In today's market of dwindling reimbursement, efficiency in all areas of the billing process is paramount.
Your ASC can't produce a successful financial outcome if you have random and unsupervised billing and collection procedures. For the best reimbursement results, provide revenue cycle staff with specific billing guidelines and a well-organized plan.
The following eight suggestions for coding and claim submission will assist your team in consistently submitting a "clean claim."
Submitting the claim
In revenue cycle management lingo, a "clean claim" means exactly what it sounds like: a claim that has every "i" dotted and "t" crossed. This term takes on significant meaning in relationship to getting paid promptly and accurately. When your billing team submits a clean claim, that defeats the payer's first line of defense: automatic denial for errors.
Here's what you need to consider when assembling and submitting the claim.
1. Provider reports. Providers have a responsibility to supply explicit documentation in their operative reports to support all procedures performed. Areas that need special clarification include the following:
• Bilateral or multiple procedures
• Implants used (with complete description)
• Ancillary services (e.g., billable supplies/medications, x-rays, certain therapy)
• Diagnoses compatible to procedure and specific to contributing factors
• Specific areas treated (e.g., medial compartment, lateral compartment)
• Accurate identification of surgical site in order to apply appropriate modifiers (e.g., fingers, toes)
2. Coding. Don't over-economize by not providing your coders with current and necessary references. In addition to the latest CPT and ICD-10 reference books, coders may need specialty references to assist in optimizing coding and a product (e.g., book, software) that helps prevent unbundling.
3. Charge posting and claim submission. This is the final checkpoint for remitting a clean claim. Charge posters must be knowledgeable in several areas as they ascertain whether the claim contains all required components, which include the following:
• Specific contract requirements for acceptance by payer
• All numbers (e.g., NPI, ASC code, physician code)
• Copy of operative note or invoice enclosed (if required)
• Procedure and diagnosis codes, complete with modifiers
It's important to recheck the claim once more before submitting and then obtaining a receipt from the clearinghouse or payer verifying the claim has been received.
Collecting your reimbursement
Just as important as timely submission of a clean claim is persistent follow-up to get it paid. The need for more aggressive collections has become the norm as payments are often delayed for myriad reasons. It's important to realize that the collection process now takes almost twice as much follow-up and man-hours than in the past.
Here are some of the steps you will want to take to help ensure you receive the payment you are owed.
4. Collection (phase 1). The first step in collection from third-party payers starts within 24 hours of submission. Confirm the payer received and accepted (without error) the claim. This can usually be completed electronically.
5. Check the status of the claim. When speaking with payer representatives, be sure to:
• Record their name and ask for payment status. Do not accept "it's being processed" as an answer.
• Determine if claim status is not being delayed for lack of information. Ask when payment will be sent.
• Clarify why the claim is delayed and get a detailed explanation. If the payer needs additional information that the ASC can provide, send it immediately.
• Document the results of the call/contact in detail. As in all areas of the billing process, good documentation is a necessity.
6. Payment posting. When payment arrives:
• Determine if payment accurately reflects contract allowance.
• If payment is incorrect or claim is denied, immediately call to resolve the problem.
• If resolution is reached, ask when payment should be expected.
• If no settlement is achieved, start appeals process immediately.
• If correct payment is received, after posting payment, transfer to secondary insurance or patient guarantor and bill for balance on the same day.
7. Collection (phase 2). The second phase of collections entails following up on all areas of unpaid services.
• Third-party payers — Follow up on tickler files. All outstanding balances should be contacted at least every 30 days. Be sure to include workers' compensation, automobile and attorney claims.
When you call an insurance company, save time by checking on all outstanding claims with that payer. Track and report any trends to management (e.g., Medicare computer system down for several days, ABC insurance company does not have the ASC listed as a participant).
• Patient accounts — If your state and contracts allow up-front collection of unpaid deductibles, it is advisable to take this approach. Fees not collected in advance are often fees never collected.
It is preferable not to offer payment plans longer than 90 days. However, if your ASC finds this necessary, make sure that patients understand the full amount will become due and payable if there is a default in meeting the payment arrangement agreement. Be sure all patient accounts are billed every 30 days, including payment plans.
8. Audits. Although important, auditing is not just for ensuring compliance with private and government payers' regulations. It is also for determining if all of your claims are being processed and paid efficiently. Internal audits of coding and billing should be performed at least monthly. An external audit performed annually by ASC revenue cycle experts is also recommended.
Set your ASC up for success
Efficiency is key to maintaining a positive cash flow. Hire competent, experienced staff and provide incentives for good performance. Supervision of the revenue cycle personnel by a member of management is essential to keeping the business office running smoothly and staff working at their full potential. Keep an open mind to change. Review processes frequently to see if improvements can be made.
Caryl Serbin, RN, BSN, LHRM (caryl@serbinmedicalbilling.com), 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. Serbin has been a leader in the ASC industry for 30 years. She was the founder of the first ASC-specific billing company.
The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.