is the best option for the patient and you can document it and it's covered, I think you have less risk. But unfortunately we're all subject to some pretty high pressure sales pitches. And what they don't tell you is that you're the person dropping the claim. The physician is the one who's ultimately responsible for dropping the claim. So if there's any issue of fraud and abuse, the manufacturer or the distributor or the salesperson, they're scot-free. It's on the back of the person who dropped the inappropriate charge. So just be wise in your use of these procedures or products and decide whether or not there is adequate science behind it and adequate coverage.
Jayesh Shah, MD:
I appreciate the nuance there because this is rarely a simple “good versus bad” conversation. Most clinicians are trying to do the right thing for patients while also working within this real operational constraints trying to keep the lights on. So thank you for that great conversation. But for clinicians who want to do what's best for patient but also needs to keep a practice viable, how do you personally approach that balance?
Helen Gelly, MD:
We've make sure that we've exhausted all reasonable and basic interventions before we advance to higher levels of care. So we do nutritional interventions, edema control, offloading, all of the things that have a significant impact on outcomes. For example, all lower extremity ulcers need a vascular assessment. And if you look at the literature, between 50,000 and 70,000 amputations occur every year in patients who've never had a vascular assessment. And over 50% of the patients that have a lower extremity ulcer never get studied. So these very basic things help us to make sure that we have checked all the boxes necessary so that when we do the advanced therapeutics, we will get paid because we've proven that we've corrected everything that can be possibly addressed. It's still not working and now we're going to try whatever X, Y, Z that we're going to do to get this patient to heal.
So if you appropriately document all of the interventions that you've done, all of the things that are clinically appropriate, then I think that financial viability will follow because you may get audited, but you will pass and so money will not be taken back.
Jayesh Shah, MD:
So if you could give one piece of business advice to a newer wound care clinicians to help them avoid costly mistakes early on, what will it be?
Helen Gelly, MD:
Well, you need to establish really good communication with your billing and coding people. It is essential that you have them review the medical records that you create for compliance. This is a second look at what you've documented and they're comparing it to what is required for payment. And if they have concerns, believe them. You need to change the way you're documenting and not pull the I'm the doctor card and say, I know better than you because this is what these people do for a living. They look at the documentation to make sure that it fits the charge that you're dropping. So they're trying to save you. They're trying to get you paid. And so if you can establish a relationship with your billing and coding department and you listen to them, I think that's invaluable. The other thing is that when denials come, you really need to work every single one.
20% of the claims are denied on the first round, depending on the insurance carrier, maybe between 10 and 20% just because this is their business plan. And if you never appeal it, that's money they've won and money that's not in your bank account. So I would appeal, we appeal every single denial and we take it to the highest level possible. You do not want to leave money on the table.
Jayesh Shah, MD:
Wow, what advice. I just think it just takes the doctor or a provider away from patients trying to do all this administrative work. And it just is not a system that can last because we have such an access issue. So many patients will benefit from doctor doing their doctor thing than trying to do what? Trying to just defend or work on denials. And I understand the frustration from the physician and providers standpoint too, but thank you for your advice. Thank you. Before we close, let's finish with another wound to the wise. From everything we have discussed across these two episodes, what is one final principle or perspective on the intersection of business and medicine that you hope wound care clinicians carry with them as they grow professionally?
Helen Gelly, MD:
Well, on the whole, I would say do the right thing for the patient that's in front of you. Make sure that you take into account their limitations. Make sure you start with the basics. And then you need to approach the problem like a detective. You're looking for the reason why they're coming to see you, the expert, where other people have potentially intervened but they've not had a good result. So you have to think outside the box, you have to be creative. And if you do all of these things, you're going to become a better practitioner and the patients are going to have better outcomes.
Jayesh Shah, MD:
So that's such a meaningful perspective because success in wound care isn't only about technical knowledge. It's also about learning how to think critically, practice ethically, communicate clearly and continue evolving. Dr. Gelly, thank you again for joining us and for sharing both practical guidance and thoughtful perspective with our audience. And thank you to everyone listening. We hope this two-part conversation helped make the business realities of wound care feel more understandable, approachable and actionable. Be sure to explore additional clinical and professional education resources at woundsource.com and check out upcoming accredited virtual learning opportunities through WoundCon. You can find this and future episodes on woundcon.com, SoundCloud, Apple Podcasts, and Spotify. Until next time, listen today and apply tomorrow.