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pinnacleiii

Apr 14
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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

Apr 12
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change

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

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

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.

Counseling

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.

Leadership

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.

Monitoring

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

Apr 06
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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

Physicians

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

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]

Conclusion

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

Apr 04
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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

Mar 30
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medical coders

Medical Coders – The Front Line of Your ASC’s Reimbursement

By Revenue Cycle Management No Comments

Prior to the advent of electronic claims submission – mandated by the administrative simplification portion of the Health Insurance Portability and Accountability Act of 1996 – many claims submitted by ambulatory surgery centers (ASCs) were coded by business office personnel who either relied upon information from superbills provided by surgery center providers or their own hands-on expertise.  Today, however, submitting medical claims without the benefit of professional coding expertise can negatively impact your ASC’s reimbursement.

If your ambulatory surgery center employs certified professional coders (CPCs), you’ve positioned yourself well.  However, it’s important to ensure their approach is not only outpatient driven, but ASC centric.  ASC billing is unique and has become increasingly complex with movement of high acuity cases from inpatient settings to ambulatory venues. 

Here are some ways to establish a strong team of certified professional coders for your ASC:

Hire smart.

Certified professional coders are bound by the code of ethics established by their credentialing organization. Their certification denotes implied trust.  In other words, you can assume certified coders comprehend the anatomy, physiology, and techniques used in a variety of specialties.  Insist on high levels of CPT, ICD-10, modifier, and HCPCS accuracy.  Put coders through the paces before you hire them.  Have them code sample cases (remove all PHI beforehand) that have been performed in your center and send them to an external auditor to assess coding accuracy.

Perform routine coding audits.

Gauge and manage coding accuracy by auditing often.  Internal and external audits identify educational opportunities and ensure upcoding (billing procedures beyond what is documented) and undercoding (not billing procedures supported by documentation) from plaguing your accounts receivable.

Ensure provider documentation is comprehensive.

Medical coders are not diagnosticians!  Their role is to provide the insurance carrier with a claim that accurately describes the patient/physician interaction. ASC medical coders depend on the information documented within the operative report to establish appropriate billing codes.  When medical necessity denials occur, this can be a sign that the information initially provided in the claim and supporting documentation does not adequately substantiate the billed charge(s).  Therefore, when coders approach physicians to request additional information, they are not impugning the physician’s expertise.  They are likely seeking one or more of the following: 

  • ICD-10 diagnosis codes which require a higher level of specificity and must be incorporated into the postoperative diagnosis.
  • More specific procedure headings that sufficiently support the CPT codes billed.

Coders are trained to rely on the information contained in the body of the report.   If the headings state something that is not reiterated or fully supported in the body of the report, they are not allowed to bill those codes.  To assist them in capturing all billable codes, ensure the narratives in operative reports contain the details necessary to communicate as much as possible about the encounter.

Ensure your coding team knows about new service lines you want to offer.

If your facility is thinking about expansion into new specialties or considering adding high acuity cases, provide ample notice to your coders so they can adequately prepare for these types of cases.  They will need to access additional tools to ensure the correct codes are used to describe the services provided. Further, they’ll want to research how to effectively maximize reimbursement of multiple procedures without improperly unbundling the codes.

Confirm implants will be separately reimbursed.

Forward the vendor cut sheets to your coding team as soon as you begin shopping for emerging technology or new implants.  Coders are not solely exclusive to your back-end billing process.  Involve them early and often.  They can crosscheck medical policies on the front end to prevent facility losses.  

Require your coders to routinely review carrier guidelines and familiarize themselves with payors’ reimbursement habits.

A seasoned ASC medical coder is familiar with carrier guidelines and payors’ reimbursement habits.  Third-party payor expectations are often outlined in your insurance contracts and supplemented by carrier-specific billing manuals. Require your coders to review these often.  Using the correct combination of form type and modifiers will mitigate the risk of claim denials.  Increase your output of clean claims by giving coders access to these tools early.

Make continuing education a priority.

Certified coders are required to amass a defined number of continuing education credits annually to maintain their certification designation.  Support their efforts by routinely enrolling them in courses that bolster their knowledge.  Consider allowing them to obtain specialty-specific certification.  Continuing education and familiarity with Medicare, Medicaid, and commercial medical policies can increase clean claim submissions and reduce preventable payment lags.

