5 tips to improve ASC implant payments

Implants typically require a significant investment on the part of an ASC, which makes it critical to capture reimbursement for these FDA-approved devices. Missing an implant payment can instantly turn a profitable procedure into a money loser.

Follow these five tips to improve your chances of getting paid for implants.

1. Use a cover letter and include the implant log. If the claim is denied because it requires the invoice, do not resubmit the claim with the invoice alone. Send a cover letter explaining that the requested information (i.e., invoice and log) is attached for the payor to reprocess for additional payment.

It's also a good practice to note on the cover letter that "this is not a duplicate submission.". Make sure to submit the manufacturer's invoice and implant log, not the purchase order.

When submitting a case with the invoice, include a copy of the implant log. Confirm that the lot or reference number matches the stickers on the log. Highlight the lot number on the invoice so it's easier for the processor to identify the item on the invoice.

2. Craft a detailed appeal. If an implant is covered under your contract, and is denied as non-covered due to the invoice not being available from the manufacturer, an appeal will be required. Send a custom appeal with a copy of the contract showing the coverage. Include a copy of the manufacturer's invoice and implant log. Make sure to lay out the contract terms in the appeal with the exact amount of the expected reimbursement.

3. Review codes. Prior to submitting a claim/appeal, confirm the correct use of the HCPCS code. If a generic code was used (e.g., L8699), check if a more specific code is appropriate.

When updating the HCPCS code to a more specific code, submit a corrected claim. A best practice is to include a cover letter explaining the corrected claim, what was corrected, what additional payment is expected and what supporting documentation is attached.

4. Check contracts. Review contracts for implant reimbursement eligibility and any implant reimbursement thresholds. Some carriers will not reimburse for implants below $250.

Also, verify the carrier's coding preference: L codes versus C codes.

5. Factor in invoice delay. One of the biggest challenges for contracted centers is when a payor requires a copy of the invoice for implant reimbursement. Device manufacturers typically do not send out invoices for 2-4 weeks post service date.

There are a few ways to handle these payors, and it depends on the specific payor and how they processes claims. The optimal approach would be to submit the claim without the invoice. If this approach is taken, make sure the charge amount complies with the contract by using the cost in the purchase order. Follow up by faxing a cover letter, invoice, implant log, and a copy of the claim when the invoice becomes available.

As a last resort, hold the claim until the invoice is available from the manufacturer. Some payors will process a claim without the invoice and do quarterly audits of the implants. Another option is to contact the manufacturer and request a better process to receive the invoice earlier.

Stay vigilant

Getting paid for implants is often no easy task. Even in the best of circumstances, it's not unusual to see payments missed or underpayments made. That's why ASCs must develop processes to effectively monitor implant payments and address when payments are missed or underpaid. Failure to do so could result in leaving thousands of dollars on the table every time a payment is not completed correctly.

Angela Mattioda (amattioda@surgicalnotes.com) is vice president of revenue cycle management services for Surgical Notes RCM. Surgical Notes is a nationwide provider of revenue cycle solutions, including, transcription, coding, revenue cycle management (RCM), and document management applications for the ASC and surgical hospital markets. Mattioda oversees the SNBilling RCM service, the newest component of Surgical Notes' complete end-to-end revenue cycle solution offering.


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