Here are six tips from ambulatory surgery center experts on optimizing billing operations and reducing claim denials from commercial payors.
1. Look out for bundled codes. Insurance companies have recently bundled several codes together to reduce reimbursement for the overall episode of care. Unbundling these codes to increase reimbursements is unlawful, so pay attention to these changes.
"As with all surgical specialties over the years, spine procedures have seen many services that were once paid separately bundled as a way of saving payors money," said Sean Weiss, vice president and chief compliance officer for DoctorsManagement. "The coverage guidelines with every revision seem to have more and more exclusions or restrictions to them. Again, insurance coding and billing is a game the payors have forced physicians and their staff to learn how to play and just when you believe you have it figured out they have changed the rules on you again."
Spine surgeons can do little to combat bundling codes. However, lobbying congressional representatives can make an impact as Congress seeks to reform the healthcare system in the future.
"Things continue to change and unfortunately until physicians get a stronger voice on Capitol Hill they will not be changing for the better," he said. "It has gotten harder and harder to not only get paid for spinal procedures but to actually be paid what a surgeon is entitled to."
2. Make sure no information is missing. Missing information on the claim is one of the biggest reasons for denied claims, according to published reports by the health insurance industry. For the most part, these denials are completely avoidable. Payors that receive claims with incomplete information will generally reject them automatically, they say, which is why surgery center staff must be trained to catch omissions. The sophisticated claims adjudication systems deployed by payors are much more advanced than they were five years ago, and in many cases, the software deployed by centers has not caught up.
"Studies show that if you had that information on the claim upfront, the vast majority of those claims would not be denied," said Brice Voithofer, vice president of ASC and anesthesia services for AdvantEdge Healthcare Solutions. Missing information could include the group tax ID number and the group address and constitutes the most common cause of "administrative denials," he said. Administrative denials, for the most part, are self-inflicted issues that should be avoided.
3. Do not misuse modifiers. Another common mistake, especially in GI claims, that leads to denials is the inappropriate use of modifiers. Modifiers need to be used if a case is canceled prior to a procedure, for bilateral procedures and if multiple procedures are performed at one time (e.g., modifiers -50 and -51), Mr. Voithofer said. Many ASCs do not use modifiers appropriately, which can lead to inaccurate reimbursement and/or increases in denials.
"Claims are often denied if these aren't coded correctly. For example, some payors may pay only 50 percent for secondary procedures performed at the same time as another, and they will deny an ASC's claim for full payment," he said.
Accurate documentation is needed for these cases, as it can help billing staff determine what was done in the OR if and when they need to follow up on a denied claim. "An important part of coding and acting on denied claims is understanding the root cause of the denials and effectively communicating not only to the billing staff, but also to the source of the denials," Mr. Voithofer said.
4. Check for problem with the payor's system. If your surgery center is receiving numerous denials from the same payor and you can't identify the cause, there may be a problem with the payor's system. "If we have enough data to support a trend, we speak with the payor to say, 'Hey, there's something wrong with your system,'" Mr. Voithofer said. "Their system is the same as any other, where the edits are electronic and humans touch fewer than 5 percent of claims. We need to isolate the error, because they're not going to spend the time and effort to correct an error they are not aware of."
For example, he said, the payor may have an incorrect ICD-9 CPT code crosswalk or may be using the wrong error rates to kick claims to medical review.
5. Work with coding professionals. Coding is complex and focused expertise is more likely to optimize returns. Consider outsourcing billing responsibilities to experts in the field if you don't have the resources to hire an expert in-house. If you do not have the staff thoroughly trained, then consider seeking help from a consultancy with qualified staff to ensure a focus on spinal procedures.
More Articles on Coding, Billing and Collections:
CMS Adjusts Medicare RAC Documentation Limits
Medicaid Saved From Cuts in Obama's Upcoming Budget
Surgical Notes Releases Application to Improve Accounts Receivable
1. Look out for bundled codes. Insurance companies have recently bundled several codes together to reduce reimbursement for the overall episode of care. Unbundling these codes to increase reimbursements is unlawful, so pay attention to these changes.
"As with all surgical specialties over the years, spine procedures have seen many services that were once paid separately bundled as a way of saving payors money," said Sean Weiss, vice president and chief compliance officer for DoctorsManagement. "The coverage guidelines with every revision seem to have more and more exclusions or restrictions to them. Again, insurance coding and billing is a game the payors have forced physicians and their staff to learn how to play and just when you believe you have it figured out they have changed the rules on you again."
Spine surgeons can do little to combat bundling codes. However, lobbying congressional representatives can make an impact as Congress seeks to reform the healthcare system in the future.
"Things continue to change and unfortunately until physicians get a stronger voice on Capitol Hill they will not be changing for the better," he said. "It has gotten harder and harder to not only get paid for spinal procedures but to actually be paid what a surgeon is entitled to."
2. Make sure no information is missing. Missing information on the claim is one of the biggest reasons for denied claims, according to published reports by the health insurance industry. For the most part, these denials are completely avoidable. Payors that receive claims with incomplete information will generally reject them automatically, they say, which is why surgery center staff must be trained to catch omissions. The sophisticated claims adjudication systems deployed by payors are much more advanced than they were five years ago, and in many cases, the software deployed by centers has not caught up.
"Studies show that if you had that information on the claim upfront, the vast majority of those claims would not be denied," said Brice Voithofer, vice president of ASC and anesthesia services for AdvantEdge Healthcare Solutions. Missing information could include the group tax ID number and the group address and constitutes the most common cause of "administrative denials," he said. Administrative denials, for the most part, are self-inflicted issues that should be avoided.
3. Do not misuse modifiers. Another common mistake, especially in GI claims, that leads to denials is the inappropriate use of modifiers. Modifiers need to be used if a case is canceled prior to a procedure, for bilateral procedures and if multiple procedures are performed at one time (e.g., modifiers -50 and -51), Mr. Voithofer said. Many ASCs do not use modifiers appropriately, which can lead to inaccurate reimbursement and/or increases in denials.
"Claims are often denied if these aren't coded correctly. For example, some payors may pay only 50 percent for secondary procedures performed at the same time as another, and they will deny an ASC's claim for full payment," he said.
Accurate documentation is needed for these cases, as it can help billing staff determine what was done in the OR if and when they need to follow up on a denied claim. "An important part of coding and acting on denied claims is understanding the root cause of the denials and effectively communicating not only to the billing staff, but also to the source of the denials," Mr. Voithofer said.
4. Check for problem with the payor's system. If your surgery center is receiving numerous denials from the same payor and you can't identify the cause, there may be a problem with the payor's system. "If we have enough data to support a trend, we speak with the payor to say, 'Hey, there's something wrong with your system,'" Mr. Voithofer said. "Their system is the same as any other, where the edits are electronic and humans touch fewer than 5 percent of claims. We need to isolate the error, because they're not going to spend the time and effort to correct an error they are not aware of."
For example, he said, the payor may have an incorrect ICD-9 CPT code crosswalk or may be using the wrong error rates to kick claims to medical review.
5. Work with coding professionals. Coding is complex and focused expertise is more likely to optimize returns. Consider outsourcing billing responsibilities to experts in the field if you don't have the resources to hire an expert in-house. If you do not have the staff thoroughly trained, then consider seeking help from a consultancy with qualified staff to ensure a focus on spinal procedures.
More Articles on Coding, Billing and Collections:
CMS Adjusts Medicare RAC Documentation Limits
Medicaid Saved From Cuts in Obama's Upcoming Budget
Surgical Notes Releases Application to Improve Accounts Receivable