There are many processes that affect your ASC's profitability. So many, in fact, that it is often extremely difficult to find and fix all of the potential revenue leaks occurring in these processes.
Part I of this two-part article series highlights eight pre-procedure reasons why your ASC may be losing money and provides recommendations for correcting these problems.
Reason #1: Non-covered procedures
Cause: No policy or procedure is in place to determine whether a scheduled case (i.e., CPT) is covered by the patient's carrier or approved for performing in ASC setting.
Solution: Schedulers must be terminology and CPT savvy and understand how their job impacts revenue. Ensure that schedulers have a list of covered procedures by CPT as well as an insurance matrix showing all carriers accepted by the ASC.
Schedulers are your first contact to receive accurate demographic and insurance information from the provider. Nothing increases your accounts receivable (A/R) like performing a non-covered procedure.
Reason #2: Non-specific and incomplete insurance verification
Cause: Insurance verification specialist is only performing non-specific Internet verification of patient's insurance. This type of verification does not require identification of CPT or diagnosis code to confirm coverage.
Solution: Direct contact with the insurance carrier may be required to obtain necessary information. Determine eligibility for the patient for the specific day of surgery, specific planned surgery and diagnosis code. Verification should reveal medical necessity (as determined by provider), second opinion requirements, limits of coverage, pre-authorization code, non-covered pre-existing condition, coverage of specific family member scheduled, out-of-network benefits, claims address and patient financial responsibility (i.e., co-payment, deductible, co-insurance).
Reason #3: No pre-procedure patient financial counseling
Cause: Patient financial counseling is not performed until patient arrives on the day of their procedure. The patient is unprepared to pay copayment, deductible and/or co-insurance amounts.
Solution: Contact the patient at least three or more days prior to procedure to advise them of their financial responsibility as the patient may need such time to make payment arrangements. Provide the patient with all methods of payment offered by the ASC (e.g., cash, credit cards, healthcare credit companies, credit card or checking account debit payment plans, promissory notes (as a last resort)). Advise registration desk of pre-procedure payment commitment/arrangement.
Reason #4: No verification of patient information at registration
Cause: Demographic information and insurance information in computer are not verified with the patient at time of registration on day of procedure.
Solution: The registration clerk performs an important function in the collections process. The information in the computer is third-hand information: patient to provider's office, provider's office to scheduler and scheduler to computer. Although the patient financial counselor verifies information when contacting the patient by phone, the importance of this final check for accuracy cannot be stressed enough.
Review the information with the patient — it may have changed or be incorrect. Request additional phone numbers, such as mobile and business. Inaccurate or missing information tends to cause delayed or denied claims.
Reason #5: No copy of patient's insurance cards
Cause: Registration clerk does not make a copy or scan of the front and back of the patient's insurance identification card.
Solution: Even if you have a copy of the insurance card from the provider's office, make another copy or scan at the time of registration. The patient's insurance may have changed. Be sure to copy or scan both the front and back of the card as the back is often where you find the claim address. Be sure the copy is legible. Verify or correct insurance information in computer.
Reason #6: No pre-procedure collections
Cause: Registration clerk not consulting information provided by patient financial counselor regarding patient's payment commitment, therefore no collection of patient's financial responsibility prior to procedure occurs.
Solution: On day of procedure, the registration clerk or designee should privately consult with the patient regarding financial responsibility commitment made to the financial counselor and collect agreed-upon amounts from patient. It is much easier to collect prior to the procedure than after.
Reason #7: Long-term payment plans (promissory notes)
Cause: The ASC accepts payment plans that are for long periods of time or worse, such as accepting whatever the patient pays, whenever they pay it, with no designated and enforced payment plan.
Solution: If a patient is unable to meet their financial responsibility, and none of the other offered payment alternatives are viable, ask them to sign and agree to a payment plan (promissory note). This process of signing a document and having their signature witnessed and notarized promotes the appearance of a binding contract. If at all possible, avoid offering payment plans longer than 90 days.
The collector should monitor any payment plans monthly for timely payments and notify management of default.
Reason #8: Delayed operative/procedure notes
Cause: Providers are delinquent or non-compliant with dictation of operative/procedure notes.
Solution: Each day that dictation is delayed increases the days in A/R, decreases the projected revenue and often makes collection more difficult. The primary goal is to have the claim go out in 48 hours. The coder can only code from the actual operative/procedure note, not the title of the procedure from the schedule. Ask the provider to dictate on a timely basis and fully dictate all procedures/treatments.
As problems grow, so do losses
The scenarios above illustrate some common and often undetected processes where an ASC can lose money. Even if some of these shortcomings occur infrequently, multiple occurrences can adversely affect your ASC's revenue stream.
Part II of this two-part article series will address post-procedure reasons why your ASC may face a decreased revenue stream.
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.