Mary Kerrigan, business office manager at Mokena, Ill.-based Center for Minimally Invasive Surgery, highlights challenges surgery centers face in receiving the appropriate reimbursement and steps they should take throughout the revenue cycle process.
Question: What are some pitfalls ASCs make that made impede their ability to receive the appropriate reimbursement?
Mary Kerrigan: This is a loaded question and a great topic for discussion…where to begin? Understanding your contracts, and administration thereof, is key to evaluating expected and appropriate reimbursement (i.e., Are implants included? Is reimbursement appropriate for the cost to perform the case? Are there payer medical/reimbursement policies that need to be considered? Any contract limitations?)
In order to understand your contracts, payer policies and reimbursement anticipated, complete and correct assignment of applicable codes to the scheduled procedure (by the facility) is a must. (Any and all coding possibilities should be included). This is the information that leads to everything else that must be considered and evaluated. Adhering to any applicable timely filing guidelines and specific payer billing requirements is also essential for appropriate reimbursement.
Q: What does your ASC do every case to receive the maximum reimbursement?
MK: Each and every phase of the revenue cycle needs to be thoroughly regarded — The "Before the case," the "During the case" and the "After the case." Some highlights include:
"Before the case" includes all that was listed in the question above and much more. "Vetting cases" thoroughly is key. Verifying correct demographics and payer information, and ensuring that all required authorizations, pre-certifications and predeterminations are obtained, in advance of the scheduled procedure date, is essential. Communicating the patient's responsibility and having a policy to address payment due is also beneficial.
"During the case" would include a re-verification of information, eligibility and collection of any payment due at registration. Timely and complete documentation of all procedures performed, accurate coding and capture of all billable services, with timely and complete bill submission (including all necessary information) is essential.
As for the "After the case," ensure there are no claim billing rejections due to edits or missing information, ensure the payer is in receipt of claim and processes timely, verify reimbursement is correct and timely appeal of any low reimbursements/claim denials. Have a collection policy in place to insure collection of patient balances. After the case is closed, it is a great opportunity to analyze retrospectively to learn from any issues that may have been encountered along the way, to address and improve moving forward.
Q: How do you see payment faring for surgery centers moving forward? Are more payers engaging in contract negotiations with ASCs?
MK: With healthcare reform and payment methodologies changing at lightning speed, it will be incumbent on the ASC to be engaged with industry changes and trends, and in particular; coding updates that may impact how payers reimburse. Any impacts on existing contracts should be considered, as well as any new procedures being added as a new service line to a center. As more payers are following Medicare and/or a Medicare-payment based methodology, the disparity between ASC and hospital outpatient department rates is of concern. Moreover, as Medicare adds additional procedures to the ASC payable list, such as multilevel anterior cervical discectomy and fusion procedures, the challenge is to advocate for adequate reimbursement (as additional levels are considered packaged with no separate payment being made) for these procedures as well as for any future additions to the ASC payable list.
Learn more from Ms. Kerrigan at the 24th Annual Meeting: The Business and Operations of ASCs in October 2017. Click here for more information.