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30 Coding & Billing A re managed care contracts complicating your ambulatory surgery center's cash flow? Answering this question confidently is a prereq- uisite for success in today's competitive ASC mar- ketplace. In the past, managed care contracts were often filed away once the ink was dry, only to be unearthed again when it came time for renewal. Few, if any, staff were familiar with the agreement, its language or, many times, its very existence. Affordable Care Act implementation is changing that practice. Lower reimbursements and higher patient volume mean that ASC staff must now ac- quire a deep fluency in the logic and framework of their managed care contracts, particularly in three important areas. Multiple procedure discounting When ASCs sign a managed care contract, they often assume the agreement follows the stan- dard Centers for Medicare and Medicaid Services methodology, coding and reimbursement sched- ules, if not stated otherwise. That assumption is not always correct. And making matters worse, contractual language, especially for multiple pro- cedures, can be ambiguous and complex. For example, a contract may offer to reimburse at 200 percent of the Medicare rate. At first glance, this appears to be a more than fair rate — that is, until you read the fine print. In many cases, these seemingly competitive reimburse- ment rates may only apply to the first line of a claim. After that, the reimbursement for the sec- ond line may decrease to 25 percent, while the third and subsequent lines drop to zero. As a comparison, the standard Medicare reim- bursement methodology is 100 percent for the first procedure and 50 percent for each subse- quent procedure. While it's typical practice for payers to alter mul- tiple procedure logic or cap the total amount of reimbursements for a single patient, understand- ing a carrier's reimbursement methodology when multiple procedures are performed will help you negotiate a fair deal before the contract is signed. Proper claims submission Submitting claims improperly also can constrain an ASC's cash flow. ASCs should never standardize claims filings across the board for all payers and the appropriate payer-designated form should always be used. Failing to do so may mean pay- ment processing delays, revenue cycle disruptions or even outright claim denials. Claim submission on the wrong claim form could also result in the payer paying the claim at the professional rate, which may be lower than the facility rate. These requirements are often set forth in the pages of a managed care contract, and most carriers even specify the precise type of claim form that must be used. If this information is not included in the con- tract language, it's best to call the carrier directly to understand the proper claims submission. For example, some Medicare Advantage prod- ucts require a UB form rather than the CMS 1500 AnticipAte chAnge. We do. 2013 ® 636.273.6711 | www.nationalASCbilling.com the ASc Revenue cycle. It's all we do. It's all we think about. And it shows. Named one of the world's best outsourcing service providers two years in a row. – Fortune Magazine 2013 ACA Implementation Heightens Importance of Managed Care Contracts By Scott Allen, Vice President, Managed Care Contracting, National Medical Billing Services