In a webinar titled "Maximizing Reimbursement for ASCs," Caryl Serbin of SourceMedical Revenue Cycle Solutions discussed eight problem areas that delay ASC reimbursement and increase the likelihood of denials.
1. Finding sufficient and experienced staff. When ASCs are experiencing financial problems, boards often recommend cutting business office staff to save money, Ms. Serbin says. She says ASCs should be aware that cutting billing staff leads to slower reimbursement and thus more need for budget cuts. Be mindful of this cycle before you eliminate billing staff to save money. She adds that ASCs should look for billing staff leaders with surgery center experience, as the ASC is a unique setting and hospital/practice experience cannot always be applied.
2. Too many special projects. A surgery center's revenue cycle team should not be constantly embarking on special projects, Ms. Serbin says. "You absolutely need to have a good, consistent process and routine," she says. Special projects are a sign that routine daily work is not getting done. It could mean you don’t have enough staff or the right staff. For example if you find a need to have a “special project” for keeping up with payment posting or refunds when you have had no volume changes then you need to find the cause.
She says revenue cycle processes should verge on "boring" because they are so systematic. Ms. Serbin also advises surgery centers to change aspects of the revenue cycle process one at a time. "Don't change 10 things at once," she says. "Change one, monitor it and go forward."
3. Clearinghouse rejections. Most claims are submitted via a clearinghouse, which scrubs claims prior to submission, allows corrections to be made and submits claims to payors. Make sure to review clearinghouse reports to determine when claims have been accepted by the clearinghouse and sent the payor and which claims have been rejected or accepted by the payor. Ms. Serbin says one of the biggest problems surgery centers experience is the failure to understand clearinghouse reports and notice when claims have not been sent to the payor.
"The claim can sit out there for weeks, and you go looking for a payment and find out the payor never received the claim," she says. If staff members don't understand the clearinghouse report, they should call the clearinghouse to ask why the claim has been rejected and find out if the surgery center is at fault. The next step is to ask for additional training so you know how to follow the claim all the way through the process utilizing reports.
4. Lack of appropriate follow-up on claims, denials and appeals. Surgery centers may fail to follow up on claims, denials and appeals if they lack the necessary staff to do so. Billing teams should keep track of claims to make sure the correct reimbursement is received in a timely fashion; if not, they should take steps to find out what went wrong. Staff members should feel comfortable using the payor website and making phone calls; sometimes the website is enough to follow up, but often a phone call can save time and help your ASC build a relationship with the payor representative.
Billing staff should also be alert to common payor responses, such as, "The claim is not on file" or "The claim is processing." Be persistent and make sure you understand the status of your claims by the time the phone call is over. Most importantly, document your findings so you can refer to the payor's response later. For example, if the payor says the claim will be paid by a certain date, document the date and then check in to make sure the payor has followed through.
5. Implant reimbursement vs. implant cost. If payor contracts do not include adequate reimbursement for implants, surgery centers will lose money on implant cases because the cost is not covered. Ms. Serbin recommends keeping an implant fee matrix that details which implants are covered by which payors. Refer to the matrix when scheduling cases to avoid losing money on the back end.
6. Not appealing to the highest available level. Once staff members have started the appeals process, they must follow through to the end of the process, Ms. Serbin says. "Staff members in charge of appeals may start the appeals process and give up because it's too lengthy," she says. "When you appeal, there can be anywhere from four to five levels." She says surgery centers must follow payor rules when it comes to filing appeals. This means using the correct forms, following the payor's appeal process and understanding which information payors require to support the claim. "Surgery centers want to take a shortcut and get innovative, but you have to think of it as the government when you're paying your taxes," she says. "You don't get to fill out any form you want to — you have to fill out their form."
7. Not knowing and following managed care billing policies. Billing teams need to keep track of payor billing policies, which can change without a notification sent to the ASC. "You have to be diligent," Ms. Serbin says. "Policies will change and you won't get an update." Make sure the billing team knows your carrier's policies and procedures for adjudicating claims, as well as claim form requirements and requirements for submitting implants for reimbursement.
Also keep an eye on timely filing deadlines, which payors can change without notice to avoid payments. For example, Ms. Serbin says some secondary payors are attempting to change timely filing from primary payment date to date of surgery.
8. Unfavorable A/R trends — or "even worse, not knowing you're having unfavorable A/R trends," Ms. Serbin says. She recommends that ASCs use both industry benchmarks and internal benchmarks to monitor the health of their A/R. "Industry benchmarks are helpful, but they do not represent total A/R health," she says. Make sure to create center-specific benchmarks that include a combination of total A/R, A/R by payor, aging of A/R, days in A/R and patient portion of A/R.
Learn more about SourceMedical Revenue Cycle Solutions.
