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Monthly Archives

April 2017

ASC Cybersecurity

Why Good Enough is Not Good for ASC Cybersecurity

By ASC Management No Comments

There’s good news and bad news when it comes to cybersecurity and ASCs.  The good news is healthcare organizations saw fewer records compromised by cyberattacks in 2016.[1]  In 2016, “only” 12 million records were compromised, down from nearly 100 million compromised records in 2015.

The bad news is two-fold.  First, cybercriminals compromised millions of records.  And second, they focused on smaller targets, which likely includes ambulatory surgery centers.

Cybersecurity must be a high priority for ASCs.  In fact, ASCs should treat cybersecurity with the same care and attention as they extend to their patients. Cybercriminals are looking to exploit even the smallest mistake or shortcoming. You cannot afford to give them such an opportunity.

Consider this scenario 

An ASC performs a top-level information technology (IT) assessment.  It finds frequent communications and discussions are occurring with the surgery center’s IT vendor. A monthly activity log indicates the servers are routinely checked for viruses, unusual activities in event logs, and overall IT performance. Basic server maintenance is ongoing.  When the IT vendor installed a new server, they implemented appropriate security measures (e.g., anti-virus and anti-spyware protection, firewall, backup system).

Sounds pretty good, right?  The basics seem to be in place.  Unfortunately, pretty good does not mean great, nor does it indicate perfection.  And when there are imperfections, there are open doors for possible cybercriminal intrusion.

Potential risks and concerns

Here are some potential risks and concerns a top-level assessment like the one above may overlook.

1. Anti-virus software installed on some computers and servers. If even a single computer connected to the network or server is missed, this creates a vulnerability.

2. Like most software, antivirus and antispyware programs must undergo regular updates. When a security software update is missed, the wall of protection is weakened.

3. Servers must also undergo updates. Updates often address security gaps identified by the server’s operating system developer (e.g., Microsoft).  Once again, if an update is missed, security could be compromised.

4. The use of a backup system is critical. It can allow you to restore data in the event of data loss due to viruses, accidents, or disasters.  However, that’s only the case if the backup system is configured properly to backup data correctly, efficiently, and with the right amount of data retention.  Simply “having” a backup system does not mean proper backups occur.

5. An ASC should use a firewall to protect against possible outside threats and intrusions. Think of a firewall as filling the role of disease prevention while antivirus software is more for infection control. A firewall will maximize its effectiveness when configured properly.  But as with disease prevention, problems may develop if the ASC neglects anything. 

Although installing a firewall is an important security step, additional steps must follow.  A firewall without content filtering that prevents users from visiting any website could open your surgery center to security problems.  It also reduces staff productivity.  Firewalls can filter out identified, malicious, virus-infected websites, but only with the proper configuration.

Some firewalls can provide an “intrusion prevention system.”  This functionality is designed to detect and block attempts to exploit network vulnerabilities for taking control of a computer or network.  Enable and configure this functionality to better protect the network.

6. Conversations with an IT vendor are nice, but what happens if you need hands-on expertise on short notice? This is where the use of a remote monitoring and management system comes into play.

When installed, the system permits the IT vendor to keep an eye on what is happening with an ASC’s network.  The vendor can monitor the server, network, and workstation health.  When an issue is identified, the vendor may be able to address it before cybercriminals exploit the problem.

If your IT looks fine on the surface, such a system may seem unnecessary . . . until it becomes very necessary.  By then, it may be too late to use the system effectively.

Be proactive  

When it comes to cybersecurity, you cannot afford to be reactive.  There is a good chance a cybercriminal will be faster at reacting than you.

Work with your IT vendor to ensure your ASC is doing everything possible to identify and address potential risks and concerns.  Put processes in place to help maintain the highest level of cybersecurity and keep cybercriminals at bay.

Diane Lampron – Director of Operations

[1]According to the 2017 IBM X-Force Threat Intelligence Index

Management page header image

A Clinical Approach to Healthcare Business Management & Problem Solving

By ASC Governance, ASC Management, Leadership No Comments

I am a physical therapist (PT) by education and training.  I graduated from Wayne State University in Detroit, Michigan with a Bachelor of Science in PT. Go Warriors!

