1. Get paid
for what you should get paid for.
Under the new payment system, ASCs can get paid for many new ancillary procedures and drugs. But ASCs wont get paid unless they know to include these reimbursable items on their Medicare claims.
Im still finding that a lot of people didnt know what things are covered and not covered, says Caryl Serbin, RN, BSN, LHRM, president and founder of Surgery Consultants of America and Serbin Surgery Center Billing. The big thing is that they dont have a mechanism for capturing the charges.
The first step to resolving this issue is for the administrator to go to the Medicare ASC-approved list and identify what procedures and ancillary procedures the ASC performs, and what drugs it uses that are covered by Medicare. When this information is gathered, disseminate it to the entire billing office staff.
I would imagine that there are a lot of ASC coding people who may not even be aware of some of the ancillary procedures they can now charge for, says Judie English, vice president of business operations and a partner in Surgery Consultants of America and Serbin Surgery Center Billing.
If your ASC adds a new surgeon, verify whether this addition will require your list of covered procedures/drugs to include new items, says Ms. Serbin.
Once you have this list developed, now you must address the next challenge ensuring your billers and coders know when a physician performs any ancillary procedures or provides any covered drugs.
You want to certainly encourage your physicians to perform their dictations and encourage the nurses to provide all the information and details about the cases as well. You may also want to consider developing a charge sheet, says Ms. Serbin.
There needs to be a charge sheet to say that you used mitomycin, or this or that,” she says. No system has been put in place to capture the charges for things they didnt get to charge before.
You will want your charge sheet to list just the covered ancillary procedures and drugs that apply to your center. Omit anything that does not apply to your center to keep the charge sheet simple and concise. After a procedure, the nurse can go through the charge sheet and check off the reimbursable items that apply to that particular case.
You used to do this when you charged for supplies back when we originally could bill for supplies with Medicare many moons ago, says Ms. English. We always had a list taken from the preference cards and put it in the chart, and you just checked off what was used. But now just have it with these ancillary procedures that are applicable to your specialty.
If there are only a few ancillary procedures/drugs that apply to your center, such a charge sheet may not be necessary. But its still wise to explore other methods to remind physicians and nurses about these reimbursable opportunities they should note on their reports.
Maybe hang a little sign [listing these items] where the nurses do their charts or where the doctors dictate that says, Remember, starting in 2008 you can get paid for this, this and this by Medicare, rather than creating a big checklist to go through, says Ms. Serbin. If youve got it culled out to five or six things, then theyll be able to go, Oh, yeah, I used that. It helps with the education process.
2. Expect out-of-network coverage to initially be a trial-and-error process.
Receiving out-of-network reimbursement is becoming more and more difficult, says Ms. English.
Not that weve ever necessarily been a proponent of it, but when youre still trying to contract with somebody, or they wont contract with you or they wont give you decent rates, its become almost impossible now to do out-of-network, she says.
Payors are trying to come up with different ways to keep you from going out-of-network, says Ms. Serbin.
Sending payments to the patients; giving you different discounts from being in-network; and different usual and customary (fees) applied to one set rules to in-network and one set of rules to out-of-network, she says. If you can get them to tell you what their tactics are, this is good. But generally they wont exactly tell you.
If you cant find this out from the payor, you have to find another way to learn what happens when you go out-of-network, and the only way may be to perform just a few cases and monitor the results, says Ms. Serbin. In some instances, payors simply won’t reimburse you. In other instances, they may pay you or they may send the payment to the patient. Once youve learned the results, you can determine whether going out-of-network is worthwhile for your ASC or something to avoid entirely.
3. Educate self-insured employers.
An increasingly growing trend has insurance providers writing their plan designs in such a way that they are selling capped outpatient surgery rates to employer groups, observes Elizabeth Smallwood, CMPE, vice president, contracting and reimbursement, for Blue Chip Surgical Center Partners, and a former director of contracting for Humana of Ohio, with experience working for Aetna, and Anthem Blue Cross and Blue Shield.
In the benefit plan design, theyll limit (for example) all outpatient surgeries to $1,200, she says. Some are also saying that they will only follow Medicares rules for what is on the ASC-approved procedure list; if a CPT code is not on the CMS ASC list, then it cannot be done in an ASC setting like spine.
Weve seen a lot of carriers writing that into their plan design, so it makes it difficult for out-of-network providers to get reimbursed for that, Ms. Smallwood continues. I think youre going to see health plans writing their certificates of coverage differently for their outpatient surgery benefit.
Education of employer groups about these limitations is crucial so the employers can decide whether this is the kind of restricted care they want to offer their employees. An ASC would be wise to reach out to the employers and serve as an informational resource.
Its going to be important for ASC leadership and governance to talk to the self-insured employers in their area the large employer groups to make sure they understand that when they buy a consumer-driven health plan PPO that it may not be a PPO because they capped a specific site of service or restricted it based on reimbursement limitations, says Ms. Smallwood.
It is also important for the front office of an ASC, when scheduling a patient, to confirm whether the patient has a capped outpatient surgery rate.
Ask, What is the allowable amount for this procedure? If they just asked that one more question, they would determine that its capped at $1,200 when [the patient is having] a $2,000 procedure, says Ms. Smallwood. This question could make the difference between performing a procedure for a loss and, perhaps wisely, sending the procedure to a hospital.
4. Watch for contract language preventing up-front collections.
You could run into even more problems with up-front collections if you allow a clause in your contract that says you will not collect up front.
I think youd be remiss in your duty if you let that go through with that language in there because I dont think its any of the payors business to determine whether you can collect from the patient up front, says Ms. English.
If your state law says you cannot collect up front, then the language would be acceptable. Otherwise, keep this clause out of your contract as this is an uphill battle you will want to avoid.
