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The 2019 guide to ASC billing, collections & contract negotiations

High-deductible health plans, value-based care, site-neutral payments and many more factors are reshaping how ASCs manage finances.

Effective revenue cycle management remains as vital as ever in this changing landscape, so Becker's ASC Review rounded up strategies that can help ASCs succeed. Here's a compilation of coding, billing and collections tips we've shared so far in 2019:

Six contract negotiation strategies (Suzann Crowder, CEO at Health Care Billing of St. Charles)

1. Gather data on case costs, mix and volume, as well as patient satisfaction rates and quality measures, from the past 12 months.

2. Understand what sets your ASC apart from others, such as convenience, renowned surgeons on staff or lower costs per case than competitors.

3. Determine the ASC's goals in terms of implant payments, carve outs, discount rates and annual rate increases.

4. Understand the payer's concerns, including patient access to outpatient facilities, availability of specialty services and predictable costs.

5. Communicate to stakeholders as the negotiation progresses.

6. Promote the new or revised relationship once an agreement is reached.

 

Two common mistakes for physician leaders to avoid (MedHQ)

1. Not staying up to date on new codes and billing regulations 

2. Failing to monitor and protect patient, provider and payer data

 

Five strategies for denial tracking and management (Erin Petrie, director of revenue cycle management for Regent RCM)

1. Get everybody to track denials and the reasons for them.

2. Look for trends among different payers.

3. Create an action plan to fix any problems causing denials.

4. Know which payers and procedures require preauthorization.

5. Use multiple transaction codes to explain denials.

 

Three ways to keep your ASC's claims clean (Surgical Information Systems' Jho Outlaw, senior vice president of revenue cycle services, and Jessica Nelson, director of revenue cycle services)

1. Periodically check with payers to find out when policies might be changing.

2. Ask payers if they received the ASC's claims to avoid submitting the same claim twice.

3. Don't miss payer filing deadlines — Medicare and other payers have different deadlines for filing claims.

 

Three ways to prevent ASC accounts-receivable revenue leaks (Serbin Medical Billing)

1. Identify and address decreases in physician utilization.

2. Address outstanding revenue in accounts receivable.

3. Run reports to identify long-outstanding claims.

 

Three ASC revenue cycle areas to monitor to improve cash flow (Serbin Medical Billing)

1. Update and audit fee schedules to increase revenue.

2. Negotiate for higher implant coverage and contract rates, as managed care providers may push for decreased reimbursement rates.

3. Establish policies to address patient financial responsibility, covering workers' compensation, self-pay patients and payment deadlines.

 

Five strategies to improve ASC billing and collections (Medisys Data Solutions)

1. Continuously measure performance against national averages and market leaders.

2. Automate menial tasks that would otherwise require manual input from billers.

3. Identify opportunities for improvement by retroactively reviewing and reporting any changes made to claims.

4. Make billers' jobs more rewarding by allowing them to review and analyze edits, make decisions and provide feedback.

5. Because payers' guidelines and rules vary, have billers specialize in one payer type.

 

Eight revenue cycle benchmarks for ASCs (Regent RCM)

1. Accounts receivable over 90 days: 20 percent or less
2. A/R follow-up: 95 percent of claims in a month
3. Claim/charge lag: 48 hours
4. Statement lag: 48 hours
5. Clean claims: 98 percent
6. Denials: Under 5 percent
7. Net collections rate: Over 97 percent
8. Days outstanding: Under 30 days

 

Three ways ASCs can improve cash flow (Serbin Medical Billing)

1. Properly train business office staff, audit performance and have enough staff to compensate for surgical volume.

2. To improve managed care contracts, focus on insufficient implant coverage, contracts missing from an ASC's billing system and contract rates that are lower than what cases cost.

3. Address duplicate fee schedules, load fee schedules into the ASC billing system and update them as necessary.

 

Three things to know about developing bundled payments in ASCs (Simplify ASC)

1. High-deductible insurance plans. With more patients enrolled in health plans that require them to meet a higher deductible, payment plans for procedures are becoming more common. ASCs should consult with patients before surgery to discuss their payment options.

