One of the most important facets of ambulatory surgery center (ASC) revenue cycle management is securing accurate and timely reimbursement from third-party payers.
This can also be one of the most difficult. Purposefully or not, payers often look for any reason they can to deny or delay proper reimbursement. The best remedy to thwarting these actions is to not provide a reason. If you do, then it's pivotal that you correct it in a timely manner.
The following tips cover best practices for successful third-party payer collections.
1. Recheck the accuracy of registration information prior to claim submission.
2. Understand the different ways your revenue cycle software measures accounts receivable (A/R) and which reports are pertinent to collection tasks.
3. Keep third-party payer contracts and fee schedules updated in the software.
4. If allowed, file all claims electronically. If a claim must be filed on paper, file it immediately and include all additional information required (e.g., operative note, invoice, history and physical).
5. Receive receipt from clearinghouse ensuring all electronic claims have been accepted and forwarded to payer.
6. Immediately follow up on all clearinghouse denials.
7. After electronic submission, ensure payer has received the claim (i.e., the claim is on file).
8. Follow up on claim progress (e.g., first follow-up in approximately two weeks, thereafter additional follow-ups conducted at least every 30 days until resolution).
9. Establish collector goals and enforce them. Consider offering an incentive for consistently meeting goals.
10. Run the "aging report by payer" in your software on a weekly basis to identify and contact delinquent payers.
11. Develop protocol for handling delinquent payers.
12. Develop a method of tracking denials to identify trends.
13. Understand the terms in your payer contracts (e.g., requirements for timely filing, appeals, claim corrections) and your state’s prompt payment regulations. Enforce these with your payers.
14. Immediately respond to payer requests for additional information (e.g., operative notes, invoices).
15. When necessary, copy your state insurance commissioner on improperly paid claims or claims not paid in a timely manner.
16. If indicated, consider involving the payer's provider representative concerning reimbursement issues.
17. Ask pertinent questions of payers that require more than a form letter response.
18. Document all correspondence (letters, e-mails, telephone calls) with payers. Include date, name of payer representative and any actions taken or promised by payer.
19. Customize appeal letters to payers and always include supporting documentation.
20. Always take appeals to highest level of adjudication.
Although there are always exceptions to the rule, following these best practices will give you the best chance of receiving accurate reimbursement in a timely manner from your third-party payers.
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.