Certified coders are key to ensure clean claims and maximum reimbursement are generated for cases performed at your ASC.   Since the ambulatory surgery center is a niche industry, it is important to employ experienced CPCs who are willing to learn the nuances of the ASC billing process.  Collaboration between your coders, ASC leadership. and operations team, fosters an efficient claims process that will enhance profitability.

Bethany Bueno – Director of Billing Operations

Mar 28
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ASC Materials Coordinator

Your ASC Materials Coordinator May Be Your Greatest Asset in Controlling Medical Supply Expenses

By ASC Management No Comments

Medical supplies are one of the most significant expenses incurred by an ambulatory surgery center (ASC).  In fact, they may run as high as 10 to 20% of your net revenue.  Your ASC materials coordinator is on the front line when it comes to controlling medical supply expenses.  The more knowledge the person who fulfills this role has regarding business operations and budget expectations, the better equipped they are to serve your facility well.

Here are seven ways to actively engage your materials coordinator:

1. Include your materials coordinator in the budget process.

Their assistance can provide you with valuable insights about what to anticipate for the coming year – annual increase expectations from vendors and potential cost savings measures, for example.  Involving them in the process early affords them an opportunity to embrace your expectations, then operate within the guidelines of the budget.

2. Ensure material coordinators maintain an up-to-date item master.

Updating your item master is an ongoing process.  When new supplies are added, ask your materials coordinator to ensure they aren’t duplicating previous entries.  Have them compare the item pricing with the order confirmation and/or invoice to verify the most current price is loaded in your inventory system.  Set an expectation for consistency in nomenclature to assist with item searches and reporting.  Provide a big picture perspective – a clean, up-to-date item master provides accurate case costing reports necessary to make sound business decisions.

3. Utilize just-in-time inventory.

Ask your materials coordinator to limit stock items on your storage shelves to basics and items that can only be ordered as a case unit.  Have them check with your distributor to determine which items are sold individually.  To effectively handle order or delivery delays, plan on keeping several days of inventory for fast-moving items on hand.  Order enough supplies to cover procedures until the next delivery date but avoid overstocking your shelves.  While overstocking may meet a materials coordinator’s desire to reduce time spent placing and receiving orders, it creates an unnecessary increase in expenses that doesn’t directly correlate to case volumes.  Again, providing the big picture perspective to your materials coordinator can create buy-in to just-in time inventory methods.

4. Involve material coordinators in your preference card process.

Consider allowing them full access to physicians’ preference cards including permission to change items reflected there.  If you are uncomfortable with this, ensure they have access to a clinician authorized to make those changes on the material coordinator’s behalf.  This access ensures preference cards are updated when ‘old’ items are replaced with ‘new’ items.  Up-to-date preference cards assist your clinical team to efficiently pick supplies for the facility’s cases.

5. Provide education to your materials coordinator on payer contracts, especially those that reimburse for implants separately.

Because materials coordinators are responsible for ordering implants, they need to understand when implants are included in your facility’s procedure reimbursement and when they are reimbursed separately.  Creating a ‘cheat’ sheet of payers with implant reimbursement information can help guide them in their purchasing process.  Armed with this information, your materials coordinator can assist with surgeon education on the cost of implants and payer reimbursement.

6. Ensure your materials coordinator has a refined process for receiving and invoicing supplies.

Having the following process for your materials coordinator will provide inventory control and accurate financials –

  • Enter receipt of supplies from packing slip into inventory module.
  • Review the invoice against the purchase order (PO) and packing slip to confirm receipt of invoiced products.
  • Compare invoice pricing to the facility’s inventory item master.
  • Code the invoice for accounting.
  • Input the invoice number into the inventory or patient accounting system.
  • Close the PO once all items are received and invoiced.
  • If your facility prepares financial statements based on accrual accounting, provide an open PO accrual log report to your accountant at the end of each month. Doing so will ensure the current month’s supply costs are accrued for with the current month’s revenue and expenses.  This also helps your materials coordinator stay on top of open invoices.  Having this list provides your materials coordinator an opportunity to call vendors to request delayed invoices thereby avoiding late payment fees or account holds. 

7. Have your materials coordinator perform an annual physical count at year-end.

If inventory has been managed properly during the year, and there have been no significant changes in your business, the inventory adjustment from the previous year should be minimal.  If specialties were added, there may be an increase in on-hand inventory to cover supplies purchased for the new specialty.