2. Bundled payments. With the ongoing shift to value-based care, ASCs are well-positioned to adopt bundled payments due to their ability to help patients avoid copays and deductibles.

3. Undercoding. Complex orthopedic and podiatry procedures may not be billed correctly. Advising staff to note all billable components can help ensure the procedures are billed correctly.

 

Three things to know about developing bundled payments in ASCs (Regent Surgical Health)

1. Identify payers and other stakeholders involved with developing bundles early in the process of negotiating bundles.

2. Key stakeholders include surgeons, anesthesia providers and facilities, including ASCs and hospitals.

3. Knowing the services included in the bundle and the expected savings can be helpful when ASCs negotiate with payers.

 

Six ways to improve ASC patient collections (Surgical Information Systems' Jho Outlaw and Jessica Nelson)

1. Collect physician and surgical fees before surgery. The risk of not getting paid afterward is too great.

2. Offer discounts for financial hardship. Offering a prompt-pay discount for payment at the time of service is recommended. It's often not legal to waive the patient's portion due, as it can negatively affect the payer. ASC staff should check state law and payer policies on discounting before offering discounts to patients.

3. Offer payment plans for copays. Basing payment plans on dollar amounts rather than coinsurance is the practice Ms. Outlaw and Ms. Nelson recommend. Payment plans should also be offered to all patients, including those on Medicare and commercial insurance.

4. Ensure that payment plans last no longer than six months, with the preferred amount of time being three months. If an ASC wants to avoid payment plans altogether, it can offer a discount for paying up front.

5. Aim to secure payments through debit and credit cards when possible. If patients pay by check, don't issue refunds for overpayments until the check clears the bank.

6. Have patients sign documentation stating that amounts quoted prior to surgery are estimates.

 

Three ways to improve ASC billing processes (Pinnacle III)

1. Ensure staff are updated on coding and regulation changes by consulting revenue cycle resources, medical societies and vendors.

2. Analyze logs to discover trends in the types of claims denied and inefficiencies within the billing office.

3. Cross-train multiple employees on how to perform billing office duties so that everything runs smoothly when billing staff is out.

 

Five best practices for payer contracting (Healthcents)

1. Examine top codes and identify which ones drive revenue.

2. Benchmark against existing contracts with other payers to determine whether certain areas are under-reimbursed.

3. Analyze strengths, weaknesses, opportunities and threats related to payer fee schedules.

4. Compose a strong proposal letter, deliver it to the appropriate network manager and follow up with persistence.

5. Establish rapport with the payer representative and respond quickly to any proposals or requests for additional information.

 

Top four reasons ASC claims are denied (Will Israel, vice president of enterprise analytics solutions for The SSI Group)

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)

 

Three key ASC coding and billing areas for staff to watch (Serbin Medical Billing)

1. Avoid billing Medicare for canceled procedures. Medicare can only be billed when the patient is at the ASC prior to receiving treatment. If the case is canceled when the patient is in the preoperative area, Medicare still can't be billed.

2. Don't knowingly bill Medicare for procedures more complex than the ones performed. A routine audit can root out any issues with upcoding.

3. Don't bill Medicare for services that aren't completed or create records that falsely indicate services were performed.

 

Five ways ASCs can streamline the preauthorization process (Tara Vail, COO of HSTpathways)

1. Confirm insurance benefits, eligibility and coverage right away.

2. Determine if the procedure needs preauthorization by checking payer contracts.

3. Record the authorized procedure and date, as well as how long the authorization is valid.

4. Request a retroactive authorization for additional services not included in the original authorization, if necessary.

5. Double check to ensure codes for treatment match the codes in the authorization before submitting the claim.

 

Four strategies to minimize wasted time, reduce claim denials (HSTpathways' Tara Vail)

1. Verify the patient's insurance eligibility, benefits and coverage upfront, and consider using low-cost automation tools that give real-time confirmation.

2. Note exactly which procedure codes were included in the prior authorization and document the time frame of the preauthorization.

