In order for an ASC to operate efficiently, there must be processes in place to allow the business office to effectively perform its job functions. Several best practices should be considered when assessing and developing measurable processes for the business office. Effective communication, teamwork and management oversight are essential for a successful ASC.
1. Qualified/Experienced Staff. Find appropriate personnel to fill all positions of your business office and establish clear expectations prior to hire. High turnover rates can result in considerable costs due to a loss in productivity and new employee training. ASCs often find it difficult to hire experienced business office staff such as coders and billers because its budgets for these positions are unrealistic. Smaller ASC facilities not able to compete with larger ASCs or hospitals should consider buffering a lower salary or hourly rate with a strong benefits package or additional perks. Let's quickly review a few key business office positions:
• Scheduling. Case volume can be directly impacted by the daily actions made by the employee in this position. Physicians want "easy" so the scheduler should strive to create a user-friendly, efficient experience. If the scheduling process is too cumbersome, the physician or his scheduler may opt for a different facility or hospital that doesn't require jumping through hoops. Most ASC facilities have implemented either a hard-copy or electronic scheduling form that the physician office utilizes rather than the traditional phone call.
Since the scheduler has a direct relationship with physician office staff, it is important to monitor the scheduler and assess relations with the physician office. This is achieved easily by communicating directly with the surgeon and/or the physician office scheduler on a regular basis to determine whether there are any issues. If emails are utilized between the schedulers, it is important to review emails particularly since emails are so easily misinterpreted.
• Insurance Verification & Precertification. An ASC should not depend on the physician's office for insurance verification or precertification of the procedure. There's a big difference in whether the patient has insurance coverage versus whether a surgical procedure is "covered" according to the insurance policy. An insurance verifier needs to know the appropriate questions to ask.
Protocols should be established when there is a significant lapse in time from the initial verification of coverage until the date of the surgery. A patient eligible for coverage in June may not be covered for a procedure performed in July. Deductibles that are met in December are fully collectable in January of a new year. If the insurance verifier doesn't provide or isn't asked for the date of the service, the information received from the insurance company can be misleading. An ASC should establish a policy for verification/precertification to include a re-verification process pending the number of days out from the scheduled procedure (new month/new year).
Be up front with collections. Notify the patient in advance of his estimated financial responsibility to the ASC with payment due on if not prior to the date of service. Patient responsibility should be calculated utilizing the most updated contract and policy information. While most facilities offer payment plans for patients who cannot afford to pay their responsibility, payment plans should not be the first option. Provide the methods of payment traditionally accepted by the facility first. Do not make the mistake of asking a patient if they can pay their estimated portion. Instead, advise "We accept all major credit cards, checks, cash and have financing available through ABC Credit Services." A payment plan should be the last resort.
To avoid any additional surprises for the patient, inform the patient of the potential for separate fees for services performed by the surgeon, anesthesiologist and pathologist in addition to the fees for the ASC facility. Some ASC facilities reiterate the potential for separate fees once the patient arrives at the facility or as part of its "new patient" information package online.
• Registration. Customer service is essential to the success of an ASC. In many cases, the patient's first person-to-person contact in the ASC is with the front desk staff. It is crucial to have professional, personable, sympathetic and compassionate team players in these positions. The ASC may have the misconception that it can put "anyone" in this position to hand out a few forms and verify the information, but will that same person take the necessary time to reassure the patient when needed? Patients do not want to feel as if they are being run through an assembly line of sorts during their surgical experience.
Patients typically experience a measure of anxiety upon arriving for their procedure. Spending time filling out forms can add undue stress. Many ASC facilities are including some pre-registration and instruction forms online for patients with computer access to review and complete prior to the date of surgery. Pre-registering minimizes the time the patient spends filling out forms and reduces the number of errors made the morning of surgery due to nervousness and lack of concentration. This will also help reduce delays in the reimbursement process.
• Coding. The ASC coder must be experienced with the case mix of the facility. Consider testing coding applicants with actual operative reports from your facility case mix prior to making an offer. This will not only provide a baseline of the coder's knowledge and comfort level of the procedures, but also reflect the amount of time it takes for the coder to code the cases. Facilities looking to outsource coding should interview potential coding companies as to ASC experience.
Operative reports should be coded within 24 to 48 hours from the date of the surgery. Determine accountability for delays in coding (i.e. coder, physician or transcription issue). Establish a protocol to track all cases that have not been dictated and a policy for outstanding dictation.
Establish a query process for deficient documentation. The coder is the most knowledgeable of those surgeons providing ambiguous operative dictation and should keep track of the issues. Management should incorporate coding reimbursement/documentation issues and its financial impact as part of the medical executive committee meetings held by the facility.
Facilities should adopt a standardized method to measure coding quality performance. A coding audit will serve as a baseline indicator of coding accuracy, by identifying root causes for coding errors, which should decrease variance and increase reliability. An audit will identify strengths and weaknesses of the coder, biller and physician (documentation), thereby facilitating the establishment of education goals.
2. Billing. Timely and accurate billing is critical to reduce or maintain low AR days. All claims should be filed no later than three business days of the DOS if not sooner pending ASC facility protocol. Track unbilled cases at mid-month and again during the month-end process. Running a mid-month unbilled case report may alleviate month-end close delays.