For over ten years, I practiced in a variety of settings, including my time spent as a clinical faculty member at the University.  After that, I moved full time into the world of management.  I like to think I could still earn an honest living as a clinician if I needed to.

As my career moved away from clinical practice, I retained my clinical approach when dealing with issues related to business practices.

The American Physical Therapy Association uses the following statement to describe what a physical therapist does:

“PTs examine each individual and develop a plan, using treatment techniques to promote the ability to move, reduce pain, restore function, and prevent disability.  In addition, PTs work with individuals to prevent the loss of mobility before it occurs by developing fitness and wellness-oriented programs for healthier and more active lifestyles.”[1]

Essentially, PTs evaluate the situation and assess findings to develop a treatment plan.  Our goal is to return patients to their previous or higher level of function.  In some cases, we develop a plan to prevent or forestall further disability.  Sound familiar?

As is the case with many healthcare disciplines, we learned to evaluate someone and then document our findings in a format called the SOAP note.

Here is what the SOAP note entails:

Subjective – Detailed notes regarding what the patient relays about their status in terms of function, disability, symptoms, and history.

Objective – This is derived from the clinician’s objective observations.  It can include visual observations such as posture and swelling, actual measurements such as range of motion or strength, and hands-on techniques such as palpation.

Assessment – The clinician’s analysis of the various subjective and objective findings yields an assessment.  It explains the reasoning behind the decisions made and clarifies the analytical thinking behind the problem-solving process.

Plan – Conveys how the clinician develops treatment to reach goals or objectives.

As a business leader, I use the clinical approach I learned and practiced to solve management problems.  Here is how:

Subjective – Years ago I read the difference between clinicians heralded at the top of their profession and those considered more average was based on the quality and thoroughness of the clinician’s ability to subjectively capture a patient’s history.  I believe the same is true in business problem solving.

In business, it is important to seek information directly from the source when issues arise.  For instance, I prefer to meet stakeholders in person to obtain the history of the situation and gain an understanding of how it developed.  What areas have been impacted?  What actions have been taken to resolve the issue?  What, if any, impact have those efforts had?  Lastly, I like to ask the stakeholders for their suggestions on resolving the situation.

Objective – When appropriate, I begin the objective portion of my evaluation visually, just like when I treated patients.  This can entail simply walking through the facility or office.  Many times, it involves taking subjective “histories” from stakeholders.  The measurement and hands-on review, in many cases, involves evaluating existing data and reports.  When necessary, and possible, it includes asking for additional information.  This provides me with a complete view of the situation.

Assessment – Again, the assessment is where the expertise and experience of the “clinician” shines through.  Taking all information gleaned from the subjective and objective portions of my evaluation, I can generate a list of problems.  Next, I can prioritize the items on my list.

Plan – Lastly, just as in a clinical setting, I develop a “treatment” plan for the problems in my facility.  The plan addresses not only the symptoms but also their underlying causes.

The business side of healthcare is made up of many clinicians who have transcended their clinical roles into business management and leadership.  I am one of those individuals.  The skills we learned as clinicians allow us to be effective problem solvers in the operational management side of the business as well.

Robert Carrera – President/CEO


Patients Overnight

Can I Keep Patients Overnight at My ASC?

By ASC Development No Comments

The short answer is, it depends.

The CMS interpretive guideline 416.2 defines an ASC as “any distinct entity that operates exclusively for providing surgical services to patients not requiring hospitalization and in which the expected duration of services would not exceed 24hours following an admission.” [1]  Therefore, not all state ASC regulations allow for overnight recovery observation.  However, several states allow for a prolonged recovery period for observation of patients.  It is important to know your state regulations to maintain compliance.  Some states allow for 23-hour observation.  Some allow for 23-hour and 59 minutes of observation. 

Understand ahead of time when the observation clock starts ticking.  CMS, and most states, start the clock at admission.  Therefore, if you are admitting a patient at 7:00 a.m., you must discharge them at either 6:00 a.m. or 6:59 a.m. the next day, depending on your state regulations.   

Be aware of the regulations regarding limitations of ambulatory surgical procedure operating room time and direct supervised recovery time.  Common regulations indicate operating room time and supervised recovery time should not exceed four hours.  If these regulations apply to you, patients would also need to meet the criteria for discharge from PACU.

