12 Critical Areas of Focus to Increase Your ASC's Reimbursement
1. Fee schedule
Have you reviewed your fee schedule recently? Many ASC fee schedules have deficit areas where they are not charging as much as Medicare would pay. Depending on your findings, this may result in a significant increase in revenue.
Take the time to do a comparison. Prepare a spreadsheet with your fee schedule and the current Medicare ASC fee schedule (wage adjusted for your area). An example (Table 1) is provided below. Determine the multiplier you want to use – this example is using 350 percent.. In the last column, select whichever is highest, as demonstrated by the example below: your fee (green) or 350 percent of Medicare (yellow). You can also consider setting a minimum fee such as the $1,200 illustrated in pink as opposed to 350 percent of Medicare. Prepare a recommended fee schedule and present it to your board.
Note: Depending on area's prevailing fees and your complementation, the multiplier may be varied.
2. Payor contracts
Carefully review your contracts. Start working on your negotiations at least six months prior to renewal date — it usually takes that long. Several critical processes and factors to consider in this process include:
- make a list of your ten most common procedures — do case costing;.
- case cost procedures that you do that are cost intensive (i.e., implants, manhours, OR time, costly equipment, etc.);
- if your figures are based on Medicare rates, they are probably the lower rates from 2006 or before; you'll want to aim for fully implemented Medicare rates (2011) if possible;
- implant reimbursement — at least cost plus shipping and handling; and
- multiple procedure discounts — aim for Medicare rules, 50 percent for all procedures after first.
Depending on how long ago you renegotiated your contracts, you may be surprised at the improvement in revenue you can enjoy by doing some up-front homework and persistence.
3. Insurance verification
Stress the importance of verifying coverage and benefits to your staff. No verification or lack of sufficient information often negates or delays claim reimbursement. In most cases, verification of Medicare coverage online is fine. However, for most managed care companies, usually it's necessary to make human contact to get all the necessary benefit information. Develop an insurance verification form and incorporate at least the following:
|Verify patient eligibility and SS#
||Verify contract holder name and SS #|
|Type of contract – PPO, POS, indemnity
|Second opinion clause
||Precertification or authorization number|
|Amount of copay or deductible met||Coverage percentage|
|Maximum out of pocket amount
|Verify claims address
||Name of contact person|
For out-of-network patients, workers compensation and other types of cases, additional information is required.
4. Patient financial counseling
This is often the first contact between the ASC and the patient, and this call will set the stage for how the patient views the ASC. Be understanding and caring but firm, and follow these best practices:
- Call far enough in advance (minimum of 3 days); be considerate of the fact they may have to adjust their finances.
- Inform them that their company's representative advised you how much of their insurance contract's copay and/or deductible was unmet. Stress the fact that it is their company and their contract but you will gladly submit the claim for them.
- Explain fully their economic responsibility and the center's financial policy of collecting this amount (the fair share) prior to surgery.
- Ask them how they would like to handle payment — offer cash, check, credit cards, healthcare financing (for larger amounts).
- Remember the economy is hitting them hard as well. If necessary, offer the alternative of a signed promissory note with a maximum of 90 days. Holding a note any longer than that is cost prohibitive.
- If they do not have a secondary insurance, remind them that they will also be receiving a statement for the balance that the insurance does not allow.
The success of upfront collections is much greater than trying to collect after the service has been provided. The amount of money that can be saved by not having to send statements is phenomenal.
5. Physician dictation
Get your physicians' buy-in on helping the center obtain optimal reimbursement by providing detailed operative notes. Provide your physicians with hints on dictation to obtain better reimbursement, including:
- spelling of patient's name;
- site orientation (left, right);
- description of complexity (more than one compartment, extra time, complications encountered);
- detailed diagnosis;
- size of excision (not just size of lesion); and
- implant description, etc.
Having a certified coder is your best choice. Having a certified coder who is experienced in ASC or surgical coding is even better. This type of coder can usually optimize your coding and increase your billable revenue far beyond the possible difference in salary of a less experienced coder. A good coder can:
- read and understand the entire operative note, not just the title;
- be aware of possible procedures that may have been performed but not explained fully;
- asks physician if further details might substantiate additional codes;
- understands compliance in coding and billing, and follows all rules and regulations; and
- ensures that all implants and allowable supplies (i.e. x-rays, drugs, etc.) are coded appropriately.
