Don't hire coders from hospitals or practices. "A coder with inpatient hospital certification can't handle an ASC, says Eva-Marie Alexander, West Coast regional director for American Academy of Professional Coders Physician Services, based in Redondo Beach, Calif. "They need to be able to handle the outpatient side." Likewise, "don't just bring over a biller or coder from a physician partner's office," advises says Joan G. Dentler, president of ASC Strategies in Austin, Texas. "Handling ASC revenue involves a different skill-set. Hire staff experienced in ASC-specific revenue work."
Hire an adequate number of staff. When visiting ASCs, Caryl Serbin, executive vice president and chief strategy officer for SourceMedical in Wallingford, Conn., said she is often amazed about how few revenue cycle staff there are. "The ASC might have two to three employees to do the same work that we'd have six to eight people working on," she said. Ms. Serbin wouldn't set a particular ratio of billing employees per volume of cases because the number depends on many factors, including the percentage of cases with more time-consuming payors, such as worker's compensation. Ms. Alexander says staffing levels also depend on case mix. For example, GI and eye cases require fewer billing staff members because they are easier to bill and code, while orthopedic, spine and pain cases tend to be more complex and need more people in the business office.
Pay revenue staff well. "Generally, ASCs often find it difficult to hire experienced coders and billers because their business office salary budgets are unrealistic," Ms. Serbin says. "Talented billing personnel tend to migrate to the hospital setting, not necessarily because they pay more, but because they offer better benefits," she says. It is more difficult for a small employer like an ASC to have a good benefits package, but competitive benefits are essential to attracting higher-level employees, she says. Ms. Alexander says the administrator also need to make sure revenue staff are happy. That means frequently reaching out to them, meeting with them and making them part of the larger ASC team. "You need a good paycheck but you also need to be happy to go into work," she says.
Make sure they are IT-savvy. Revenue office staff members need to be IT-savvy, Ms. Alexander says. "They can't be afraid to use automated systems. They need to go online and check the status of a case to see if has been paid," she says. "This is much faster than calling up the insurer."
Hire a detail-oriented biller. The biller, who sends out the claim and makes sure it reaches the payor, has to be detail-oriented, says Melody Winter-Jabeck, administrator at Ravine Way Surgery Center in Glenview, Ill. The work involves dealing with a claims clearinghouse, so billers have to learn the language of the clearinghouses. "They have to interpret the data and determine trends," she says. "They have to always ask, are we billing something in an inconsistent manner?"
Allow coders to specialize. Of all revenue staff positions, the coder has the highest level of expertise and usually the highest pay. Many centers are large enough to have one full-time coder, allowing this person to specialize and do a better job, Ms. Winter-Jabeck says. "This is not a punch-the-clock position," she says. "It requires a lot of concentration and attention to detail." Rather than just looking at the operative report and extracting codes, the coder needs to "review it in an insightful way," picking up potential items for billing that the physician may have overlooked, she says. Ms. Alexander recommends hiring coders with a clinical background. "The best coders in the world are retired nurses or OR techs," she says. "They know exactly what the physician is doing in the OR and can talk peer-to-peer."
Certification counts, to an extent. While it is possible to find a certified coder in urban areas, it can be challenging in less populated areas, Ms. Winter-Jabeck says. Certification is important because "it provides some guarantee of a coder's knowledge level," she says. "It also shows they have some personal initiative and want to reach a more professional level." Ms. Alexander says large ASCs demand certification of coders, "but just having the certificate without experience is not going to help." If presented with the choice of a new coder who has just been certified and an uncertified coder with several years' experience, she would pick the uncertified coder. As part of the hiring agreement, however, that person should agree to get certification within six months, she says. While certification is important, "it doesn't tell you everything," Ms. Dentler says. "Check out their skills. Many certified coders don't keep up with continuing education like they should."
Hire a well-organized collector. Even though the collector is often an entry-level job, the work requires a great deal of diligence and organizational skills, Ms. Winter-Jabeck says. "Accounts receivables can quickly get away from you if you don’t have an organized system," she says. Collectors have to spot trends, such as why a certain type of claim is not being paid. "The sharp collector will say, 'I've noticed in the last month we haven't gotten paid for x, y and z,' " she says. Collectors "touch" every outstanding account every so many days, depending on the ASC's own predetermined billing schedule, and start working the account when it gets past due.
Collectors have to deal with non-paying patients. Being a collector can be a stressful job because it involves asking patients for money, Ms. Winter-Jabeck says. Self-pay patients can be can become angry or evasive, requiring collectors to combine the skills of a diplomat and a detective. "It takes a little bit of detective work to locate account-holders and verify their explanation as to why they have not paid," she says. "The work can take multiple phone calls to multiple numbers and perhaps writing letters." To reduce stress, self-pay accounts are often shared among two or more people in the billing office. "You don't want to have one person handling all of these difficult bills," she says.
Staff should help each other out. Revenue office personnel need to be cross-trained so that they can handle several roles. "If you are a good collector, you have to be a good biller," Ms. Alexander says. "The scheduler can do verification of insurance." Cross-training is more efficient because when one person is done with her work, she can help others out with theirs. She says this mutual approach also helps staff understand the big picture. "They need to understand how every single step of the process affects billing, starting with checking in," Ms. Alexander says. However, she advises allowing the coder to concentrate on coding, because it is more intensive work. "You can't interrupt what you are doing and make a phone call on a billing issue," she says.
Groom new coders in-house. "It's always a good idea to start grooming a new coder," Ms. Winter-Jabeck says. "The ASC may need a replacement if the current coder is retiring or if it is expanding." It's advisable to groom someone from within the revenue office, because that person's work habits will be familiar and she will already understand the needs of the organization. "You can deal with a known entity," she says. "You have to have a lot of trust in this person, because they will be coding your operative reports. If you already have that trust, you only need to increase the skill level." She says a good candidate for the next coder is the collector, because the work already requires some familiarity with coding.
Allow non-coding staff to seek coding certification. Of all the tasks within the revenue office, only coding has a certification process, but it is worthwhile for other revenue office staff to seek coding certification, too, because coding knowledge can help them with their work, Ms. Winter-Jabeck says. Her practice reimburses for the cost of coding courses, provided that the employee gets certified.
Encourage continuing education. Continuing education is particularly crucial for coders, because they need to continually keep up with changes in coding rules, Ms. Winter-Jabeck says. Since those rules change annually, the training should be annual. Even brush-up courses can be fairly substantial, lasting half a day or even a full day. Check with community colleges and commercial firms like Karen Zupko & Associates, Ms. Winter-Jabeck says. In less populated areas, coders may have to rely on internet-based training. "Web-based training can be very helpful, although they will miss the classroom interaction," she says. "People learn from each others' questions." In addition, groups like the American Academy of Professional Coders provide continuing education for coders at their conferences.
Consider outsourcing revenue functions. Outsourcing is a good alternative for ASCs that don't have enough volume to support a full-time position, but it requires a great deal of interaction and strong bonds of trust, Ms. Winter-Jabeck says. Her practice, Ravine Way, outsources coding. "We're not responsible for keeping that person busy and we don't need to train them," she says. The coder has to have open access to the physicians, because she has to continually ask them about their operative notes. "It wouldn't work if the physicians were not cooperative," she says. Ms. Winter-Jabeck adds that collections are easier to outsource than coding. The collection contractor can follow the criteria the ASC sets down. "If the center sees A/R go through the roof, it's obvious the agency is not doing a good job," she says.
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5 Best Practices to Improve Your ASC's Revenue Cycle
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7 Ways to Improve ASC Billing Operations