If you do keep your patients “overnight,” ensure policies are in place for their prolonged care.  Include provisions for an available shower, food preparation, nutrition, and dietary consultations.  Additionally, develop an appropriate staffing plan to ensure quality care is provided throughout the stay.  If you are prepping patients at 6:00 a.m. and simultaneously discharging 23-hour patients, a flurry of activity can occur.  Have a plan to keep things calm and orderly.

Another vital component to consider is your managed care contracts.   Do they include reimbursement for the observation stay?  There are no financial gains to be made by providing this care.  Some payors do not cover this option.  If they do reimburse you, it may only be $400-500/night.  With staffing costs, you may break even.  The important thing is to have knowledgeable expectations.   

Lisa Austin – Vice President of Facility Development   



ASC Investors

ASC Investors, Your Management Company May Be Able to Save You Money on Your Personal Income Tax

By ASC Governance No Comments

A recent federal tax code ruling[1] concluded an ambulatory surgery center (ASC) investor, who has no direct management responsibilities, can exempt their ASC investment income (distributions) from self-employment tax.

The investor, Dr. Stephen P. Hardy, a pediatric reconstructive plastic surgeon in Montana, challenged the tax court with regards to his distribution income from the ASC.  He stated he was entitled to treat it as passive income due to his non-involvement in any management or operational support.

Hardy argued his primary income came from his private practice and he is only a minor investor (12.5%) in the ASC. He indicated he is not involved in the ASC’s day-to-day management responsibilities.  However, he has input on the procedures he performs in the facility.  Further, he stated he does not make management decisions.  Decision-making is left up to the management team. He also confirmed his role has not changed since he started performing procedures at the ASC.

Hardy underscored he has no obligation to perform surgical procedures at the ASC and the number of cases he brings to the facility have no bearing on his distributions. Therefore, his investment should be considered passive.

His argument held and an opinion granted by the tax court concluded Dr. Hardy’s ASC distribution income is not subject to self-employment tax. However, they have not yet established if he may deduct any passive activity loss carryover from prior years.

This tax ruling is significant for ASC partners who are self-employed.  Most ASC investors are subject to a 13.85% tax on their ASC distributions when claimed as ordinary self-employment income.  For ASC investors who employ an outside management company, or are not directly involved in the day-to-day management functions of the ASC, this income is exempt.  Check with your accountant to determine if this new IRS event positively impacts you.

Rick DeHart – Principal Partner

[1] Stephen P. Hardy & Angela M. Hardy, Petitioners v. Commissioner of Internal Revenue, Respondent.

manager rounding

ASC Manager Rounding: Maximizing the Benefits

By ASC Management, Leadership No Comments

Manager rounding is the process of visiting patients and families.  It affords surgery center leadership an opportunity to monitor progress, provide education, and identify areas for improvement.  While rounding benefits an ASC’s leadership team and facility personnel, the most important byproduct is the impact it can have on patients and their families.  There are a number of ways to maximize those benefits and achieve short- and long-term improvements in a surgery center.  Here are some helpful steps to consider.

1. Be consistent.

Perform rounds every day, without fail.  The goal is to round multiple times a day, and do so in a purposeful, productive manner.  This may sound cliché, but it’s the only way to develop an effective process.

Maintaining this consistency requires planning.  Consider in advance how you will perform rounding, when you will do it, and the way you will evaluate the information you pick up along the way.

Be consistent with where you go.  Most rounding occurs in the center’s lobby, but it is worthwhile to add the pre-op area to your walkthrough.  This isn’t something most administrators do.  But you might be surprised how much you can learn from a quick visit to patients before their procedure.

2. Keep it a management responsibility.

Rounding is best performed by an ASC’s managers. They’re in an optimal position to represent the facility then take what they learn and turn it into actionable information.

The task should not be delegated to staff even if management is busy.  It is up to other members of the facility’s leadership team to step up if a round cannot be completed by the manager who was originally assigned the task.

3. Educate on processes.

Effective rounding is not improvised.  Education is vital and may need to be tailored to each individual.  Some types of education to consider follow:

  • What to say to start conversations
  • What questions to ask (i.e., a script)
  • How to respond to different comments and questions from family members and patients
  • How to approach strangers and speak with them (and do so confidently)
  • How to read people
  • How to document what is learned (see #4 below)
  • When to elevate an issue and involve other managers or physicians

The goal with rounding is to move through the lobby or pre-op, meet people, make connections, gain information, provide information, and move onto the next person.  Upfront and ongoing education will help make rounding an efficient and productive process.

