November 12, 2015
Ambulatory surgery centers (ASCs) are gearing themselves to face the new challenges that can arise with the coding changes including ICD-10, which can add to the woes of the physicians. All along, physicians have been collecting payments from payers; however, with new changes being enforced in the reimbursement models, the burdens of the patients will see a marked increase. Here are 5 unique things that are set to make ASC billing a lot more complicated.
Errors in codes and OP reports
Some physicians are quite meticulous in their ways, and insist on preparing exacting operative notes, especially CPT codes. For instance, with ICD 10, it would be helpful if physicians focused on improving clinical documentation at the front end. This way, coders don’t have to go back retrieving information that was not provided in the first place itself. However, in spite of this, it is the bounden duty of the coder to scan through the OP report and ensure that the codes entered are absolutely correct. If the ASC wants the claims to be settled without any hassles, documentation has to be perfect, ensuring there is no error in the coding before the billing procedure can commence.
Out-of-Network a Big Challenge
The out-of-network claims that are being processed each year across the country add up to a whopping $600 billion. More often than not, most big-time and small-time payers tend to clamp down on out-of-network payments. They tend to scrounge and either pay a much smaller amount, or prefer to not pay at all. In such cases the ASC has to fight for its money. This is a recurring issue with most physicians and surgery centers. Most out-of-network claims are scrutinized thoroughly, and payers too tend to be quite aggressive with their audit procedures. They even go to the extent of demanding refunds from providers. Some would rather terminate a contractual relationship with a provider, leading to physicians desisting from conducting surgical procedures in any out-of-network surgery center.
Using tailor-made reports
According to Stephanie Ellis, Founder-President of Ellis Medical Consulting, more often than not physicians resort to using template reports for a record. Instead, they should be creating individual outpatient reports relating to a particular patient detailing the procedure that was performed. While physicians who are hard pressed for time find the easy way out with these templates, the ASC concerned may be pulled up for shoddy documentation. Medicare for one frowns at such practices, and considers such template based reports equivalent to ‘cloned records’, which as per law is considered fraudulent and abusive. However, physicians may use templates, though they need to ensure that vital information like patient complications, procedural complications and any changes in medication or dosage need to be included.
Physicians generally are a harried lot, splitting and juggling their time between the various locations they need to be at in the course of the day or night. Physicians may indulge in dictating from a remote location while they are on the move, often leading to compliance issues. Operative reports should list the ASC the procedure was performed at, rather than the hospital or clinic the physician is attached to. Unless this is followed religiously, there is bound to be a mismatch in the operative report and claim as far as the location where the procedure was conducted is concerned. This is considered as gross violation, and can be classified as a fraudulent claim by Medicare.
Geography makes the difference
The exact location of the ASC makes all the difference in the long run. While some parts of the country may have either very low number of independent physicians, yet others may have an abundant number. The presence of constitutional law (CON) is also a factor. Moreover, most of the local hospitals may not be in favor of joint ventures. There may also be a concentration of hospital employment in some parts of the country, which again is a deciding factor. Some markets suffer from poor market reimbursement, while yet others have excellent evidence for the same.
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