Involving your materials coordinator in the ASC’s business operations and budgeting processes could contribute significantly to your center’s bottom line. The key is to provide them with clear expectations and explain how their daily activities impact your vision for the upcoming year.  Then, empower them to make decisions that positively impact your surgery center’s finances.  

Kelli McMahan – Vice President of Operations

Mar 22
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High Deductible Health Plan Members

When is a Self-Pay Arrangement a Good Prescription for High Deductible Health Plan Members?

By Payor Contracting No Comments

Recently I was asked what ASCs could do to assist patients who can’t afford to pay for a procedure that’s covered under their high deductible health plan (HDHP).  If you haven’t faced this question yet, brace yourself!  The findings of the Kaiser Foundation and Health Research and Education Trust’s 2016 Annual Survey suggest you will soon.

Kaiser’s survey indicates four out of five patients who arrive in your facility are likely covered by a high deductible plan.  It further reveals that deductibles on employer sponsored health insurance policies rose 12% in 2016.  This is four times faster than premiums increased.  The average deductible for single coverage is almost $1,500 with many plans exceeding that amount.  Since 150 million Americans have coverage through their employers, expect to see patients with high deductibles more often.[1]  

I negotiated a contract with a payor on behalf of a client and was pleased the end result was exceptional reimbursement for the ASC.  However, one of the facility’s surgeons was approached by a patient who had insurance with that payor.  To my surprise, the surgeon was not as impressed with the reimbursement as I was.  He was concerned the payor’s contract made the ASC cost-prohibitive for his HDHP patients.  Talk about unintended consequences!  

Since I contributed to creating the problem, I had a stake in finding ways to minimize the adverse effects for the ASC and its patients.  One way was to educate patients on their right to opt-out of insurance and create a self-pay arrangement.  If you are wondering if your ASC and its patients could benefit from a self-pay arrangement, consider the following:

  • What limitations does your ASC need to be aware of prior to pursuing this route?
  • When can your ASC recommend to a patient that it may make sense for them to opt-out and enter into a self-pay arrangement?

What limitations does your ASC need to be aware of?

Review your contracts to determine which ones call for direct billing.  Most, if not all, contracts with insurance companies require providers to directly bill the insurer for covered services provided to their members.  

Federal regulations now allow patients covered by health plans the right to opt-out (typically for privacy reasons).  As Wall Street Journal clarifies: “Cash prices are officially aimed at the uninsured, but people with coverage aren’t legally required to use it.”[2]  If they opt-out, they choose to pay a provider in full on or before the day of surgery and relinquish the privilege of the provider billing the insurance company on their behalf.  

Some precautionary measures your ASC should be aware of include:  

  • Does your contract have a “most favored nation (MFN)” clause?  A MFN clause essentially restricts your ASC from accepting lower payment for a service from anyone other than the payor that mandated the clause.  In other words, your discounted rate for self-pay patients cannot be lower than what the insurer with the MFN status pays your ASC.  Fortunately, MFN clauses are not common these days.  But if they’re overlooked, this condition could present a problem if you deeply discount ASC fees for self-pay patients.      
  • Your patients need to be informed they can’t avoid paying their deductible under their HDHP. If the patient opts to seek care under a self-pay arrangement, an insurance claim will not be filed.  This means the amount they remit under the self-pay arrangements is not credited to (applied against) their deductible.      
  • Once a patient opts out of insurance, they cannot expect the ASC to bill the insurance company at a later date. By that point, it is likely the claim would be outside of timely filing requirements and subject to denial.

The primary message is “do your homework.”  This starts with knowing the terms in each of your insurance contracts and, when necessary, seeking legal opinion about your options.  Further, find out if there are laws in your state that override federal regulation.  Typically, the most restrictive laws will dictate your self-pay pricing.

When can your ASC recommend a self-pay option?

It makes sense for a patient to elect self-pay when:

  • The patient expects to be responsible for paying the ASC the full amount due under their HDHP.
  • The patient’s deductible is high and their health is such they do not anticipate reaching their deductible during their plan year.
  • The amount the patient will pay under your ASC’s self-pay policy will be substantially less than they would owe if you submitted the claim under their HDHP. Remember to take into consideration the contracted rate (allowable), not merely the fee you bill to the payor.  
  • The patient is able to pay for services in full, via cash or cashier’s check, on or before the day of surgery.
  • The patient is willing to sign a form electing to opt-out of insurance and enter into a self-pay arrangement.
  • The patient, for privacy reasons, wishes to withhold releasing their medical records to their insurance carrier.

