When evaluating claim denials, ASCs should focus on payers and their individually negotiated contracts, according to Will Israel, vice president of enterprise analytics solutions for The SSI Group, a revenue cycle management service provider.
Mr. Israel told Becker's ASC Review what centers should know about avoiding and resolving denials.
Note: Responses have been lightly edited for style and clarity.
Question: What are the top reasons ASC claims are denied? Are there certain codes or procedures that commonly result in denials?
Will Israel: The top four reasons claims are denied in ASCs, by category, generally are:
1. Non-covered charges (Adjustment reason code 96)
2. Duplicate claim/payment (Adjustment reason code 18)
3. Medical necessity (Adjustment reason code 50)
4. Timely filing (Adjustment reason code 29)
That covers that vast majority of denials in ASCs. Certain codes and procedures can certainly potentially result in denials, but payers are more important, generally, than codes and procedures.
Q: What steps can ASCs take to ensure their claims aren't denied?
WI: One important step is to have better process design on getting claims out, particularly around claims scrubbing and ensuring that best practice edits are in place to prevent those denials. Additionally, doing better eligibility checks for plan benefits upfront can be particularly useful. In a recent analysis, almost 7 percent of all denials had remark code N130, which is: "Consult plan benefit documents/guidelines for information about restrictions for this service."
Q: Which coding/reimbursement changes made in the past year are most important for ASCs to know about?
WI: Coding and reimbursement changes that ASCs need to pay the most attention to are the ones that apply specifically to each of them individually. That may sound like a circular answer to the question, but it is not. The individually negotiated contracts are what actually cause the coding and reimbursement changes, so understanding what, exactly, is in each of their respective contracts will likely have the greatest impact on understanding where and what those changes might be.
Q: What step in the revenue cycle do ASCs struggle with the most?
WI: Follow-up seems to be a key area that ASCs have trouble running down. The number of hats personnel wear in the ASC space means that denial follow up isn't usually top of mind. Review denials and dollars to try and evaluate whether or not actually bringing in someone with this specialty is worth considering.
Q: What is your No. 1 piece of advice for ASCs trying to maximize their payments?
WI: It's two-fold: one, make sure the claims going out the door are clean, and two, follow up on the denials that are actually worth following up on. Preventing easy mistakes (e.g. missing information) on the claims going out means they don't have to be worked on the back end, and those accounts that really need additional looks can be focused on.
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