One of the most challenging aspects of running a surgery center is eliminating claims processing errors and denials. These issues lead to delays in reimbursement and decreased revenue. When it comes to claims processing errors and denials, there are several items your front office can control. ASC administrators can prevent many of these errors by establishing financial benchmarks that track front office performance. Implementing these benchmarks will demonstrate to your staff how these controllable factors go a long way toward maintaining healthy reimbursement for your ASC.
To accomplish this, ask yourself the following questions:
Are you tracking registration data entry errors that cause claim denials?
An incorrect insurance address, inaccurate insurance provider, forgetting to include the subscriber date of birth (if subscriber is not the patient), and entering the wrong patient ID number create claim denials.
Review data entry errors with personnel responsible for patient registration. Most patient accounting systems contain audit mechanisms that allow you to track field updates by user. Encouraging staff to methodically enter data, then double-check their work typically improves accuracy.
Are you tracking denials based on no pre-authorization?
Many payers have pre-authorization requirements for various procedures. If pre-authorizations are completed prior to the date of service, payers will deny the claims.
Review denials that occur for this reason with your front office staff. Ask them to determine why pre-authorizations were not obtained to identify process issues. Most insurance providers outline pre-authorization requirements on their websites. Ask your staff to access these websites to review pre-authorization requirements. They can print this information and place it in a resource binder for future reference. Consider having your team develop a flow sheet identifying your facility’s top CPT codes, top insurance providers, and corresponding pre-authorization requirements. These tools will be an invaluable resource.
Are you tracking time of service collection of co-pays and deductibles? Have you outlined expected time of service collection goals?
Set goals for upfront collections and track progress towards those goals. Share monthly reports with your front office to review any co-pays or deductibles that were not collected. Determine what types of actions, if any, can be implemented to increase time of service collections.
Are you tracking whether supporting documents needed for claims processing are provided in a timely manner?
Set benchmark due dates on documents such as operative notes, implant invoices (when applicable), and pathology reports. Track monthly documents that are not available on the due date.
Work with your staff to determine why set goals are not met and identify how they can reduce the frequency of late documents.
Is your front office routinely receiving updates on insurance changes such as new contracts and sample cards?
When evaluating trends, you may discover failure to achieve established benchmarks ties back to outdated information.
Many payers have comprehensive information on their websites regarding benefits. They often display sample insurance cards to assist providers with proper identification of patient plans. Best practice is for your front office to maintain up-to-date payer information in a resource binder (paper or electronic, whichever works best). If you maintain sample insurance cards on patients you’ve treated in your ASC, be sure to redact patient-specific information to remain HIPAA compliant.
Set benchmark goals to track the above-mentioned items, then meet monthly with your front office staff to review these measures. Identify trends. Encourage open discussion regarding benchmarks, errors, and denials, to help your staff understand how their role affects the health of your ASC. Provide additional training when warranted to create a work environment where your staff can succeed. Keep them engaged by asking for suggestions on best practices to optimize their efforts. Celebrate their successes and enjoy watching your ASC thrive!
Kelli McMahan – Vice President of Operations