Becker's ASC Review

24 • Patient education. Our staff uses a personalized approach to educate patients. is allows patients to know exactly what to expect before, during and aer surgery in both clinical and financial terms. We are 100% transparent with surgical costs and advertise the low-cost benefits of TJR surgeries performed in our surgery center via our website, the radio and highway billboards. • Aggressive post-operation recovery. We make sure that patients are up on their feet the same day as surgery, usually within two hours aer the procedure, depending on the rate of progress. is allows both the patient and the physician to feel comfortable with releasing the patient quickly. • Coordinating home care. We ensure beforehand that patients have adequate support at home aer their surgery, whether it's a family member or professional home healthcare worker. We work closely with home healthcare workers so that they contact the patient, and visit before surgery, to let them know what to expect once home. ey also visit the patient at home the day of surgery. • Losing the tourniquet. We've been able to take advantage of modern technology to begin conducting knee surgeries as computer-navigated, tourniquet-less procedures, which ultimately allow for a much quicker recovery with less pain. • Using an anterior approach on hips. Surgeons have refined surgical approaches over the years to aid in maximizing exposure necessary to complete the surgery successfully, while minimizing adverse effects and cuts to the surrounding tissue and muscle. Less pain decreases the need for prescription narcotics, which could be beneficial considering our nation's current opioid crisis. Individuals seen in an outpatient facility are at lower risk for exposure to infections, which is oen a concern in hospitals. Since beginning total joint replacement procedures on optimized patients, we've had a total of zero infections at our surgery center. While it's important for TJR surgery to be successful from the patient's perspective, it must also be successful—or profitable—for us as a business. erefore, medical coding and billing procedures need to be accurate and efficient, while creating cordial working relationships with insurers to ensure optimized reimbursement. anks to profit-sharing with all employees, the Surgery Center at Pelham has lower staff turnover than most facilities. Giving employees a vested interest can encourage reduced cost and waste. Both our surgeons and business office staff are experienced and knowledgeable, creating a more streamlined process for clinical and front-desk procedures. Perhaps the most significant of the business office staff 's responsibilities—one where it's critical not to lose that knowledge base—affecting patient satisfaction and an organization's bottom line are coding and billing. One year before performing our first total joint procedure, we began working with third-party insurers and employers to develop clinical protocols in hopes of standardizing care and generating quicker pre-approval from payors for these types of surgeries. In fact, insurance companies have since used our proposed standardized protocol to judge the processes of other healthcare organizations in various regions. It's no question the business office personnel are integral to coding, billing and proper reimbursement. Naturally, they need to ensure that patients meet pre-surgery requirements, but they also need to be thoroughly trained in financial counseling, the pre-authorization process, insurance verification and eligibility, providing an estimate of the patient's financial responsibility in addition to collecting the deductible, co-pay or co-insurance in advance or on the day of surgery. Indeed, each of these functions encompass numerous other components that can ultimately affect a patient's health and an organization's revenue. If the staff doesn't have comprehensive knowledge of these areas, costly errors are likely to be made. Medical coders must know each patient's specific health insurance contracts through and through. Not only do they need to know the relevant codes for each surgery, but how particular implants and procedures are reimbursed. Every contract uses the same common procedural terminology (CPT) codes, for example, but how they determine implant reimbursement will likely be different depending on the contract. Creating summaries of pertinent information from each contract can enable coders to easily and quickly find needed information. Each managed care contract is likely to stipulate exactly how an implant must be billed. For example: An insurance carrier's HMO contract might outline a specific amount be paid to the ASC for a total joint procedure, with the implant cost included in that reimbursement amount. e same carrier's PPO contract may pay a certain amount for the procedure, with separate reimbursement for the implant and even additional reimbursement for shipping, handling and tax. Managed care contracts will also stipulate what documentation each payer requires for different implant charges. Some payers require electronic billing and then may request the implant invoice later. Others may have a portal where the ASC is required to upload each implant invoice or may request paper copies of invoices. When the payments are received, staff members need to ensure that the payments match the amount stipulated in the contracts. Most importantly, they need to flag underpayments. For example, when a payment was received for $18,000 but the contract stipulated $22,000, staff members need to note this underpayment and follow up. In addition, sometimes payers will lump payments into one line on the EOB. ese payments must be posted by line item to ensure that each code is reimbursed properly. Because total joint surgeries are big ticket items, it's important to conduct a monthly audit to ensure that each procedure was coded, billed and paid correctly. If you uncover any discrepancies, drill down to see where the mistake originated, and then file an appeal if warranted. Pay particularly close attention to implant billing, since implants are expensive items that could represent 25% to 30% of your overall reimbursement and payment for them is closely tied to very specific contract stipulations. Remember, your center has to buy these implants upfront--so if you are not paid correctly, your ASC will take a hard-dollar loss. e devil is in the details, as the saying goes. Even a seemingly insignificant mistake could lead to denials, incorrect payments, underpayments or even no payment at all aer we have already incurred significant expenses. Whatever the case, the more knowledge of contract details an ASC's staff has, the less likely it will be to delay the billing process and lower potential reimbursement. For Surgery Center at Pelham, knowledgeable patients and skilled staff, as well as a proactive team work approach to patient education and clinical procedural modification, has led to successful and profitable total joint replacement surgeries for patients in an outpatient setting. References 1. Vizient. Outpatient Joint Replacement: An Unnecessary Concern or Market Reality? https://newsroom. vizientinc.com/newsletter/research-and-insights-news/outpatient-joint-replacement-unnecessary-concern- or-market-rea

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