Becker's ASC Review

Executive Briefing: 22 Executive Briefing: Coding, Billing & Collections common procedures performed at the ASC for each payer and then assess the economic benefit of going OON versus staying in-network. "Don't go all in and cancel all of your in-network contracts at once," says Mr. Bartos. "We recommend a 'dip your toe in the water approach,' in which you choose one or two payers that represent a small amount of your business and go OON with those. If you are doing a good job after six to nine months, then you'll know you're in a position to go OON with other payers," says Mr. Bartos. "It is critical to take a structured, analytical ap- proach to this issue, so providers can assess which payers and procedures to focus on, whether you're handling it in-house or using an outside company," says Mr. Bartos. Myth 3: I am covered by my third-party rental network agreement. Providers may think third-party rental network agreements work on their behalf, but usually they have very little idea of who is actually accessing those contracts. As a result, providers get caught in a web of different types of contracts, and may be subject to a contract they don't even know exists. Third-party rental networks are not signed with an individual payer, but with a company which contracts with numerous pay- ers. Providers are contracted with all payers involved in the third-party network, but this can be disadvantageous from the provider perspective. "Third-party rental networks are a cost containment strategy for payers," says Mr. Bartos. A key point to consider with such agreements is there is no pa- tient steerage, unlike traditional managed care agreements, in which a provider accepts a lower reimbursement rate in ex- change for a higher volume of patients. Additionally, payers are not required to accept these contracts — they will pick and choose the contract that will get them the lowest rate. Also, they typically reimburse based on OON benefits, but allow the pay- ers to reduce allowables via UCR cuts, multiple procedure re- ductions and code edits, all in addition to the actual discount provided in the agreements. Myth 4: We are doing fine with our OON reimburse- ments. "When people think of their OON reimbursements, they have a tendency to compare them with their in-network, Medi- care and Medicaid rates and think that they're doing alright," says Mr. Bartos. "However, these are the wrong comparisons. The right comparison is whether they have maximized their OON reimbursements." When evaluating their current OON reimbursements rates, ASCs should assess their resource allocation. Does it have dedicated resources to handle OON claims? Does it have the specialized expertise necessary to be successful in dealing with OON bills? Does it have enough data to support negotiations? Are there defined appeals and audit processes in place? After addressing any deficiencies, ASCs will be positioned to achieve even higher OON reimbursements. Myth 5: Outsourcing doesn't make a difference. Increasing OON reimbursements is a labor-intensive process for ASC staff requiring focus. Before diving in, ASC leaders need to know if they have the proper resources and expertise on hand. For ex- ample, from start to finish, appealing an OON bill includes: • Initial intake: Have all necessary documentation, such as the explanation of benefits as well as a well-crafted assign- ment of benefits, on hand. • Payer verification: Contact the payer for a verbal explana- tion of the reimbursement. • Payer engagement: Present the relevant facts and data. Es- calate the issue when necessary. • Appeal follow-up: Ensure appeal reviewed and bill re-con- sidered appropriately. • Additional payment (if successful): Payers do not always pay on time or with the correct amount. Follow-up to en- sure the ASC is paid. • Auditing OON activity: Consistent monitoring of OON activity will allow ASC leaders to gauge how effective the strategy is. "Even with all the resources and data they have at their disposal, most payers outsource the handling of OON reimbursements, so ASCs should at least consider it," according to Mr. Bartos. If an ASC does not have the resources, expertise, or ability to manage the challenges posed by OON reimbursements, out- sourcing the job may be in its best interest. n Collect Rx Inc. provides services to hospitals, ambulatory surgical centers, physicians, and other healthcare providers to maximize reimbursements on out-of-network bills. Utilizing its proprietary CRXIS business intelligence engine and extensive industry exper- tise, Collect Rx Inc. helps providers increase revenue, save time, and improve the bottom-line.

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