Is Your Billing Team Performing Optimally?
- 1. T H E A S C A J O U R N A L | M AY 2 0 2 1 | a s c f o c u s . o r g STAYING AFLOAT DURING AND AFTER THE PANDEMIC MANDATING COVID-19 VACCINATION Which Patients Can Undergo Your Higher Acuity Procedures? Develop protocols to guide decisions
- 2. 20 ASC FOCUS MAY 2021 |ascfocus.org BILLING Your ASC is well-positioned in the community. It has a good reputation, as do your providers. Your caseload is steady or perhaps growing. You have a happy, busy staff. Your budget, however, is on track for expenditures but not projected income. Your investors are questioning why dividends are small or non-exis- tent. Why is your center not achieving its financial potential? To answer these questions, your cen- ter must take a deep dive into the work- ings of your billing process and deter- mine how well these tasks are being performed. The potential for revenue- related problems and leaks is present in each area of the revenue cycle. Areas Indirectly Affecting Reimbursement Some areas that might affect consistent and optimum reimbursement are likely not responsibilities of your billing staff. These include your fee sched- ule, managed care contracts, financial policies and payer mix. Evaluating these areas will help you determine whether they are negatively affecting cash flow. Assess your fee schedule to deter- mine if your fees are commensurate with your geographical location and sufficient to cover costs and meet your projected profit margin. In addi- tion, assess your managed care con- tracts to ascertain whether rates are sufficient to meet procedural costs and equitable to other reimbursement rates for your area. It also is important to review your financial policies and procedures to determine whether they clearly outline your center's manage- ment of areas that directly affect reve- nue, such as upfront collections, self- pay patients and payment plans. Audit The advice and opinions expressed in this column are those of the author and do not represent official Ambulatory Surgery Center Association policy or opinion. Is Your Billing Team Performing Optimally? Take a deep dive into your processes to decide BY CARYL SERBIN, RN to verify that policies and procedures are being enforced. Finally, evaluate your payer mix. Determine the percentage of cases being performed according to payer, recognizing that a preponderance of low-paying and/or delayed reim- bursement payers (e.g., Medicaid, workersâ compensation, liability cases) can adversely affect a consis- tent revenue stream. Areas Directly Affecting Reimbursement (Pre-Procedure) Monies owed are easier to collect prior to the service than on the back end. To perform successful upfront col- lections, start with insurance verifica- tion to identify the amount of expected reimbursement from payers and patientsâ likely financial responsibil- ity. Auditing your insurance verifierâs performance for timeliness, complete- ness and accuracy is essential to deter- mining if they are gathering the infor- mation needed for financial counseling and upfront collections. Next, evaluate your financial coun- seling. This process informs patients about how much their insurance com- pany promised to pay on their behalf and their personal financial respon- sibility. Provide this information to patients at least 3â5 days prior to their date of surgery. In addition, inform patients of all payment types offered by your center and obtain a commit- ment on how they plan to cover their responsibility on the date of surgery. Timeliness and proficiency of your financial counselor can be measured by the success of upfront collections and the number of promissory notes or payment plans issued. Collecting the patient's financial responsibility prior to the procedure is the final essential process. Its success largely depends on how well the pre- vious processes were performed. Prior to surgery, your financial counselor Reprinted with permission from the Ambulatory Surgery Center Association.
- 3. ASC FOCUS MAY 2021 |ascfocus.org 21 BILLING should provide the registration clerk with the amount of the patient's finan- cial responsibility and how the patient is planning to meet their financial obli- gation. To measure the upfront collec- tions success, compare the patient's commitments to pay, as provided by the financial counselor, to the upfront col- lection amounts. Areas Directly Affecting Reimbursement (Post-Procedure) Following the procedure, certain steps must be completed properly and con- sistently to help ensure your ASC obtains appropriate reimbursement. Accurate coding is the bedrock of reimbursement. Errors can financially impact your center and put you at risk for noncompliance. Submitting claims with procedure and/or diagnosis codes not supported by the operative note puts your center at risk of a compliance audit and resulting fines and presents the pos- sibility your center is not obtaining allowable reimbursement. Coding mis- takes also often result in claim delays or denials. Establishing a denial log listing the reasons for denials will help pinpoint the number of claims denied or delayed because of coding errors.Addi- tionally, check your coder's accuracy with regular internal audits and annual audits by an independent third party. After receipt of coding information, your charge poster should enter charges in the proper format and submit claims via your clearinghouse. Clearinghouse reports identify errors that require cor- rection. After making necessary correc- tions, resubmit claims. Finally, to ascer- tain the submission of all claims, tally the number of accepted claims listed on the clearinghouse receipt against the number of coded cases listed on the coder's report. To determine percentage of clean claims submitted, compare the total number of claims submitted to the number of rejected claims. Also, audit reasons for rejections and timeliness of correction/resubmission and com- pare the number of claims submitted to the number of scheduled cases for the specific date. Proper submission of claims as described above should result in timely and accurate reimbursement. Payment posting should be performed on the date of payment receipt. Your payment poster should be familiar with contract allowances. Better yet, the specific contract rates should be entered in your ASC's software, help- ing ensure that you can recognize the accuracy of payments and appropriate adjustment of fees. Payment posters are responsible for completing the denial log and disburs- ing information to the appropriate reve- nue cycle team member to fix errors and resubmit corrected claims. The pay- ment poster also is responsible for ini- tiating the appeals process when there is a discrepancy or payment denial. To measure the proficiency of the payment posting process, compare daily bank deposit to your payment posting batch report, audit the denial log to deter- mine if it is current and all entries have been assigned to the appropriate team member for follow-up and run an aging report on claims in appeals. Depending on the carrier's guide- lines, follow up on electronically sub- mitted claims should begin as soon as seven days to a maximum of 21 days. Collectors can often obtain the status of specific claims via payer websites, but some must be contacted directly. Collection efforts should be noted in the patient's chart, and information regarding date of expected payment should also be entered in a tickler file to help ensure timely follow up. Depending on your center's soft- ware, collectors may be able to access reports on aged accounts receivable (AR) by payer to help pinpoint which accounts should be followed up on first. To measure collection efforts, audit appropriate AR reports to assess age of accounts, timeliness of follow up, claim denial management and other important processes. Following the receipt of full and accurate reimbursement and any nec- essary and approved write-offs, trans- fer the remaining account balance to patient/guarantor responsibility. Send patient statements immediately and then every four weeks until yourASC is paid. To determine if patient collections are followed appropriately, run aging reports of patient balances and appoint a team member to follow up on them. Stronger Staff Performance, Stronger Bottom Line When your ASC appears to be running efficiently but cash flow is less than anticipated, doing a deep dive into all areas of the revenue cycle will help determine where revenue leaks are occurring. Take the time to effectively assess whether your billing staff is at peak performance, paying particular attention to timeliness and accuracy of revenue cycle tasks. These two param- eters must be met to ensure a consis- tent revenue flow and financial success for your ASC. Caryl Serbin, RN, is the president and founder of Serbin Medical Billing in Fort Myers, Florida. Write her at caryl@ serbinmedicalbilling.com. Reprinted with permission from the Ambulatory Surgery Center Association.