Becker's ASC Review

Executive Briefing: 20 Executive Briefing Sponsored by: Avoiding 10 Common Billing Mistakes That Slow The ASC Revenue Cycle By Angela Mattioda, Vice President of Revenue Cycle Services, Surgical Notes RCM E ffective revenue cycle management is the most important factor in maintaining the financial health of an ambulatory surgery center. The revenue cycle is comprised of sev- eral codependent processes that rely on both ASC software technology and billing expertise. The revenue cycle process begins with the capture of patient information at the time of scheduling. A complete solution also includes timely transcrip- tion services, precise coding, claims management, collections, managed care contracting, and strong business intelligence analytics. A mistake made at any point throughout the revenue cycle process can negatively impact a facility's bottom line. To help keep billing errors at a minimum, here are 10 common revenue cycle mistakes made by ASCs and guidance to avoid them. 1. Failure to thoroughly verify benefits and receive ap- propriate authorizations. Prior to the date of surgery, verify eligibility of the claim and the claim address with the payer to understand coverage and determine the party responsible for payment. Significant delays in reimbursement may be experienced if the claim is not sent to the correct managed care plan, independent practice association, carrier, or home plan. Also, obtain authorizations for the correct procedure and include implants and costly supplies. When working with out-of-network carriers, ask specific questions related to a case's reimbursement to determine the case's profitability. As an example: If the carrier is United Healthcare, ask if it is a maximum non-network reimbursement plan and if payment is based on the Medicare fee schedule. If the carrier is Aetna, ask if payment is based upon reasonable and customary fees or the Medicare fee schedule. Pre-negotiate coverage with adjusters for any uncovered pro- cedures and/or implant(s) and obtain commitments in writing. 2. Unnecessary or inappropriate discounts. ASCs should not be compelled to reduce a patient's financial responsibil- ity. While there are appropriate times to provide hardship discounts, routinely waiving or discounting patients' financial responsibilities will negatively impact the facility's bottom line. Additionally, this practice may violate certain insurance con- tracts as payers expect providers to collect fees not covered by insurance. To collect what is owed to the facility, communicate the pa- tient's financial responsibility prior to the date of service. Offer payment alternatives to help patients meet their obligation and retain copies of any such agreement in the patient chart. 3. Failure to address local coverage determinations. Com- mon reimbursement delays can be reduced by knowing your procedure's LCDs. Understanding the appropriate LCDs is necessary for thorough documentation which will prevent medical necessity denials. 4. Incomplete patient information. To ensure accurate cod- ing and billing, it is imperative to assemble a comprehensive patient chart. This includes all medical records, patient pay- ment receipts, promissory notes/payment plan agreements, implant log/invoice, patient identification, insurance identifica- tion, and insurance verification and authorization. Coders should have access to the complete patient record to avoid delays that will impact reimbursement. The coding team will often need to review medical records, pathology reports, and history and physical documentation in order to assign the most appropriate CPT codes, diagnosis codes, and modifiers. Note: Provide implant logs or invoices to billers or the revenue cycle vendor to avoid lost revenue due to unbilled implants. 5. Poor contracting. One of the fastest ways to damage finan- cial performance is agreeing to inadequate payer contracts. Skillful contract negotiation helps ensure that an ASC's inter- ests are considered fairly and appropriately. Perform a comparison of the proposed contract to other third- party payer and Medicare rates. When contracts are renegoti- ated, consider new procedures to be added, increases in sup- ply costs, and other factors that can improve reimbursement. Do not overlook procedures that use expensive implants. If the payer does not separately cover implants, make sure to ask for carve-outs, especially for higher-cost cases. The entire revenue cycle team should understand the ASC's contracts to help ensure proper payment according to negoti- ated rates and terms. 6. Lack of expeditious appeals process. Receiving an incor- rectly contracted or low OON payment is frustrating. With ASCs striving to run a profitable, high-quality facility, appeal- ing claims can feel like a distraction from other critical tasks. However, the timely appeal of incorrect payments is vital to a facility's financial stability. Erroneous payments for contracted carriers should be addressed quickly before they become a pattern. Ensure that the carrier has properly loaded the most recent version of the ASC's contract. Appealing OON cases is equally important. With OON carriers

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