4. Make the documentation easy.

The quality of the documentation can make rounding a success or failure.  To achieve the former, develop a standardized form those conducting rounds can fill out quickly and legibly.  Include the specific questions you are likely to ask and spaces for notes.

Also, include a checklist of topics on which you are likely to receive feedback. Topics could include wait times, requests for information, communication, and case delays.  Again, leave spaces for notes.

5. Use what you learn.

What you ultimately do with the feedback gleaned during rounding is as important as the rounding itself.  Establish processes for how feedback will be presented in meetings, how to determine what to focus on, and how changes or issues will be addressed.  Develop an organized way for your team to consider any problems you discovered, figure out solutions, and disseminate information to staff.

The benefits of rounding may not be noticeable immediately.  It’s not a process you can conduct for a day or week and expect significant changes.  It may take a few business weeks of consistent rounding to deliver results.

6. Hold your team accountable.

There is a reason the first step highlighted above is the need for consistency.  If a round is skipped one day and there is no ramification, soon there will be a day where two rounds are skipped. Then three. When this occurs, rounding will start to feel optional.  Managers, with their very busy schedules, may find other pressing tasks to fill the time once allocated for rounds.

That’s why it is not only important to plan who will perform rounds and when, but also ensure anyone who does not perform an assigned round is held accountable.   

7. Give rewards and recognition.

Rounding is intended to help bring about improvements.  When improvements are made, rewarding and recognizing team members who made them happen can be an effective way to bring attention to the ongoing importance and value of rounding.

Rewards and recognition can occur when a rounding manager connects with a patient or family member and receives a great suggestion or a staff member takes on greater responsibility to help implement a change.  Rewards can take the form of small gift cards or entries into drawings for more valuable gift cards. Recognition may take the form of singling out specific team members for praise at staff meetings.

8. Focus on engagement.

If a rounding program is the passion project of a single manager, it is doomed to fail.  Rounding must be ingrained in all managers and staff as a critical component of your ASC’s operations. Your team must believe in its purpose and not merely view rounding as yet another task to complete.

In the early stages of a rounding program, emphasize the objectives of rounding: to bring about operational improvements that will make everyone’s job easier and better while making sure patients and their families are safe and comfortable.  When managers are enthusiastic about performing rounds and staff are eagerly awaiting new feedback to drive improvements, you will know your rounding program has established a strong foundation for success.

Jebby Mathew – Director of Operations


Achieve Meaningful Change in Your ASC With a Plan

By ASC Management, Leadership No Comments

Viable contributors to our healthcare system consistently demonstrate the ability to implement effective changes.  Being flexible and able to adapt quickly to patient, provider, and payer developments in your market is critical to your ASC’s success.

Typically, change is not comfortable for most of the workforce including leaders. That’s where having a plan comes in handy.

Here are some key plan components that will help you effectively engage your team and adhere to a path for successful implementation of change.


Communication concerning the change is vital – but it cannot just be communication from the top down.  Communication must occur between leadership and staff, not from leadership to staff.  Make sure input is solicited from everyone involved in making the change as well as those persons affected by the change.

Convey the reason(s) for making the change.  If your team members understand why the change is necessary, they are more likely to buy into the change and actively participate in the process.

Lay out a timeline for the change process.  Although the timeline may need to be adjusted throughout the process, providing a general outline of the plan provides your ASC team an opportunity to envision the path ahead.  They can prepare for what is going to happen and when, and contribute to the end result.


Training may be a crucial component of your plan.  Many changes in ASCs today encompass new technologies – implementing electronic health records and patient portals, upgrading phone systems, or adding new surgical/clinical procedures, for example.

To ensure staff become comfortable using, and maximizing the benefits of, new technologies, extensive hands-on training may be necessary.  While it may be tempting to provide this education in the fastest and least expensive way possible, doing so may end up costing more in the long run.