Ensure patients who opt-out, specifically sign an “election to opt-out of insurance” clause on your self-pay form.  

By acknowledging this clause, the patient is stating they understand:

  • They have chosen to opt-out of their insurance.
  • Your ASC will not be filing a claim with their insurance company.
  • If the patient were to file a claim on their own, there is no guarantee it will apply towards their deductible. This is because the patient chose not to use insurance.

At the time of scheduling, it can be difficult to predict all the procedures that will be performed when the surgery actually takes place.  For that reason, add a disclaimer to the election form alerting the patient to the possibility of an alternate procedure and/or additional procedures being performed. Ensure they accept responsibility for paying the difference between the quoted price and the actual price after the “time of service” discount is applied.

Also, it is important to clarify upfront that receiving the discounted self-pay price is contingent upon payment being made on or before the date of service via cash, money order, or cashier’s check.   If your ASC opts to accept payment from the self-pay patient via credit card, consider adding a 3% credit card processing fee to your cash price.  Doing so will incentivize self-pay patients to pay with cash, money order, or a cashier’s check.

Finally, your ASC should not send any claims to the carrier for the opt-out episode of care, nor provide a claim form to the patient for claim filing purposes. Instead, incorporate all charge and payment information into the opt-out self-pay election form.  This precautionary measure may deter opt-out self-pay patients from sending a claim to their insurance company.   

Dan Connolly – Vice President of Payor Relations and Contracting

[1] “The Kaiser Family Foundation and Health Research & Education Trust. “Employer Health Benefits,” 2016      

[2] “How to Cut Your Health-Care Bill – Pay Cash,” The Wall Street Journal, February 2017

 

Mar 20
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Changing Banks

Time for Your ASC to Consider Changing Banks? What You Need to Know

By ASC Governance, ASC Management No Comments

The threat of rising interest rates in the banking industry came to fruition in November 2016.  If your ASC has not taken advantage of refinancing its debt at a lower rate, your days to do so may be numbered.  Unfortunately, if the refinancing of your outstanding notes also includes a change in bank relationships, significant forethought is required to ensure the process does not negatively impact your business operations.

It is best to use a team approach to manage this process.  Team members could include administration, revenue cycle management, managed care, accounting, accounts payable, materials management, and human resources.  The process may take several months to manage safely and effectively, so plan accordingly.

First, have your team identify all aspects of your business that changing banks will impact.  Here are some areas to consider:

Accounting, Accounts Payable, & Materials Management

  • Transfer of deposits between accounts and/or lockbox
  • Current bank credit card
  • New bank credit card
  • Automatic lease payments
  • Online banking fees
  • Automatic vendor payments

Human Resources

  • Payroll
  • 401(k) withdrawals
  • HSA withdrawals
  • Automatic employee benefit provider payments

Revenue Cycle & Managed Care

  • Electronic fund transfer (EFT) payments
  • Lockbox
  • Online bill pay
  • Merchant services accounts

Next, delegate responsibilities to team members for each aspect of your business.  Responsibility and delineation of duties may look something like this:

Administration

Administration may be the best department in your organization to oversee the process.  Arrange bi-weekly calls with all stakeholders to enhance communication.  Have an agenda with specific items to accomplish before the next meeting to maintain project organization and oversight.  Prepare owners for potential disruption in cash flow. Discuss precautions, such as keeping extra cash on hand, to proactively manage worst case scenarios. 

Managed Care

Coordinate a strategy with revenue cycle management to communicate with payers about the change in payment remittance.  It may not be in your best interest to notify all payers at once that you have changed banks.  Stagger payer notifications.  When funds begin to flow through the new account from a given payer, proceed with notifying the next payer.

In advance of changing banks, and based on the schedule developed in conjunction with revenue cycle management, begin notifying key commercial payers via email the ASC’s plan to change the lockbox or EFT address.  Provide the following information based on the contract requirements:

  • The old remittance address
  • The new remittance address
  • The effective date of change – build in a 10-14 day delay between the notice and effective date
  • An updated W-9
  • Submit all information on your ASC’s letterhead as an attachment to your email notification

After you have received confirmation from each commercial payer that the new lockbox or EFT address has been loaded into their system, ask your revenue cycle management team to recommence billing.  At that time, you can begin dropping claims reflecting the new remittance address.