3. Immediately identify any discrepancies between the services preauthorized and the ones included in the physician's operative report. If necessary, request a retroactive authorization for additional services rendered as soon as possible.

4. Before submitting a claim, double check that all codes detailing the billed treatment and procedures match the authorized codes.

 

Four steps to ensure accurate payment posting (Serbin Medical Billing)

1. Post monies to patient accounts the day they're received.

2. Collect official bank deposit slips with the date deposited, and itemize monies received on a bank deposit form, including the form of payment.

3. Put management in charge of making bank deposits.

4. Use lockbox deposits to eliminate direct money handling, making payment posting more secure.

 

Four tips for hiring the best revenue cycle staff (Serbin Medical Billing)

1. Determine the skills you need in a new team member. These can include certifications, ASC experience and surgical coding skills.

2. Post the job opening on healthcare job boards, such as those hosted by the Ambulatory Surgery Center Association and professional revenue cycle associations.

3. Create a coding test for applicants to take as part of their interview. This helps to ensure the applicant is qualified for the position.

4. Prepare your new hires for success by auditing their work. Share collections data with them and the entire team.

 

Four helpful benchmarking tips (Surgical Information Systems' Jho Outlaw)

1. Set realistic goals.

2. Use data to help staff pinpoint areas for improvement.

3. Don't assume a change will be effective.

4. Encourage staff involvement and generate excitement about improving key performance indicators.

 

Three strategies for navigating the complex billing process (Medical Healthcare Solutions' Stephen Brighton)

1. Send claims the same day charges are entered. Charges should be entered two to five days after the service is provided.

2. Ensure every patient chart includes thorough details, with information on patient identification, insurance verification, insurance authorization, all medical records and any payment agreements.

3. Communicate with patients from the moment they arrive until their very last payment is made and help them understand their financial obligations every step of the way.

 

Three ways to file ASC claims in a timely fashion (Serbin Medical Billing)

1. Be familiar with managed care contracts' filing deadlines.

2. Be aware that claims may be delayed because of delays in receiving operating notes, short staffing situations and clearinghouses not being checked for accepted or rejected claims.

3. Remember that contracts with short filing deadlines can be revisited and renegotiated.

 

Five red flags health plans monitor in ASC claims (Optum Payment Integrity Facility Ideation Leader Robin Richards)

1. Increased patient volumes
2. Decreased patient volumes
3. Procedures performed outside an ASC's normal specialty
4. New providers billing for the first time
5. Claims for the same patient at several ASCs

 

Three billing challenges ASCs should address (TeleVox Solutions)

1. Pricing confusion. Ninety-four percent of Americans want healthcare providers to help them understand their medical bills, yet more than one-third of providers never discuss patient financial responsibility.

2. Forgetful patients. Thirty-six percent of patients report having trouble remembering to pay their bills on time.

3. Payment convenience. Mailing statements can cost as much as $10 per statement, whereas automated patient payment reminders cost mere pennies per notification.

 

Three ways ASCs can decrease denied claims (Regent RCM)

1. Don't wait. Address denied claims within a week of receiving notice.

2. Take time to investigate. Contact the payer and determine why the claim was denied, as well as how it can be fixed.

3. Note patterns. Errors such as misspelled names and missing information are common.

 

Three important nuances in payer-contract wording (Regent Surgical Health)

1. Contract terms. When contracts extend for more than one year, ASCs can negotiate a cost-of-living increase for subsequent years.

2. "Lesser of" language. Third-party administrators and preferred provider organizations often negotiate 65 percent of the bill charge, but the language says "lesser of" the amount charged.

3. The escape clause. The ability to get out of a contract is language to look out for. A 90- to 120-day cancellation clause is ideal for ASCs.

 

To have your coding, billing and collections tips featured on Becker's ASC Review, contact Angie Stewart: astewart@beckershealthcare.com.

 

More articles on coding, billing and collections:
5 interesting ASC company partnerships to know
Minnesota hospitals challenge Blue Cross policy shifting services to ASCs
Regent Surgical Health, Conformis partner to cut ASC joint replacement costs 

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