One of our ASCs recently went through a software system transition.  The vendor offered off-site training for super-users.  We invested the time and money to send three members of the ASC’s team to receive that upfront training.  Upon their return to the ASC, these super-users were extremely valuable in educating and supporting their fellow staff members and physicians during the onsite training process. The team required less intensive training from the vendor, which ultimately saved time and money and promoted a smooth “go live” environment.

It is important to note that people learn at different paces.  When training team members, make sure individual needs are addressed.  More training may be required for some, while less training is necessary for others.


It is not likely everyone will be on the same page the moment you start moving forward with implementing a change.  Some members of your team may embrace the change from the beginning and easily move through the process. Others may exhibit various levels of resistance.

Team members who are hesitant or actively pushing back against a change will require additional attention.  Engage them in conversations to learn about their reservations.  Answer questions about why the change is necessary.  Provide emotional support.  You may not be able to eliminate all their concerns but taking the time to listen and actively support them throughout the process will elicit more positive engagement.

Individuals providing support and engaging in these conversations do not necessarily need to be formal leaders. In fact, peers who have bought into the change may better understand a fellow team member’s struggle and more effectively facilitate their colleague’s buy-in.


For a plan to be successful, leadership must be 100% on board throughout the change process.  They are the change champions.  This is true even if leaders are uncertain about the change or the approved approach to making the change.

In times of uncertainty, leadership must come to terms with the situation, put feelings of doubt aside, and figure out a way to stay positive.  This can be difficult, but the emotions leadership project — whether intentional or not — are inevitably picked up by staff.


An effective plan for change should take the ASC through completion of the process.  Ensure the plan spells out how you will monitor if the change achieves its intended short and long-term goals. 

If the change does not deliver the benefits you were hoping for, additional improvements and other changes may be required.

It is also important to evaluate if the change has any unintended effects on your facility’s operations.  For example, changes can affect customer service and the organization’s culture. Sometimes these changes are positive.  However, if a big change affects these or any other processes negatively, you will want to go back to the drawing board and work to right the ship.

Catherine Sayers – Director of Operations

ASC Team

Harnessing the Power of Your ASC Team

By ASC Governance, ASC Management, Leadership No Comments

Organizations who harness the power of teamwork thrive.  You can sense their vibrant energy the minute you step through their front door.  Positive momentum permeates every aspect of their business.  Their collaborative spirit is infectious.        

Teamwork in your ASC can easily make the difference between your place of business being merely another place to work or a workplace of choice.  It can also make the difference between your ASC being yet another place to receive care or the preferred patient option for ambulatory surgical services. 

ASC leaders who understand who makes up their team and what allows for a dynamic work environment are better equipped to harness the power of their team.

The diagram above is a visual representation of an ASC’s stakeholders.  Let’s explore how to engage individual team members to create a vibrant team.

What is Important to the team?

Whether an ASC is in the planning stages, has recently opened, or is in its tenth year of operation, the organization’s mission statement is critical to developing and maintaining its goals.   It serves as the cornerstone of the ASC’s culture. 

A properly crafted mission statement –

  • Communicates the purpose of the organization
  • Serves as a filter to separate what is, and is not, important to the organization
  • Clearly states which markets the organization will serve and how
  • Communicates a sense of intended direction to the entire organization

The mission statement guides the actions of the ASC, articulates its overall goals, provides a path to achieve those goals, and ensures decision-making is in keeping with those goals.  It provides the framework to develop the company’s strategies.

When crafting a mission statement, consider –

  • Quality and consistency
  • Customer service
  • Diversity and individuality
  • Professionalism
  • Specific ideals of a sponsoring or partnering health system or organization

Although it is not uncommon for a mission statement to remain the same over time, it should not remain static due to inattention or apathy.  Markets, goals, leadership, and organizations change and evolve.  Review your mission statement on a regular basis to ensure it reflects any substantial changes.

The Team


As I have discussed in other posts, physicians become members of ASCs for a variety of reasons. Ensure you recruit physicians based on how they will function as part of your team. Careful selection is the key to success. If physicians participate for the right reasons and their previous track record demonstrates they are “team players,” integrating them into your team should not be difficult.

Because physicians interact daily with your patients and staff, it is critical for them to buy into, and actively support, the ASC’s mission and culture.  There is no quicker way to undermine the effectiveness of your workplace than to work with physicians who do not respect your organization’s purpose.

