How to Collect More Often on Spine Cases

Written by Laura Dyrda | March 27, 2012 | Print  |

This article was written by Barbara Cataletto, MBA, CPC, Chief Executive Office Business Dynamics Limited

It is amazing to me that we still have the propensity to lose earned revenues due to customer failures that are the result of our own business associates. This includes the physician, ancillary support staff, coders and reimbursement teams that are put into place to ensure a collective and successful process. Now before you get into a tiff and think that I am speaking about the other Spine ASC's and practices in your community, you may want to take a closer look at your Quality Assurance programs before dismissing this article. With over 25 years of engaging in revenue cycle management for spine facilities and practices, I have come to take QA as the utmost critical component of our business. The QA factor forces the staff, both executive and clerical alike to answer to a higher authority other than themselves, and it is here, in this venue that we are able to critique and improve our financial position by way of improving the financial position of the spine institutions we represent.

Yes, I know that there are so many issues to contend with in the area of spine procedure: federal and state guidelines, regulatory mandates, coding and reimbursement changes, independent carrier and state policy positions and last, but not least, is the patient and their experience with your facility. How does the staff and administration keep tabs on the continuously difficult and often adversarial conditions that keep the spine business afloat?

The only way to continue to improve your financial platform is to focus on the basics of service delivery at every turn. This may seem near impossible and most administration or executive personnel will say that there is not enough time in the day to qualify and quantify all levels of service. Our challenge is to find steps that will support a strong QA based company. If not, I can guarantee that managing from 10 thousand feet without looking at your QA failures will surely result in denied procedures, lost revenue and a diminished patient experience.

It is not possible to discuss all of the elements involving QA for an ASC, facility or spine practice in just one article, so I will focus on the basic requirements for the immediate improvement in the revenue cycle and present a series of questions that you can ask yourself about your particular situation. Once you complete the question and answer session, you can think about your own personal experience and begin to determine if your QA protocols are providing you with the information and tools necessary to make the necessary positive adjustments to secure future growth in both the quantity and quality of your services.

Do you have a QA that guarantees that all services performed in your business are billed each month?

Seems like a ridiculous question, but what measures do you take to ensure that all services are billed out each month. We recommend a series of QA techniques, most are pretty unsophisticated, but hit the mark.
We recommend that this become part of your month end protocols, as this will surely increase your billings since most facilities and practices miss several claims submission opportunities more times than you think. You may find that surgeons have not dictated a medical note or that an emergency or “squeezed in” case has not been accounted for or that the surgical listing for the facility does not match that of the surgeons’ calendar; these can all identify missed billing opportunities. If you think these issues don’t apply in your case, do your own audit of services and respective submission for the past year and look at your results.

Do you have a protocol that reviews canceled cases/appointments?

Well, most booking staff think that a canceled patient will reschedule at a later time, but the ability to capture information about the cancellation may be pretty revealing. Most patients cancel due to personal or scheduling reasons, but others cancel for reasons that require a "fix" in your business. We have found that asking patients why they are canceling can provide the QA necessary to evoke changes in the presentation, positioning and overall personality of the business. You would be interested to note that cancellation issues reveal scheduling difficulties, staff interaction concerns, insurance and financial difficulties, etc., that can be assessed and revamped, depending on the situation.

Let's look at these different scenarios
• Cancelled appointments due to scheduling may be due to the fact that your schedule is full for the next six weeks and patients/physicians are not interested in waiting that long to have their procedures completed so they look elsewhere to accommodate their needs. If you know this may be the situation in your business, you may want to consider expanding your office hours to reduce the risk of lost opportunities.

• If we look further into the reason for cancellations and note that certain representatives have a higher cancellation rate than others, it may be time to evaluate their customer service skills. Perhaps consider whether the patient that cancels after booking their service had an issue with the insurance carrier.

• If your preauthorization or financial team cannot emulate a positive business environment and secure the required documents specific to patient financial responsibility and translate that information adequately to the patient, you may lose that service opportunity, thus resulting in a cancellation.

Are you able to review your reimbursements and improve your coding and reimbursement process?

So let’s look at your revenue cycle management QA from the most basic understanding of how your RCM department works.

• The claims are coded, submitted and collected upon. How often do you review your payments on each case, not account, but each case?
• Are all codes accounted for, all line items paid and all billable medical
materials reimbursed?
• If yes to the above, how do you ensure that all items are paid at contract or at the expected reimbursement level for non-contracted or out of network services?

Well, there are several factors that may inhibit the level of reimbursement expected. First, let’s start with the coding and documentation.

• Is the documentation complete, concise and timely?

The last thing you want is to lose revenue due to a timely filing issue with the carrier.
Secondly, how is the coding?

• Is it up to date and accurate, and has it been checked by a second staff member that is qualified to critique the first coder.
Just because your surgeon or physician codes a case, doesn’t mean that it is complete and accurate. So to that end, it is recommended that at least two coding experts review the coding to be submitted to ensure accuracy and coding compliance. It is interesting to note that about 20 percent of all spine claims are coded incorrectly when only one coder is involved and this number drops to about 1 percent if two coders review each case. Calculate out those numbers and you will be able to get sense of what you are losing.

Now let’s look at the reimbursement end of this cycle.

• Have you reviewed each account to ensure payment is received in a timely manner;
• Follow up on your claims not later than four weeks after submission of your claim; do you follow through to completion every two weeks or so after that to push for your payment?

You may be thinking "Who has the staff for that" or "Once I have proof of filing from my electronic submission, I will get paid eventually." If that is your thought process, I guarantee that your business is losing money. The ability to collect on spine cases in a timely and complete fashion requires the right staff and the right amount of staff to stay on top of your claims. Reducing staff to save money in a spine business will surely result in a much higher financial loss of income when compared to the cost of hiring the proper number of trained staff for your volume. The continuance of spine education for your staff will also prove to benefit your bottom line.

Following the above statement, how many of you review "zero" pays? Many spine businesses get to the "zero" pays when they have a free moment, and keep in mind that free moments really don’t exist in a busy spine business! Managing "zeros" provides a wealth of information if you have a QA policy of assessing them. Many zero payments are the result of incorrect coding or poor documentation that can be adjusted internally to correct such deficiencies.

But many "zero" pays are also the result of inappropriate insurance denials as well. Examining these issues will allow the organization to improve their documentation and coding process and look to improve their appeals position to ensure that the revenue cycle team is successful in securing denied payments. We have found that an aggressive appeals department is worth its' weight in gold in resolving unwarranted denials, retractions and can actually produce a significant increase in income. This will require properly positioned and trained staff capable of studying specific carrier expectations in coding, reimbursement and preauthorization processes for specific carrier coverage guidelines and provide the necessary implementation processes to ensure successful reimbursements.

So I have only asked three basic Quality Assurance questions, followed by challenging statements to push you to consider your own business application:
A positive answer to all of the above questions is the only path one should to take to ensure the continued success with your spine business.


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