Errors that prevent your ASC from receiving full reimbursement may occur in several areas of the revenue cycle. The following are eight common mistakes that may affect your ASC's reimbursement.
1. Missed coding opportunities — Inexperienced coders often code from the surgery schedule or operative note title, which may lead to missed allowable codes and less reimbursement. Reading the entire operative note sometimes reveals that the provider performs more procedures than those listed in the title. Coders should recognize when additional procedure codes may be added while still maintaining compliance with state and federal healthcare requirements.
Another area of coding importance is the proper use of modifiers. Modifiers not only help correctly identify parts of the anatomy but also variations or specificities to the procedure. Failure to use the appropriate modifiers may negatively affect your reimbursement and possibly cause an unnecessary denial. Using certified, ASC-experienced coders is your best choice for optimized coding, whether through in-house employment or outsourcing to a reliable company partner.
2. Not updating coding reference guides — Using outdated CPT and ICD-10 reference books may lead to serious compliance issues as regulations and requirements change frequently. The Office of Inspector General monitors and enforces these changes and non-compliance may result in fines. It is a smart investment to purchase the annual updates of necessary coding books/software.
3. Failure to verify patient's insurance — Eligibility determination (establishing whether a patient's insurance will reimburse your ASC) is vital. Prior to the date of the procedure, it's important to acquire all necessary information needed to submit a clean claim (e.g., precertification or authorization numbers, dates of injury for workers' compensation, in- or out-of-network benefits, patient financial responsibility, eligibility).
4. No pre-procedure financial counseling — After verifying the patient's primary and, if applicable, secondary insurance coverage and determining their estimated financial responsibility (deductible, co-payment, co-insurance), it is imperative to contact the patient in advance of the procedure date and provide them with this information. You should also alert them to the fact that these are estimates and they will be billed post-insurance payment for the amount their insurance company doesn't cover (co-insurance/out-of-pocket amounts).
In today's managed care markets, high-deductible plans are becoming more common; however, this increased financial burden may be difficult for some patients to meet. If patients are aware of their financial responsibility, they will be provided the opportunity to determine which method of payment will best suit their needs. Offer alternatives to cash such as credit cards or medical credit companies. As a last resort, short-term promissory notes may also be an option.
5. Delayed claim filing — Understand your filing deadlines as outlined in your third-party payer contracts. Some payer contracts may require a short timeline, with failure to meet these constraints possibly resulting in non-payment of claims. When negotiating your contracts, it is important to aim for a one-year timely filing deadline such as those through Medicare and most government payers.
6. Neglecting to appeal denied claims or erroneous reimbursement — It's important that your ASC has an experienced payment poster who knows when a claim is paid improperly (or denied completely) and understands the need for submitting an immediate appeal. The best preventative measure in catching these errors is to enter your third-party-payer contract allowances into your billing software so that it will automatically alert your payment poster of improper reimbursement.
If your software does not have this capability, create an insurance matrix with contract allowances for each payer and ensure that your poster refers to these when posting payments.
7. Not billing patients on a timely basis — Patient billing is a task that is often overlooked or postponed. Be sure that your ASC is collecting deductibles, co-payments and co-insurance prior to surgery. As soon as you receive payment from the insurance company, it is important that you immediately bill the patient for their co-insurance/out-of-pocket amount. If a patient doesn't receive a bill for several months, they may assume they do not owe you money. These patient balances, while often not large amounts, increase your overall accounts receivable total.
8. Failure to negotiate good managed care contracts — Managed care companies continue to tighten contract requirements, decrease reimbursement rates and increase patient financial responsibility — all while patient premiums continue to escalate. That's why it's so important to have a knowledgeable and experienced managed care contract negotiator assisting your ASC in obtaining the best possible contract rates and terms. There is so much more to successful negotiations than just receiving across-the-board reimbursement rates (e.g., implant coverage, carve-out procedures, claim filing requirements). Negotiating a contract that your ASC can live with has become an art form.
Improving the Bottom Line
Understanding and preventing these possible fissures in your ASC's financial foundation can be key to your economic success. Whether improving your in-house competencies or outsourcing to a reliable revenue cycle management company, it's important to remember you are protecting your ASC's reputation and making an investment in its financial future.
Caryl Serbin, RN, BSN, LHRM (caryl@serbinmedicalbilling.com), is president and founder of Serbin Medical Billing, an ASC revenue cycle management company. Serbin Medical Billing's primary objectives are to provide the best coding, billing and accounts receivable management services available to ambulatory surgery centers (hospital joint-venture, corporate-owned or independent) and anesthesia providers. Serbin has been a leader in the ASC industry for 30 years. She was the founder of the first ASC-specific billing company.
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