1. Assure assignment of benefits. Make sure the patient signs an assignment of benefits form with language that allows the ASC to sue the payor for funds on behalf of the patient. The proper language can be found on a reputable assignment of benefits form. If the center creates its own language, the authorization might be too vague to stand up in court and the insurer could ignore the ASC’s charge and pay what it wants.
2. Have the right fee levels. Make sure the “usual and customary” fees you charge for OON services are not out of line for the industry. The ASC could have a weak case if its fees are set unreasonably high.
3. Document the preauthorization call. When ASC staff members make the preauthorization call to the insurer, they need to document that the insurance representative verified coverage and explained the company’s OON policy. Documentation will mean that the insurer cannot come up with a different policy later and claim that the ASC was informed of it. Documenting the call could involve writing in a log. Better yet, Dr. Pliura recommends reading from a script and tape-recording the conversation. Be aware tape-recording will require alerting the other party by saying, “This is being recorded for quality and business purposes.”
4. Follow the internal appeals process. Following the payor’s own internal appeals process involves obtaining a copy of the patient’s agreement with the insurer, studying it carefully and meeting all deadlines for appeals in it. The internal appeals process must be exhausted before going to court. If the ASC did not follow the payor’s appeals process, it would have little legal standing and the insurer wouldn’t feel obliged to pay its share of the bill.
Contact Dr. Pliura at tom.pliura@zchart.com.
