Becker's ASC Review

6 ASC MANAGEMENT Claim checks all ASCs should have built in By Claire Wallace Billing can be a hassle for hospitals and ASC alike, and mistakes in claims submissions can be costly for health systems and patients. Brooke Day, administrator at Hastings (Neb.) Surgical Center, spoke with Becker's about the non-negotiable checkpoints every ASC needs to doublecheck before claims leave their in-house billing departments. Ms. Brooke Day: 1. Two-person verification before submission: is is your first and best line of defense. Whether you're using HST Pathways or AdvantX, two sets of eyes drastically reduce human error. ink of it as your built-in "gut check" before revenue gets le on the table. 2. Are the modifiers accurate and applicable?: Missing or incorrect modifiers are one of the most common reasons claims get denied. Are you billing multiple procedures on the same date? Are laterality or assistant-surgeon modifiers present where needed? If your coders aren't checking, your [accounts recievable] report will. For example, we always confirm in ophthalmology cases that if the diagnosis code is a le, the modifier matches. 3. Contracted rates and Medicare/Medicaid secondary: Medicaid will never pay more than its allowable, even when it's secondary. If your contracted rate exceeds that amount, you're eating the difference — no appeal, no fix. at gap can add up to thousands of dollars per case. At our centers, we always adjust the contracted rate to match the Medicaid allowable for these patients. is one step has a direct impact on your cash collections as a percentage of net revenue. We also pre-review high-dollar cases with Medicaid secondary to ensure we're not walking into a financial loss. Skipping this step leads to messy corrections, avoidable denials and tough questions during monthly financial reviews. Business office managers know the drill: Get ahead of it, or get ready to explain it. 4. Does the implant log match the charges?: e implant log isn't just documentation — it's directly tied to your revenue. If the log doesn't match what's billed at the CPT level, you're either leaving money on the table or triggering denials. is is especially crucial in orthopedic and pain-driven ASCs, where implant costs can be significant. To stay ahead, we scan and save the implant record and invoice in a shared file for every single case. Before submitting the claim, we verify the amounts to ensure accuracy. is not only speeds up clean claim submission, but it also gives us a clear audit trail for appeals. Trying to hunt down missing implant data a month — or three — aer the fact is a headache no one has time for. A few extra minutes upfront saves hours (and dollars) later. 5. Authorized code versus performed code: is is one of the easiest mistakes to make — and one of the hardest to fix aer the fact. Always confirm that the CPT code authorized by the payer matches the procedure actually performed. If there's a mismatch and no formal update or addendum, you'll end up chasing appeals instead of posting payments. is is easily managed by entering pop-up notes or alerts on the account, and ideally, your two-person verification process includes someone reviewing those notes before claim submission. We do not submit claims until this is verified and corrected if needed. Our standard is simple: Send it right, or don't send it at all. Accuracy here protects your reimbursement and avoids unnecessary delays. n A blueprint for sustainable ASC ownership By Patsy Newitt A s younger physicians weigh the burdens of ownership against the safety of employment, ASCs face a growing challenge: how to sustain physician engagement while maintaining financial stability. Shobhit Minhas, MD, an orthopedic surgeon at Fox Valley Orthopedics in Geneva, Ill., joined Becker's to share his perspective on what a best-case ASC ownership model could look like and why legacy approaches may no longer work. "I would think it would be reducing the buy-in costs into an ASC, whatever that would be," Dr. Minhas said. "But also, at the end of the day, the ASC has to make money, and that physician needs to bring it in, right?" In his view, a tiered partnership track, or "super partnership," offers a compelling structure for both younger physicians and the ASC itself. In this model, physicians don't become full partners immediately but work toward ownership over time, contingent on performance and financial contribution. "Most physicians in a private model don't become partners right away. It's usually a partnership track," he said. "If I were the CEO of an independent ASC, I would say: One, the physician has to at least demonstrate that the cases they bring in have a positive revenue margin for the ASC. Otherwise, they're not making money." One way to lower the ownership barrier, he said, is by offering financing support or spreading the buy-in cost over time. "They either provide a loan or something like that, or a way to finance it — or you pay it in dividends over three to five years," he said. "There are a lot of different models, but I would probably say even a smaller buy-in — but it may take longer to buy in — because you'd have to demonstrate that you have a robust enough practice with the right payers that allow for relatively high margins." Margin awareness is becoming critical as ASCs face tighter reimbursement and more scrutiny, particularly in joint ventures involving hospitals or private equity. While there's no one-size-fits-all solution, Dr. Minhas emphasized that flexibility and realistic financial entry points will be essential if ASCs want to attract the next generation of physicians. n

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