Overview: COVID-19 and Ambulatory Surgery Centers
Over the past six months, as hospitals worked to care for the surge of COVID-19 patients on top of their typical stream of patients requiring emergent care, ambulatory surgery centers (ASCs) further cemented their place as the preferred choice for elective surgery by patients and physicians. Industry experts are predicting that the migration of procedures out of the inpatient setting and into the outpatient setting, primarily ASCs, will continue.
They attribute this continued increase in moving cases to ASCs to reasons that include the following:
• Patients choosing ASCs over hospitals due to safety concerns (e.g., COVID-19 and other respiratory illnesses, infections) and cost savings.
• Surgeons are increasingly performing procedures in ASCs rather than hospital outpatient facilities because of safety, familiarity with staff, more control over the operating/procedure room, and patient request.
• Third-party payers are channeling more cases to ASCs due to cost savings — a trend that is expected to pick up steam.
• Centers for Medicare & Medicaid Services (CMS) is expected to continue approving more procedures that can be performed in ASCs because of safety, efficiency, and cost.
As healthcare experts predict a possible second wave of COVID-19 (or what one might consider an extension of the first wave) that will bring an increase in cases in conjunction with the fall influenza season — a potential "double epidemic" — ASCs should remain in a strong position to capture the case overflow from local hospital(s).
Preparing the ASC Revenue Cycle for a "Second Wave of Disruption"
From a financial perspective, when the stay-at-home and prohibition on elective procedures orders were issued, many ambulatory surgery centers found that they were unprepared to effectively manage their revenue cycle management tasks offsite and often with reduced staff support. This resulted in a disruption of cash flow, declining performance of key performance indicators (KPIs), and other financial harm.
In anticipation of a second wave of the novel coronavirus, and thus a potential "second wave of disruption" to business office operations and revenue cycle performance, ambulatory surgery centers should be preparing for the off-site continuation of coding, billing, and collections. This may involve ensuring provisions for current business office staff that will enable them to work effectively and efficiently from home or by outsourcing revenue cycle management to a company that prepared for disruptions and has employees able to work off site and support new clients.
Applying Revenue Cycle Management Lessons Learned
Now is also the time for ASCs to review what they learned during the initial disruption of services and undertake serious planning for the possibility of minor to major future disruptions of daily operations. Considering some of the changes that have transpired and/or may occur in the coming months, such as increased or decreased caseloads, changes to specialty mix, and staff turnover, ASCs should evaluate all areas of their revenue cycle and the supporting staff to address possible modifications to workflow and processes.
Coders
If you had an influx of new physicians with specialties and/or procedures new to your ambulatory surgery center using your ASC rather than a local hospital, are your coders able to cope with the increased volume and unfamiliar specialties/procedures? Growing your coding staff may be necessary. At a minimum, your coders may need education on the additional specialties/procedures.
Billers
For most centers that closed or greatly reduced their operations due to the COVID-19 recess, few, if any, pending claims were filed. Have these past-due claims been submitted? If so, were they sent within the third-party payers' "timely submission of claims" requirements in your contracts? If your center is experiencing a growth in its caseload, assess the ability of your billing staff to keep up with their claim submission responsibilities. It is better to address this possible problem in advance rather than trying to catch up once the billing has fallen behind.
Third-Party Payer Collectors
In most instances, collectors were unable to work with payers during the COVID-19 recess to determine if accurate reimbursement was received on previously submitted claims. The over 30-, 60-, 90-, and 120-day accounts receivable buckets ballooned, and the revenue stream slowed to a trickle. The need to clear up this backlog of erroneous or denied claims within the timely submission guidelines may have placed an increased workload on your collectors.
Therefore, it's important that you closely evaluate whether your collectors will be able to effectively handle this backlog in addition to the current caseload, which may include catching up on old claims and submitting more claims than usual if new specialties and/or procedures have been added.
Patient Collections
Due to the mass closure of businesses and lay-off of millions of workers, patients fell behind in paying their account balances and most ASCs were reluctant to invoke collection actions. As many of those who lost their jobs during this ongoing pandemic have yet to find employment, most are still unable to meet their financial responsibilities. Although patient collectors are now able to send patient statements, collection efforts are expected to meet with less than positive results.
ASCs should stay vigilant in their efforts to collect from patients but also remain sensitive to the potential financial challenges many patients are facing. Your center may want to consider offering a promissory note or payment plan as a last resort.
Staffing Levels
Many ASCs lost members of their business office staff due to layoffs, illness, or those choosing a career change that would permit work-from-home employment. Finding experienced replacement staff may prove more difficult because of the high demand for health workers and push for increased wages due to the elevated risk of delivering patient care. In addition, there remains the uncertainty of what effect the possibility of a second wave of the virus will have on whether ASCs will remain open and, thus, staff employment.
ASCs need to concentrate on replacing their staff members while best ensuring that employees will be able to work off-site in the event of center closure. This means that management also must address the need for additional equipment and off-site HIPAA-compliant network connectivity with a high enough internet speed as well as telephone, faxing, and/or printing capabilities for all members of the revenue cycle team and support staff.
Navigating More Familiar Waters
Even though medical experts are predicting another increase in COVID-19 cases this fall season, no one is sure exactly how this will affect ambulatory surgery centers and other healthcare organizations. Although everyone was essentially unprepared for the first wave, we have had time to evaluate our experiences and improve our emergency preparedness and response. ASCs must take whatever steps are necessary to ensure they are better prepared to face the possibility of another recess or decline in cases. Failure to do so could jeopardize their future.
Caryl Serbin, RN, BSN, LHRM, 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. Ms. Serbin has been a leader in the ASC industry for 30 years. She was the founder of the first ASC-specific billing company.