Michael Orseno, revenue cycle director at Regent Surgical Health, identifies four common areas that translate into lost income and the policies ambulatory surgery center leaders can put in place to overcome these revenue cycle issues. 1. Insurance verification. Insurance verification is a simple process, but when overlooked it translates into lost revenue. If insurance is not verified, ASCs may lose money on uninsured patients or those who recently lost their benefits. "At Regent centers, 100 percent of cases need to go through the insurance verification process. This has alleviated past issues of performing cases for free," says Mr. Orseno.
A policy for regular insurance verification is easily implemented. With software, such as HST Pathways and ZirMed, verification can be instantly obtained and viewed in a patient's chart. ASC leaders are able to see a whether a patient’s insurance is active, their co-pay, co-insurance, deductible and remaining deductible. Pre-operative authorizations still require manual staff time, but the entire process serves as a way to prevent lost revenue.
2. Scheduling. Proper scheduling is key to ASC efficiency and operational success. But, scheduling is not only about maximizing operating room time. The types of cases scheduled are equally important. Effective schedulers will have a grasp how profitable cases are based on case cost and payer reimbursement. "Perform case costing and know your margins," says Mr. Orseno.
Scheduling is of particular importance in centers that rely on a high volume of out-of-network cases. "In out-of-network facilities you want to avoid scheduling cases with patients that have a high out-of-network deductible or no out-of-network benefits ," says Mr. Orseno. Insurance verification is the first step in understanding which cases make sense to schedule and which do not.
As a number of ASCs begin to take on higher acuity cases, such as joint replacement, the implant price becomes an important consideration during scheduling. A single implant can cost $20,000. Perform a return on investment analysis and determine whether or not reimbursement for the procedure will cover its costs. Consider implementing a protocol requiring administrator approval before scheduling a high-price implant case.
3. Insurance follow-up. Thorough follow-up ensures ASCs capture as many dollars as possible for the cases performed. "Know your contracts and don't accept anything less than what you are contractually owed," says Mr. Orseno. In the case of out-of-network centers, payers will often attempt to settle for 20 percent or less of a procedure's gross charges.
Policies need to be put in place to verify that the center is receiving maximum reimbursement. If a payer is not meeting contractual levels, appeal the underpayment immediately. In out-of-network centers, create a threshold for reimbursement and if that threshold is not met, escalate the issue with payers.
4. Patient collections. Rising patient deductibles and out-of-pocket costs are a well-known issue in healthcare. ASCs will lose money unless they make an effort to discuss this fact with patients prior to the procedure. "The chance of collection drops 50 percent after the procedure is done and it continues to drop every 30 days without payment," says Mr. Orseno.
After insurance has been verified, ASC leaders can sketch an estimate of what a patient's financial responsibility will be based on the deductible and co-insurance. Review a patient's benefits with them and explain the cost. Determine a set amount that is due before the procedure and explain payment options for any amount remaining after the payer has adjudicated the claim. Open communication prepares patients for their financial responsibility and mitigates the risk of ASCs losing on collections.
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