Maximize your 2018 reimbursements: Know your health plans, know your market, and stay on top of trends

Maximizing claim reimbursements becomes more challenging every year. As the insurance market continues to transition to cost conscious care, ASCs are confronted with changes that add complexity to their front desk procedures, billings, and collections. Because these developments will continue indefinitely and include new regulations and cost and quality trends, providers today must be cognizant of the changes and market trends.

Although the effort may seem daunting and despite the variables, focusing on key areas can help increase your revenue by streamlining your front desk, billings, and collections processes, thereby saving you time and money.

1. Know Your Health Plans

The trouble begins when a provider assumes that every patient with an identification card bearing the same logo or company name (e.g., Cigna) shares the same filing requirements, negotiated rates, and benefits. In actuality, these are plan particulars.

Payer and managed care network logos appear on member I.D. cards to help providers recognize a patient who is eligible for a network discount and subject to special plan requirements. However, front desk staff must not assume that two patients covered by the same managed care organization will have the same requirements or reimbursement. Payers work with multiple networks and plans. In some cases, even the networks’ discounts can vary by plan.

The reasons why this is so confusing are two-fold. First, regulations vary by type of plan. The colloquialism of the word “payer” makes it impossible for providers to determine which regulatory authority applies to the plan without some analysis. Second, both insured and self-insured plans are administratively and operationally similar. Both require premiums or contributions from members, issue I.D. cards, include managed care networks, require copays and deductibles, impose plan rules and requirements, and issue payments for benefits.

A plan’s legal status, as a state-regulated insurance policy or a federally-regulated self-funded employee benefits plan ultimately determines how its benefits will be reimbursed. In order to accurately and effectively bill and manage reimbursements, providers must know the specific requirements applicable to each patient’s plan. Insurance policies are state regulated and subject to coverage and benefit mandates, while self-funded (or ERISA) plans are not insurance, so they are exempt from state mandates. In addition, some self-funded plans disregard ordinary contractual requirements, such as those pertaining to reimbursement rates and/or the timely payment of claims.


2. Know your market

Understanding the insurance market has never been easy, but today, ASCs must have a strong foundational knowledge of insurance industry practices and trends and stay on top of them.

a. Identify the key players. They include the prevalent employers, unions, and providers that do business with and alongside your practice every day. An in-depth hold on the specific payers, plans, and networks covering the majority of your patients is invaluable. By focusing on tracking and managing these major influencers, you can more efficiently manage your accounts.

b. Develop an in-depth understanding of your managed care contracts. Track the number of patients the network has introduced to your practice, the impact of its discounts on your revenue, the payment velocity of network claims, and the overall hassle-factor. This information will help you gauge the overall impact of managed care networks on your business and help you negotiate rates. Pay particular attention to language within a managed care contract that restricts a provider from directly contracting with a self-funded employer or vendor. This language can restrict your ability to meet the demands of your market.

c. Verify every patient’s eligibility, benefits, and plan requirements. This can be arduous at first, but creating a system for this effort is a worthwhile investment that will pay back substantial dividends. You will avoid the errors that impact your reimbursements and result in staff rework and patient dissatisfaction.

3. Know the Current Trends Impacting Your Business

Following are key trends impacting the ASC industry at large:

a. Narrow networks, for example, have become popular today as employers seek more specific control over how their plan dollars are spent. These networks operate similarly to managed care networks, but often tend to be limited to a specific provider or group of providers based on variables such as quality, access and cost. Just because you’re in-network with a particular payer doesn’t mean you’re part of every narrow network offered by that payer so it’s important to review your contract language.

b. Bundled payments represent another upwardly trending movement. Bundled payments could combine multiple services such as the professional reimbursement, facility reimbursement, anesthesia, lab and radiology. In addition, some payers are including global periods with ASC services for 60-90 days. Bundled payment agreements can be stand alone or in combination with in-network commercial contracts.

c. Price transparency is a growing trend for every ASC. Now more than ever, patients are inundated with information, emails and even phone calls directing them to “Centers of Excellence” for the lowest out of pocket cost. Patients are now highly informed consumers with access to payer websites/portals with pop ups, selection boxes and estimators. Numerous public and private sites now exist that provide healthcare pricing information. States are also enacting surprise billing laws and mandatory price transparency for health care providers.

d. Direction of care and patient access is an area every ASC should be focused on today. Narrow networks created by large employers offer huge incentives to patients who patron the lowest cost/highest value providers. One example of direction of care is a tiered benefit structure. In a tiered structure, employees are offered varying out of pocket responsibilities based on where they decided to go. If employees decide to go to a tier 1 provider they may have little or no out of pocket costs compared to a tier 2 or tier 3 provider with higher out of pocket costs. Other examples of direction of care, large employers offering zero out of pocket total joint replacements if services are provided by a particular hospital or medical group. ASCs must be aware of the local market and contractual requirements to take full advantage.


Scott Allen, Vice President of Managed Care Contracting, oversees all aspects of ASC contracts involving managed care networks and the revenue cycle. Scott holds a B.S in Political Science from St. Louis University and has been with National Medical for over nine years.


National Medical Billing Services is the premier revenue cycle outsourcing company serving ambulatory surgery centers and their associated surgeons nationwide. By leveraging years of expertise in surgery center billing, the company grew to become the largest and most successful solution for providers engaged in pain management, orthopedics, spine, ophthalmology, gastroenterology, otolaryngology, obstetrics and gynecology, urology, general surgery and others. National Medical is headquartered in St. Louis.


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