Build an ASC revenue cycle on accuracy, efficiency & accountability

The revenue cycle management process is becoming increasingly more complicated as CMS adds codes to reflect the industry's transition into a value-based arena.


Four industry experts spoke on how to improve revenue cycle for ambulatory surgery centers at Becker's 15th Annual Spine, Orthopedic and Pain Management-Driven ASC Conference + The Future of Spine on June 23 in Chicago.

Panelists included:

• Mihir Patel, MD, orthopedic surgeon, treasurer and board member at Indianapolis-based OrthoIndy
• Samir Sharma, MD, co-founder of Chicago-based Pain & Spine Institute
• Lisa Rock, president of St. Louis-based National Medical Billing Services
• Jocelyn Gaddie, vice president of development at Overland, Kan.-based in2itive Business Solutions

Low-hanging fruit in coding and billing
To stay ahead of the value curve, ASCs should ensure they are evaluating their entire RCM process for inefficiencies and trouble points.

"The first and the simplest thing, is looking at the beginning [of the RCM process]," said Ms. Gaddie. "In terms of verification, you really want to make sure you have a robust process in place for your revenue cycle."

To establish a sound insurance verification process, first ensure providers are entering patient information correctly every time. Additionally, inform patients of the payment due at time of service.

"In your surgery center, you want to have strict policies in place of what that financial responsibility is and that you're providing that [information] to the patients in a timely, manner," added Ms. Gaddie. "It's so much easier to collect the money on the frontend than having to chase it on the backend."

Ms. Rock agreed that ASCs should first focus on insurance verification, identifying who is paying the claim at time of insurance verification. Many organizations run into issues because no one knows who is paying.

"This is what you need to know. If you arm yourself with knowledge on the frontend, then you are going to have fewer problems on the backend," said Ms. Rock.

From a physician standpoint, Dr. Sharma said he and his colleagues learned about their practice's costs, including every cost from the front office to the procedural setting.

"You have to understand where costs can be contained, so we learned to run a very effective, cost-containing [practice]," said Dr. Sharma.

For Dr. Patel's group, the main focus revolves around getting the bill out. OrthoIndy implemented a creative incentive to push quick dictations — a 24-hour dictation rule for physicians equipped with a $50 fine if missed.

In addition to the fine, OrthoIndy established journal clubs for quarterly coding and billing presentations highlighting specific codes.

This physician education is especially important to improve a RCM process. Ms. Gaddie said in2itive holds sessions with coders and physicians to bridge the gap between action in the OR and documentation for billing.

Balanced billing
Balanced billing allows a physician to bill a patient for an outstanding balance after the payer submits its portion of the bill.

In the spine field, patients are often not cured, but rather require treatment throughout their lives. Therefore, Dr. Sharma noted his practice tries to be fiscally cognizant of patients' situations.

"Medical procedures can be a big financial hit to patients," explained Dr. Sharma. "We tend to take a more conservative approach in terms of up-front collections."

OrthoIndy providers offer a preop cost estimate. The group also employs a billing and coding team who discuss costs with patients.

Health IT and data
The revenue cycle field is increasingly leveraging IT solutions to improve accuracy and efficiency.

"Billers are hard to find and it's labor intensive," explained Ms. Gaddie. "And there's human error." She suggested ASCs consider automation any time an opportunity arises.

Dr. Sharma's practice has an in-house billing team. By leveraging data, the practice is able to control costs and see exactly when they should switch gears for improvement areas.

Via an EMR, Dr. Sharma's practice gathers outcomes data — follow-ups, outcomes, hospital admissions, etc. — and proves to payers they are a less-expensive alternative to hospitals.

Ms. Rock recommends surgery centers with at least 200 cases use an ASC-specific RCM software system. National Medical Billing Services is currently collecting data to pinpoint who is paying the claim.

"Upfront, we are trying to figure out a way to capture the employer name, and figure out how the employers are paying their claims," explained Ms. Rock. "Projecting that revenue today is critical for surgery centers."

National Medical Billing Services pulls robust data from systems and reviews it all daily, including cash, electronic data interchange and weekly reports with missing information. Additionally, at the end of the month the company identifies payer and cash trends.

RCM take-home points for ASCs
The panelists left the audience with four key takeaways:

1. Establish RCM processes. Whether an ASC keeps RCM in-house or outsources it, Ms. Gaddie urged practices to create strict processes with defined roles.

2. Outpatient has arrived. The shift from hospital to outpatient is in full swing, and Dr. Sharma suggested ASCs be ahead of the curve. Physicians are ultimately responsible for accurate coding because if coding is incorrect, the ASC won't receive adequate reimbursements.

3. Accountability. To successfully manage the RCM process, Dr. Patel believes accountability is a must from the front staff to physicians. Everyone is responsible for coding and billing and the potential mistakes, so he suggested engraining accountability into an ASC's culture.

4. Manage handoffs effectively. Saddled with a multitude of handoffs, the revenue cycle involves a variety of people, from physicians to the front office staff. Because of so many RCM handoffs, ample opportunity exists for mistakes. Ms. Rock recommended ASCs analyze each individual function and ensure efficiency and accuracy at each step.

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