Board of Managers

Ideally, the ASC’s Board of Managers (BOM) should create the facility’s mission statement, be involved in its regular review, and develop any revisions.  By setting the facility’s policies and procedures, hiring its medical director and management team, and crafting the mission statement, the BOM is the de facto owner of the ASC’s culture.

BOMs facilitate team dynamics when they are comprised of a diverse group of investors, representing different physician groups and specialties.  When the facility is joint ventured, it is important to include hospital executive representation on the BOM.

Ultimately, the most important characteristic for board members to possess is a willingness to participate and devote the time necessary to enthusiastically engage in facility-related discussions. Board members who stay informed about facility performance and operations and consider the perspectives of all stakeholders regarding ASC topics make sound business decisions.

Medical Director

The medical director is selected by the BOM.  As with physicians, this selection needs to be based on the individual’s track record of being a “team player.” Initially, the medical director will be involved in developing the ASC’s policies and procedures.

Most importantly, the medical director is charged with supporting clinical and administrative staff, enforcing policies and procedures (along with the BOM), and effectively maintaining the facility’s culture.  This will include addressing professional issues related to physicians and staff that are averse to the desired team environment.  The medical director will also function as a team member in multiple operational areas including scheduling, staffing, inventory, operating room utilization, etc.

Clinical and Administrative Staff

A popular saying is, “Hire the right people and get out of their way.”  This holds true not only for employee skill sets and work ethic, but also for their ability to effectively function as members of a team.  Educating staff about the ASC’s mission and the BOM’s commitment to that mission sets the stage for a well-informed team ready to fulfill the desired expectations.

It is critical to support and empower clinical and administrative staff to take action and make the decisions necessary to fulfill the ASC’s mission.  For example, they must feel comfortable reaching out to ASC leadership when quality of care or customer service issues are being compromised.

As new team members are added through growth or attrition, ensure a consistent message is relayed by the physician owners, BOM, medical director, and the facility’s management team. This will ensure the desired team dynamic is preserved.


Management is comprised of the ASC’s administrator and their team of program leaders.  The role of management is to own the ASC’s mission and consistently promote that message to all team members in the facility.  This is the responsibility the BOM entrusts to the center’s management. Management accomplishes this by expecting, promoting, and modeling excellent working interactions among all stakeholders.  Recognizing the contributions of all team members in pursuit of the ASC’s goals and carrying out its mission allows a team atmosphere to flourish.  

Finally, management is responsible for ensuring team members who are not bought into the organization’s mission, or do not have the skill set to contribute to that mission, are appropriately removed from the mix.  Jim Collins, renowned management consultant and author, said, “The only way to deliver to the people who are achieving is to not burden them with the people who are not achieving.” [1]


In conclusion, I am reminded of a speech given by legendary University of Michigan football coach Bo Schembechler.  It is simply referred to as “The Team! The Team! The Team!”  There are numerous YouTube versions of the speech.  My personal favorite is one pulled from a news clip (approximately 2 minutes long).  In his speech, Bo reminds us there is nothing in life we will achieve as an individual that will provide us more personal satisfaction than what we will achieve as a member of a team.  The team can be defined in many ways – your family, your place of worship, your work place – the list goes on.  The underlying message is this:  leaders need to provide the unwavering vision, mission, and culture necessary to make sure all stakeholders have a chance to experience the sense of team accomplishment described so powerfully in Bo’s speech.

Robert Carrera – President/CEO

[1] Good to Great:  Why Some Companies Make the Leap & Others Don’t, James C. Collins, 2001

Payer Meetings

Payer Meetings – Uncovering Valuable Information Hidden Inside Your Aging

By Revenue Cycle Management No Comments

An ASC’s contracts with its insurance carriers state payments on clean claims occur in 30-45 days.  A/R day benchmarks are typically tied to those clean claim expectations.  In a perfect world, clean claims would be submitted 100% of the time and payer payments would release within 30-45 days.   No claims would age over 60 days.  Yet, we do not live in a perfect world.  Unfortunately, many claims age beyond the desired A/R day timeframe.

What is behind payment delays?  Are the claims clean when submitted?  Did the claims meet all requirements specified by the payer to trigger prompt payment?  Finding answers to these questions is best served by conducting payer meetings.

