Several obstacles stand in the way of ASCs getting paid, according to Surgical Information Systems Senior Vice President of Revenue Cycle Services Jho Outlaw and Revenue Cycle Services Director Jessica Nelson.
Here are five insights they shared on overcoming those barriers:
1. What to do if a payer doesn't provide names or authorization numbers on pre-certification:
Don't allow the payer to flat-out refuse. Press for specific information so there's something to reference if the case is denied. Have staff challenge the refusal by saying something like, "I need some reference that I have spoken with you today and about what you told me."
2. What to do for pre-certification for a case added late in the afternoon for surgery the next day:
Designate a staff member to serve as the point person for the case, treating it as a top priority. That person should call the insurance company's pre-authorization department and alert patients their benefits will be verified. If add-ons account for more than 10 percent of volume, determine which physicians have a high add-on frequency and show them data to prove it.
3. How to handle surgeons who don't dictate in a timely manner:
Gather data to show what the average dictation time is for each physician. Identify which physicians are lagging, and share data with the physician leadership. Another option is to invest in dictation and documentation technology.
4. What to do if physicians disagree about the cause of denials resulting from conflict between scheduled vs. performed procedures:
Enlist coders who can communicate with surgeons by providing documentation to justify the reasons behind the denial. The coder can help explain why the CPT code has to be documented with its description in the operative note.
5. What to do if your contract has no implant carve-outs:
Make it a priority to renegotiate contracts. Review the contracts, the cost of cases with implants and their case-rate or line-item reimbursement, then find out how much money is being lost on cases due to implant expenses. Share data with payers to get renegotiations underway.
Read more insights from Surgical Information Systems here.
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