Becker's ASC Review

18 Executive Briefing Sponsored by: M ore patients, higher debt levels, lower reimbursements, increased competition, labor shortages — it's never been more difficult to run a hospital or health system. A Moody's Investors Services report released in April showed that median operating cash- flow margins at nonprofit and public hospitals dropped to 8.1 percent in 2017 from 9.5 percent in 2016, press reports indicate. Healthcare leaders are well aware of these pressures, as shown by a recent poll of CEOs at 20 health systems. 1 The poll asked executives about their top concerns, and their responses should come as no surprise to providers navigating today's complex landscape: shrinking reimbursements; a transition from fee-for- service to value-based care; dwindling margins; not enough workers; technology gaps; and an increasingly consumer- focused marketplace. With these market forces unlikely to change, shifting strategies is one way providers can remain competitive. In its recent forecast, Moody's offered one promising approach: expanding ambulatory services. Even more, however, incorporating the right technology into these expanded outpatient services can help health systems, hospitals and outpatient facilities alike optimize their revenue cycle, which can boost operating margins, improve patient satisfaction and smooth the transition to alternative and bundled payment models. The revenue cycle defined The first step in an ambulatory surgery center's revenue cycle is vetting cases. Are all of the cases performed at the center profitable — at least theoretically? How about the managed care contracts and out-of-network cases? Performing a cost analysis on each type of case, developing a strict process for insurance verification and creating a roadmap for obtaining all necessary authorizations are the three most important factors in profitability. The next steps in the revenue cycle are scheduling and the pre-registration process, which typically requires patients to register in an online system and provide their medical histories. Insurance verification and pre-authorization are next, and these typically require business office staff to work with payers and determine any out-of-pocket costs for the patient. Once a patient is authorized and on the schedule, many facilities offer financial counseling to review patient financial obligations and the ASC's payment policies. After the procedure is complete, a physician dictates all relevant information to create the necessary documentation for coding and billing purposes, including what was observed while the procedure was performed. The transcription is then submitted to the coding department, where several code sets are used to identify all details from the surgery. A coding report is then sent back to the ASC, where it is loaded into a practice management system and billing platform. Charge entry is the next step in the process. All staff assigned to these tasks should be well trained and familiar with the center's rules, contracts and common dictation and coding issues, so they can prevent entry errors and reconcile billing. Staff should also monitor key performance indicators like the timeliness of dictation transcription, an often-overlooked metric that can curb the entire revenue cycle process. After the charge enters the system, the case is scrubbed, edited, compared to similar cases at the clearinghouse and sent to the carrier. If approved, the carrier sends a reimbursement for the case and the payment is posted, which is applied to the patient's balance. Carriers are always looking for a reason not to pay, so cases are routinely denied. These cases are then handled by the denial management department or a third party, which researches and analyzes why these cases were rejected and determines how to resolve the outstanding issues. The latter process often requires several phone calls and follow-up emails and, ultimately, denied cases are typically resubmitted according to the carrier's policies. The last step in the revenue cycle process is accounts receivable, which manages incoming payments, generates analytics reports and monitors accounts with overdue patient balances and cases that have not yet been reimbursed. Technology's role in enhancing an ASC's revenue cycle and profitability By Angela Mattioda, vice president of revenue cycle management services, Surgical Notes RCM

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