Managed care contracts should be properly loaded into the patient accounting system to ensure accurate calculations are being made and contractual write‐offs are occurring at the time of billing. The biller should watch for discrepancies in contractual write-offs and communicate contract errors within the system to management.
The biller should be diligent in reviewing the exception report for each electronic billing submission and correct any areas identified as soon as possible It is recommended that the biller maintains a transmission log to establish timely filing of electronic claims submissions in the event a problem occurs.
3. Communication. Don't become a complacent facility in which the left hand doesn't know what the right hand is doing. Schedule weekly or monthly office meetings for business office staff to discuss challenges, share information and problem-solve. Discuss managed care contract updates, payer challenges, coding/billing issues, collection goals, denial trends. Understanding the job function of the other support staff within the business office goes a long way in improving its overall function.
4. Managed Care Contracts. An ASC should maintain its contracts and keep them in a central area of the business office. The business office staff should have access and understand the portions of the contract applicable to daily job responsibilities. For example, should it receive a denial for separate reimbursement of an implant, the denials department will need to know if its ABC contract allows for separate reporting and reimbursement of implants. The business office manager should ensure the business office staff receives any revised contract information and/or updates.
Create an insurance grid for business office staff to include the type of contract plan, dates of termination, rates/fee schedules, exclusions, carve outs, precertification requirements, implant reporting, Category III reporting, unlisted procedure reporting, AMA versus CMS acceptance.
The ASC should include the coding, denials, and materials managers in its contract negotiations. These departments know the issues and can provide insight regarding the implants, supplies, and procedures that may require a more strategic approach for capturing reimbursement.
5. Supply Costs and New Procedures. Procedure selection is important to ensuring successful cases in the ASC. Focus should not be placed primarily on the clinical performance requirements of a new procedure. Procedures introduced without aggressive financial analysis can spell disaster. An ASC must calculate supply costs before adding a new procedure. The costs of supplies and/or implants must be compared to the actual insurance reimbursement for the surgical procedure. An ASC should initiate negotiations with its carriers as early as possible since the process can be time-consuming.
Vendor reimbursement information/coding directives should not be utilized for new procedures without an ASC performing its due diligence and verifying the credibility of the information from a reliable source.Therefore, it is essential to notify the coder of any new procedures and/or specialties brought into the ASC. The coder should be involved in researching the appropriate coding and billing for the procedure according to carrier directives.
It is critical that the surgeons are kept updated on new procedures approved by Medicare for reimbursement in an ASC so that they bring all eligible procedures to the facility. Surgeons must also be kept updated on procedures that should not be brought to the ASC due to little to zero reimbursement.
6. Productivity and Performance Standards. Performance standards serve as diagnostic tools and goals to ensure success. All staff should work in coordination to meet these standards on a consistent basis.
Management should conduct monthly internal reviews of its patient accounting system to verify the credibility of the notations. Review insurance verification, financial responsibility, insurance follow-up, and collection notations. Establish universal abbreviation/notations that your business office will utilize when entering notations. Nothing is worse than not being able to decipher a notation. "CLD BC PT DED 2500W500 MET-PT2C&C" doesn't automatically translate to read "Blue Cross was contacted. Patient has met 500.00 of a 2500.00 deductible. Patient will bring in his portion." Even the latter isn't detailed as to the specific monetary amount due at the time of service. Notations should be concise, detailing only essential information.
Monthly goals should be displayed within the business office to include daily collections, the days in AR and monthly case volume expectations. It is interesting to see the number of ASC facilities that do not include the business office team in the monthly cash goal process. There is nothing better than some friendly competition to encourage staff to go just one step more to achieve its collection goal. Display the monthly collection goal to include all daily collections. Some ASC facilities offer an incentive if the goal is met for the month in the form of a luncheon or casual dress day. Simple yet satiating.
AR days should be maintained within corporate standards. A common benchmark for the ASC industry is under 50. Closely monitor AR buckets. Accounts should be worked by priority of age and value with AR in the over 120 day bucket being minimal.
7. Outsourcing. A facility should look at its available resources when determining whether to outsource any of its business office departments. ASCs may outsource coding, billing or collections as either a cost-savings or to meet staffing challenges posed by the need for specialized training or staff limitations. Productivity and performance standards are expected of coding, billing, and collection vendors in regards to turn around times/accuracy rates, timely filing, and monthly reporting respectively.
Whatever the motivation for outsourcing a portion of the business office, transmission of confidential protected health information outside of the facility places an obligation on the facility to ensure these companies protect the confidentiality of patient information. As a partner with the ASC, vendors should sign a Business Associate Agreement. The agreement should stipulate exactly what the information will be used for and that it will be safeguarded against misuse. Request the vendor’s policies & procedures for the electronic transmission and destruction of PHI.
Ensure that any contract with a coding, billing or collection company obligates the company to not only maintain confidentiality itself, but require any person or entity to which the company sends information to maintain confidentiality and security of information. When applicable, the facility should consider placing restrictions on the use of subcontractors by the company, explicitly requiring that any subcontractor receiving PHI from the company be physically located within the United States. The company's subcontractors should also be prohibited from sending any of the facility's information outside the United States. Entities outside of the United States are not necessarily required to adhere to the Health Insurance Portability and Accountability Act (HIPAA).
Cristina Bentin, President
Coding Compliance Management
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