7. Claim filing
Accurate and timely claim filing can increase revenue by sooner realization of spendable income which, in turn, allows revenue investment. Remember these key factors to help ensure efficient claim filing:
- Accurate data entry is imperative. Denials usually delay reimbursement by at least six weeks.
- Delays in filing or refiling a claim cost the center money by increasing reimbursement turnaround time.
- Not meeting timely filing deadlines result in no reimbursement.
8. Payment posting
Again, accuracy and timeliness are key. A meticulous payment poster can save your center very large amounts of money. As you are aware, payors often reject claims for incorrect or no reason and underpay or overpay the claims, seemingly at random. A good payment poster is responsible for:
- determining whether payors are paying correctly — this means a thorough understanding of your contracts;
- immediate follow-up on non-payment or incorrect payments. Don't put them aside for another day — delays cost money;
- accurate and up-to-date contractual adjustments; and
- transferring account balance responsibility to secondary insurances and filing immediately, or transferring account balance responsibility to patient and generating statement immediately.
9. Insurance collections
This position needs an aggressive and determined person. Payers seem to have an inexhaustible supply of excuses not to pay. The ability to determine what is real and what is smoke in invaluable. Getting promises of payments with dates and making payors deliver on their promises are characteristics of a successful collector. Ideally, depending on prompt payment legislation, electronically filed Medicare claims should be paid within 14 days and electronically filed managed care claims within 30-45 days. Here are a few best practices to help improve your collections:
- confirm receipt of claim early — 15 days after submission;
- resubmit if claim not on file;
- depending on state's prompt payment law, first follow-up at 30 days from submission — check status and get date of payment; and
- follow-ups every 30 days thereafter, at a minimum.
10. Patient collections
Getting out an easily understood, accurate and timely patient statement invites prompt patient payments. Confusing and late statements result in the dreaded angry phone call. You worked hard to provide the patient with a caring and comfortable visit to your center; don't risk the "good feeling" they have about the center. Your statement should:
- be professional looking;
- be accurate and easily understood charges and payments;
- include information on what credit cards your center honors; and
- have the phone number to call with any questions displayed prominently.
Make sure the person handling patient financial calls understands the software fully and can bring up the patient account quickly to discuss it with the patient. Financial counselors can often best handle financial calls.
11. Outsourcing billing
Another alternative that is gaining popularity is outsourcing coding and billing. More frequently, surgery centers across the country are outsourcing these tasks to ASC-experienced billing companies who have certified and experienced reimbursement specialists. The cost of this service is outweighed by the increase in reimbursement and, at the same time, alleviating the stress of finding and retaining high caliber staff members.
The current economy is resulting in a decrease in elective surgery nationwide. Your best choice is to make your facility the surgery center of choice — both to the physicians and to the patients. Involve your center's administrator, business office manager and often the medical director in marketing endeavors that are suitable for your center and your community. You may be tempted to do radio, TV or newspaper advertising; however, these types of advertising are often expensive and may not be aimed at your primary target, which are the physicians, not the patients. Suggestions to increase your visibility to physicians and community members include:
- visits to physicians' offices — both ones who work at your ASC and new physicians in the community. If possible, make an appointment to speak to the physician. Drop off applicable literature, scheduling information, block schedule openings, etc.;
- luncheons at the surgery center for physicians' business office staff — give them a tour. Make them aware of how your surgery center provides excellent care for their patient;.
- ask physician owners to perform community seminars that are of interest to possible surgical candidates (knee scopes, sinus surgery, etc.) and hold these at the surgery center;
- make your presence aware by participating in community health fairs;
- if your health department gives flu shots, ask if they would like to have your nurses assist and give them at the surgery center on a day when there are no patients;
- do a monthly or quarterly ASC newsletter for medical staff members, letting them know about changes in staff members, new equipment, better pricing on supplies, etc. Every issue should have an article on one of the specialties that you do at the center; and
- enhance your reputation as a "center of caring" with patients. Make the experience as pleasant as possible. The best way to market to patients is word of mouth.
It's difficult to quantify the effect of marketing on your center's success. However, positive efforts usually result in positive results. The steps outlined above, along with ideas of your own, not only provide welcome diversions for your administrative staff but improve relations with your medical staff members.
Individually, the suggestions outlined here may only result in incremental improvements; however, taken as a whole, they may amount to the difference between success and failure for your surgery center. Stress to your staff that it's important to the financial success of your surgery center that all areas involved in reimbursement function as a well-oiled machine. In these "tighten-your-belt" times, it's imperative that you have experienced employees who are willing to do what is necessary to refine the processes and optimize reimbursement.
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