What are payer meetings?

Payer meetings are a deep dive into each individual claim on your ASC’s aging that meet specific criteria.  For example, that criteria could be all claims over 90 days whose outstanding account balances are $1,000 or more. 

Who should attend payer meetings and how often should they occur?

Payer meeting attendees could include your administrator, payer contracting representative, revenue cycle manager, coding and billing staff, and personnel responsible for A/R follow-up.  Ideally, each of these departmental representatives meet every 30 days to uncover issues and provide insights for resolutions and process improvements. 

The purpose of payer meetings may be to determine:

  • If there is a payer trend that needs to be addressed.
  • If there is an opportunity to improve the operative report to satisfy a medical necessity denial.
  • If there is a training opportunity for personnel whose errors are contributing to payment delays.
  • If payer authorization requirements are being met thereby allowing payment to be issued.
  • If payer billing requirements are followed.

Discussion occurs on every claim that meets the criteria, including why the claim remains unpaid, the action(s) taken on the claim to date, the status of the claim, and the likelihood of payment resolution.

Information gathered from this process is invaluable in identifying payer trends.  It also provides concurrent training to all parties involved in the claims process – coding, charge entry, billing, electronic data interchange (EDI), cash posting, and accounts receivable.  Further, it helps develop strategies to deal with appeals and denials. 

Examples of payer meeting findings are:

Issue 1: Payer routinely denies separate payment for implants. 

  • Action: Multiple follow-up calls with the payer revealed the payer inaccurately loaded the facility’s contract, omitting separate implant payment despite an “implants paid separately” clause. 
  • Result: A claims issue log was submitted to the payer’s provider representative.  The payer reloaded the contract with the necessary correction.  All affected claims were reprocessed and implant payments were secured.
  • Process Improvement: Although internal processes did not need to be addressed, the payer meeting created an opportunity to reinforce to attendees how important it is to identify denial trends, quickly bring them to the payer’s attention, and work with the payer toward resolution.

Issue 2:  Claims denied after 30 days for being submitted on the wrong claim form

  • Action: Research of the payer configuration in the patient accounting system revealed the wrong claim type was selected when the payer configuration was created. 
  • Result: All affected claims were refiled with the payer.
  • Process Improvement: A process was created to notify billing personnel when a new payer configuration was created.  Those personnel now review the configurations for accuracy prior to claims submission.

Issue 3:  Multiple claim denials were received on pain management cases based on medical necessity.

  • Action: A coding review was performed on the operative reports to determine what information was needed to satisfy medical necessity requirements.
  • Result: Amended operative notes addressing medical necessity were obtained from the pain management physicians.  Appeals were submitted for payment with the additional supporting documentation.
  • Process Improvement: Consultations took place with physicians to alert them to medical necessity requirements for the procedures performed.  The medical necessity policy was provided to physicians with suggestions on how amended operative notes could substantiate the policy requirements established by the payer.

Issue 4:  Lack of prior authorization on procedures and implants resulted in multiple claim denials.

  • Action: Payer prior authorization lists were researched to confirm prior authorization was required.  Further research was conducted to verify authorizations were obtained.  The research revealed two findings.  First, required authorizations were not obtained by ASC front office personnel and, secondly, facility personnel were relying on the referring physicians’ offices to obtain the necessary ASC authorization.
  • Results: Appeals were sent to the payer requesting retroactive authorizations.  When retroactive authorizations were granted, claims were refiled with the retroactive authorization to secure payment.  When retroactive authorizations were not granted, adjustment forms were completed to write-off the claim balances.  Patients could not be held liable when authorization requirements were not followed by ASC personnel.
  • Process Improvement: Additional training and education was provided to front office personnel to review payer authorization requirements, confirm access to the payer master pre-certification lists, and explain how to use the lists.

The reasons claim payment delays occur beyond the expected 30-45 day threshold involve many parties – from patients who supply inaccurate information at time of service to payors who load inaccurate contract terms to facility and billing personnel who are unfamiliar with the nuances of ASC revenue cycle management.  It is important to take the time to discover the specific reasons related to each case then follow through on issue resolution.  Implementation of process improvements help you effectively address identified issues and proactively manage your facility’s bottom line. 

Carol Ciluffo – Vice President of Revenue Cycle Management