Effective revenue cycle management is the most important factor in maintaining the financial health of an ambulatory surgery center. The revenue cycle is comprised of several co-dependent processes that rely on both ASC software technology and billing expertise. The revenue cycle process begins with the capture of patient information at the time of scheduling. A complete solution also includes timely transcription services, precise coding, claims management, collections, managed care contracting, and strong business intelligence analytics. A mistake made at any point throughout the revenue cycle process can negatively impact a facility’s bottom line. To help keep billing errors at a minimum, here are 07 common revenue cycle mistakes made by ASCs and guidance to avoid them.
Your biller should have a copy of every managed care contract and understand the details of each one. You need to understand how long you have to submit a claim, how long you have to review an adjudicated claim, what the payment methodology is, why a carrier would reduce multiple procedures and how to appeal a claim that hasn’t been paid correctly. Your ASC should use your managed care contract to bill out, post payments and follow up, and you need it at every point of the revenue cycle.
For example, by reading your managed care contract carefully, you will avoid taking an orthopedic case with a $2500 implant attached when you have a carrier that doesn’t reimburse implants. This problem can be solved through simple research. Make sure you have your contracts on hand and refer to them frequently. Understanding the ins and outs of your contract can help you save money and make you more aware of which procedures are most profitable to your center.
Prior to the date of surgery, verify eligibility of the claim and the claim address with the payer to understand coverage and determine the party responsible for payment. Significant delays in reimbursement may be experienced if the claim is not sent to the correct managed care plan, independent practice association, carrier, or home plan. Also, obtain authorizations for the correct procedure and include implants and costly supplies. When working with out-of-network carriers, ask specific questions related to a case’s reimbursement to determine the case’s profitability. As an example: If the carrier is United Healthcare, ask if it is a maximum non-network reimbursement plan and if payment is based on the Medicare fee schedule. If the carrier is Aetna, ask if payment is based upon reasonable and customary fees or the Medicare fee schedule. Pre-negotiate coverage with adjusters for any uncovered procedures and/or implant(s) and obtain commitments in writing.
Many ASCs don’t realize that Medicare will not reimburse for a patient who is treated in an ASC that resides in a skilled nursing facility (SNF). Medicare will absolutely not reimburse any procedure for these patients in an ASC. ASCs that have previously treated patients from skilled nursing facilities will most likely be subject to reimbursement takebacks for procedures that occurred since Jan. 1, 2008. While there’s nothing ASCs can do to combat this decision, you should still prepare yourself for takebacks by identifying your skilled nursing facility patients.
You should be aware of carriers who don’t have to follow standardized coding practices because of HIPAA exemption. Worker’s comp carriers, small carriers and other carriers that are HIPAA-exempt can come up with home-grown codes, and you’re not going to get paid if you use standardized codes. To avoid having your claims rejected, make sure you know whether your carrier is exempt.
Once you’ve referenced the operative report and you know which codes to bill, it’s essential to put your codes in the right order. Make sure you record your codes from highest reimbursement to lowest reimbursement so that you don’t lose money unnecessarily. For example, Medicare will reduce the procedure you list second by 50 percent, so if you have one procedure listed at $1,000 and another listed at $750, you want to take the cut on the $750 procedure so that you lose less money. It may be possible to correct your reimbursement if you make this mistake, but we recommend doing it right the first time to save yourself a lot of hassle.
Medicare will not allow you to bill for a post-operative pain block provided by the surgeon. As per NCCI Policy Manual, Medicare global surgery rules prevent separate payment for post-op pain management when provided by the physician performing an operative procedure. The pain block if performed by the anesthesiologist, should be billed by the professional side only and not the ASC.
Coding is one of the most important functions in the revenue cycle. Common errors have the potential to significantly impact financial performance. These include not coding at the highest level, missing implants, not coding bilateral procedures, not using the correct modifiers, unbundling, and not coding for payable supplies. Per Medicare guidelines, CPT codes submitted should be the same between the surgeon and the ASC. Communicate regularly with surgeons’ offices to avoid payer delays due to coding discrepancies between claims. If coding is performed at the facility, ensure that the coding team receives ongoing ASC coding training and education on the most current coding rules as well as changes in federal regulations.
Tip: If your ASC removes one polyp with a snare technique and a separate polyp for a hot biopsy, you can report two different codes for the session. ASCs can bill for different colonoscopy techniques in the same session. However, if you remove multiple polyps with the same technique, you can still only report it once.
If you feel staffing a skilled revenue cycle team for your ASC, is a challenge, consider outsourcing. Significant efficiencies and bottom-line improvements can be realized by partnering with a vendor that offers leading technology solutions and services throughout the continuum of care. Medical Billers and Coders (MBC) offer complete transparency and control of the ASC revenue cycle along with key analytics, actionable insights, recommendations, and proven strategies. Such offerings will maximize the ASC’s efficiency, profitability, and physician disbursements. To know more about Ambulatory Surgical Center medical billing and coding services contact us at 888-357-3226 / info@medicalbillersandcoders.com