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1. Finding sufficient and experienced staff. When ASCs are experiencing financial problems, boards often recommend cutting business office staff to save money, Ms. Serbin says. She says ASCs should be aware that cutting billing staff leads to slower reimbursement and thus more need for budget cuts. Be mindful of this cycle before you eliminate billing staff to save money. She adds that ASCs should look for billing staff leaders with surgery center experience, as the ASC is a unique setting and hospital/practice experience cannot always be applied.
2. Too many special projects. A surgery center's revenue cycle team should not be constantly embarking on special projects, Ms. Serbin says. "You absolutely need to have a good, consistent process and routine," she says. Special projects are a sign that routine daily work is not getting done. It could mean you don’t have enough staff or the right staff. For example if you find a need to have a “special project” for keeping up with payment posting or refunds when you have had no volume changes then you need to find the cause.
She says revenue cycle processes should verge on "boring" because they are so systematic. Ms. Serbin also advises surgery centers to change aspects of the revenue cycle process one at a time. "Don't change 10 things at once," she says. "Change one, monitor it and go forward."
3. Clearinghouse rejections. Most claims are submitted via a clearinghouse, which scrubs claims prior to submission, allows corrections to be made and submits claims to payors. Make sure to review clearinghouse reports to determine when claims have been accepted by the clearinghouse and sent the payor and which claims have been rejected or accepted by the payor. Ms. Serbin says one of the biggest problems surgery centers experience is the failure to understand clearinghouse reports and notice when claims have not been sent to the payor.
"The claim can sit out there for weeks, and you go looking for a payment and find out the payor never received the claim," she says. If staff members don't understand the clearinghouse report, they should call the clearinghouse to ask why the claim has been rejected and find out if the surgery center is at fault. The next step is to ask for additional training so you know how to follow the claim all the way through the process utilizing reports.
4. Lack of appropriate follow-up on claims, denials and appeals. Surgery centers may fail to follow up on claims, denials and appeals if they lack the necessary staff to do so. Billing teams should keep track of claims to make sure the correct reimbursement is received in a timely fashion; if not, they should take steps to find out what went wrong. Staff members should feel comfortable using the payor website and making phone calls; sometimes the website is enough to follow up, but often a phone call can save time and help your ASC build a relationship with the payor representative.
Billing staff should also be alert to common payor responses, such as, "The claim is not on file" or "The claim is processing." Be persistent and make sure you understand the status of your claims by the time the phone call is over. Most importantly, document your findings so you can refer to the payor's response later. For example, if the payor says the claim will be paid by a certain date, document the date and then check in to make sure the payor has followed through.
5. Implant reimbursement vs. implant cost. If payor contracts do not include adequate reimbursement for implants, surgery centers will lose money on implant cases because the cost is not covered. Ms. Serbin recommends keeping an implant fee matrix that details which implants are covered by which payors. Refer to the matrix when scheduling cases to avoid losing money on the back end.
6. Not appealing to the highest available level. Once staff members have started the appeals process, they must follow through to the end of the process, Ms. Serbin says. "Staff members in charge of appeals may start the appeals process and give up because it's too lengthy," she says. "When you appeal, there can be anywhere from four to five levels." She says surgery centers must follow payor rules when it comes to filing appeals. This means using the correct forms, following the payor's appeal process and understanding which information payors require to support the claim. "Surgery centers want to take a shortcut and get innovative, but you have to think of it as the government when you're paying your taxes," she says. "You don't get to fill out any form you want to — you have to fill out their form."
7. Not knowing and following managed care billing policies. Billing teams need to keep track of payor billing policies, which can change without a notification sent to the ASC. "You have to be diligent," Ms. Serbin says. "Policies will change and you won't get an update." Make sure the billing team knows your carrier's policies and procedures for adjudicating claims, as well as claim form requirements and requirements for submitting implants for reimbursement.
Also keep an eye on timely filing deadlines, which payors can change without notice to avoid payments. For example, Ms. Serbin says some secondary payors are attempting to change timely filing from primary payment date to date of surgery.
8. Unfavorable A/R trends — or "even worse, not knowing you're having unfavorable A/R trends," Ms. Serbin says. She recommends that ASCs use both industry benchmarks and internal benchmarks to monitor the health of their A/R. "Industry benchmarks are helpful, but they do not represent total A/R health," she says. Make sure to create center-specific benchmarks that include a combination of total A/R, A/R by payor, aging of A/R, days in A/R and patient portion of A/R.
Learn more about SourceMedical Revenue Cycle Solutions.
Related Articles on Coding, Billing and Collections:
Fewer Physicians Accepting New Patients With Private Health Insurance
Arkansas Insurance Commissioner Asks to Set Up Health Insurance Exchange
Surgery Center Coding Guidance: Posterior Laminectomy or Laminotomy