The majority of your ASC's revenue is likely derived from third-party payors, both government and private managed care organizations.
The following tips primarily address the private insurance sector and common areas that often require additional scrutiny to prevent loss of revenue.
Managed Care Negotiation
1. Negotiate fair managed care contracts. Managed care organizations have been tightening their contract requirements and reimbursement rates for some time, but this trend seems to have increased over the last few years. Negotiating a fair reimbursement contract can be a lengthy process. It's important to have a knowledgeable and experienced negotiator who knows the costs of your procedures and necessary reimbursement to keep those procedures profitable as well as what concessions you can make to secure fair rates.
Insurance Verification
2. Verify patient's insurance prior to procedure. The importance of eligibility determination cannot be overstated. Determining whether a patient's insurance will reimburse your center is paramount. Some insurance payors require an authorization number for payment. Workers' compensation claims require additional information, such as employer demographics, dates of injury and authorization codes. Non-contracted carriers (i.e., out-of-network payors) often do not have out-of-network benefits, so it's definitely important to question them thoroughly and note coverage specifics.
Coding
3. Employ experienced coders. Recommended best practice is to use certified and ASC-experienced coders. What you save on salaries for inexperienced coders will cost you in lesser reimbursement and possible compliance violations (e.g., upcoding, unbundling.)
4. Optimize coding. Inexperienced coders often use the surgery schedule or operative note title to determine codes performed rather than reading the entire provider-dictated operative note. Physicians frequently perform additional procedures that are not listed in the title but are included in the body of the report. Experienced coders understand when to code additional procedures to optimize reimbursement while remaining fully compliant with state and federal guidelines.
5. Use coding modifiers. Modifiers are usually two-digit numbers or letters added to CPT procedural codes identifying variations or specificities pertaining to the procedure. They might indicate a number of things, such as complications, interrupted surgery, digit identification or bilateral procedures. Recognize the importance of using modifiers correctly as lack of use may negatively impact reimbursement and overuse may result in compliance issues.
6. Update coding reference guides. Another area of false economy is expecting coders and billers to work adequately with outdated CPT, ICD-10 and HCPCS references. Maintaining current coding and billing resources is an important investment for keeping up with frequently changing regulations and requirements. The Office of the Inspector General has made it abundantly clear that it will monitor and enforce changes. Purchasing annual CPT and other coding materials is a small price to pay for maintaining compliance.
Claim Submission
7. Submit claims in a timely manner. Not meeting the payor's timely filing requirements can cost your ASC money. Depending on your managed care contracts, your timely filing requirements could be as little as 15-30 days. The payor has the right to refuse payment if your claim is not submitted on time according to its guidelines.
When negotiating contracts, aim for a one-year timely filing deadline like that of Medicare. While claims can typically be submitted within 48-72 hours, there are occasional instances where it takes several days or even weeks to receive the operative note or pathology report, which are required to accurately code the procedures.
If your ASC has commonly used boiler-plate contracts, you may have already missed your timely filing deadline by the time you receive the operative note. In these instances, you may not get paid at all. This is a more common occurrence when ASCs lack sufficient business office staff members dedicated to keeping the revenue cycle current.
8. Verify receipt of claim by payor. This is an important and often-missed step. Submitting the claim via the clearinghouse does not automatically mean that the payor received it. First, receive clearinghouse documentation that the claim was successfully submitted and accepted by the payor. Then take the extra steps to check with the payor to determine if it received the claim and accurately record the date received in your computer's software notes section. Failure to do so often results in claims not being paid and ASCs possibly missing timely filing deadlines to resubmit.
Payment Posting
9. Appeal denied or wrongly paid claims. Failing to understand your managed care contracts and not knowing what reimbursement rate to expect can lead to lost revenue. If a claim is denied or paid incorrectly, your payment poster should be aware of what is still owed and file an appeal immediately. Contract reimbursement rates should be loaded in your software (at minimum, use an insurance matrix) so payments can be immediately compared to reimbursement rates to determine accuracy. Some payors stipulate that appealing a claim is included in the timely filing requirements, so it's important to submit appeals promptly.
Closing Thoughts
Third-party payors are becoming more imaginative in finding ways to lessen or delay reimbursement, which means that your reimbursement cycle staff must be able to recognize these tactics and combat them. It's also important that revenue cycle management be aware of and regularly audit areas that can affect its ASC's cash flow.
Caryl Serbin, RN, BSN, LHRM, is president and founder of Serbin Medical Billing, an ASC revenue cycle management company. Serbin Medical Billing's primary objectives are to provide the best coding, billing and accounts receivable management services available to ambulatory surgery centers (hospital joint-venture, corporate-owned or independent) and anesthesia providers. Ms. Serbin has been a leader in the ASC industry for 30 years. She was the founder of the first ASC-specific billing company.