The business case behind every service you offer

What drives contribution

• Per-case device or handpiece cost, which is often the largest single line and is contract-negotiable.
• Platform capital and whether it is purchased, leased or placed.
• Realistic monthly volume from your own referral and leakage history, not from market estimates.
• Site of service, which changes both the payment structure and who captures the facility component.

Where it goes wrong

• Prior authorization is commonly required by commercial payers and many Medicare Advantage plans, and criteria differ by technology.
• Documentation of prior therapy trials and symptom scoring where payer criteria require it.
• Reauthorisation when treatment is staged or delayed past the approved window.

What drives contribution

• Room and scope turnaround — reprocessing time, not procedure time, usually sets how many you can do in a session.
• Scope fleet size relative to session volume; one scope in reprocessing is one scope not in a room.
• Whether flexible or rigid, reusable or single-use, and what that does to your per-case consumable line.
• Whether a separately identifiable E/M is genuinely performed and documented on the same day.

Where it goes wrong

• Modifier 25 on a same-day E/M is heavily scrutinised and frequently under-documented.
• Therapeutic add-ons unbundled incorrectly are a common source of modifier 59 denials.
• Diagnostic versus therapeutic code selection driven by what was found rather than what was done.

What drives contribution

• Studies per week against the fixed cost of the system — this line lives or dies on utilisation.
• Technician time and whether that role is dedicated or shared with clinic.
• Component selection: which elements of a complete study are performed and documented.
• Referral pattern — a service with no internal referral base is a capital risk.

Where it goes wrong

• Component codes billed without the documentation to support each element performed.
• Medical-necessity criteria that several payers define narrowly; check current policy before scheduling.
• Supervision requirements for technician-performed components.

What drives contribution

• Slot length and how many fit a session; this is a template design question.
• Point-of-service collection where the balance is patient responsibility.
• Post-procedure semen analysis pathway and whether it is performed in-practice.
• No-show rate, which is typically higher for elective, long-lead-time procedures.

Where it goes wrong

• Coverage varies widely by plan; verify benefits before scheduling rather than after.
• Uncollected patient balances that cost far more to chase later.
• Follow-up analysis billed without a clear order and result pathway.

What drives contribution

• Surveillance recall reliability — patients lost to follow-up are lost contribution and a clinical risk.
• Agent acquisition and supply for instillation therapy, including periods of constrained supply.
• Whether pathology and imaging are retained in-practice under a compliant arrangement.
• Administration time and nursing capacity for instillation series.

Where it goes wrong

• Drug administration and supply reported inconsistently with payer rules.
• Surveillance intervals outside payer-recognised frequency limits.
• Documentation supporting medical necessity across a long treatment course.

What drives contribution

• Approach and setting, which policy has repeatedly treated differently.
• Whether imaging guidance and any fusion technology is owned, leased or provided by someone else.
• Whether pathology is retained in-practice under a compliant arrangement or exported.
• Consumables per case: needle sets, guides, antibiotic and anaesthetic protocol.

Where it goes wrong

• Specimen counting and pathology unit reporting are a recurring source of underpayment and audit exposure.
• Imaging guidance billed separately without documentation of what was actually performed.
• Setting-specific rules that change what is separately payable.

What drives contribution

• Drug acquisition arrangement and the spread against expected payment — practice-specific and time-specific.
• Wastage and unit reporting on partially used vials, where separately reportable.
• Repeat-treatment interval and whether recall is systematically managed.
• Whether the authorization function is staffed rather than squeezed between other duties.

Where it goes wrong

• Prior authorization almost always required, with documented failure of prior therapy.
• Drug units and discarded amounts reported inconsistently with payer rules.
• Starting therapy before approval is confirmed, which puts acquisition cost at risk.

What drives contribution

• Device cost for implantable therapies, and whether staged trial and permanent phases are both captured.
• Series completion rate for office-based therapies — an abandoned course is largely lost contribution.
• Scheduling density: a weekly series only works if the template protects the slots.
• Conservative-therapy documentation, which payers commonly require before approving.

Where it goes wrong

• Staged procedure coding and global-period interactions.
• Payer criteria requiring documented failure of conservative management.
• Series interruptions that break the authorised treatment window.

What drives contribution

• Laser fibre, basket and access sheath consumption per case — a controllable and frequently uncontrolled cost.
• Whether lithotripsy capacity is owned, shared through a partnership, or bought as a mobile service.
• Stent placement and removal pathway, and whether removal happens in-office.
• Imaging performed in-practice versus referred out.

Where it goes wrong

• Missing laterality modifiers on ureteral procedures — a clean, entirely avoidable denial.
• Staged procedures and global-period interactions across the episode.
• Advanced imaging that requires approval before it is performed.