Revenue Cycle Management

Work with your managed care representative to develop a schedule for notifying payers of the change in bank.  Once you gain user access to the new bank account, confirm it meets your needs to perform associated collections activities.

If using a lockbox, determine the size required.  Obtain the new lockbox address.  Complete the lockbox application form, selecting documentation delivery and storage options that meet your needs.  Then, complete the automated clearing house (ACH) transfer form with your facility’s online payment vendor.

 Once you receive the new lockbox address:

  • Update the lockbox address in your patient accounting system.
  • Change the lockbox address on your electronic and/or paper statements.
  • Complete a forwarding order with the US Postal Service to the new lockbox address.
  • Obtain a copy of a voided check required to complete many EFT change forms.
  • Review current EFT payers and timing (effective date) of EFT changes.
  • Complete third-party payer applications online and via paper.
  • Monitor both accounts to confirm when EFT changes become active in the new account.
  • For payers who are not delivering payments via EFT direct deposit, complete a W-9 form and send to them with a request to correct your remittance address in their system.
  • Monitor both accounts to confirm EFTs, credit card deposits, and all other payments are moving from the old account into the new account.
  • Ensure lockbox activity at the previous bank ceases.
  • Apply for a merchant account with your new bank. Review your merchant account contract to determine how to terminate merchant services at your old bank.  Then, terminate services with the old bank to ensure credit card payments are deposited in your new account.

Human Resources

Have human resources determine which employee benefits are directly linked to your current bank account.  Armed with this information, schedule transfer of funds to your new account.  The list may include, but not be limited to, payroll disbursements, 401(k) contributions, medical/dental/vision insurance premiums, health savings and flexible spending account transactions.

Accounting, Accounts Payable & Materials Management

Accounts payable and materials management must collaborate with accounting and administration to verify bills are paid from the proper account and the account has sufficient funds.  Ensure autopay accounts are updated to reflect the new bank account information.  If a bank credit card is in use at the facility, coordinate a schedule for terminating the old card and activating the new card. 

Keep in mind your old bank account will likely remain open for six months or longer while all required transfers take place.  Bank fees will continue to be charged until the account is closed. However, following the process outlined above will assist you in timely closure of the old account and reduction in associated bank fees.

There are many reasons your ASC may find itself in a position to change bank accounts.  Managing the process for your center with forethought will not only reduce disruption to stakeholders but ensure the advantages of doing so are clear to everyone.

Pinnacle III Leadership Team

Mar 16
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Convalescent Care Center

Value Proposition: Adding a Convalescent Care Center to Your ASC

By ASC Development, ASC Governance, ASC Management, Leadership 2 Comments

If your ASC operates in a state that allows convalescent care centers, there are numerous benefits of adding one to your existing continuum of care.  We outline some of those benefits in this value proposition.  

Convalescent Center Value Proposition

In some states, an ASC may maintain a separately licensed convalescent care center as part of its service offering.  This separate licensure provides an ASC with the opportunity to keep most commercial patients beyond the standard 23-hour stay of a regularly licensed ASC.  The extended stay is granted for observation and pain control for more extensive outpatient procedures.  

The ASC is generally directly compensated for the additional recovery time in the convalescent center.  Compensation occurs in a variety of ways including hourly rates, per day rates, or increased consideration in global or bundled fee arrangements.  In addition, the ASC may be indirectly compensated by securing greater reimbursement from commercial payers on lower acuity cases.  This is because payors recognize cost savings occur when higher acuity cases safely move from a hospital to an ASC with extended stay capability.  

The primary advantage for an ASC with a licensed convalescent center is the potential to provide services to higher acuity surgical patients.  Orthopaedics and neurosurgery specialties benefit most from this advantage, specifically in total joint replacement and spinal surgery.

The types of orthopaedic cases requiring extended stay that are well-suited for an ASC connected to a convalescent care center are: 

  • Patella femoral arthroplasty
  • Total hip arthroplasty
  • Total knee arthroplasty
  • Total shoulder arthroplasty
  • Total ankle arthroplasty

These cases traditionally restricted both physicians and patients to an inpatient setting.  Although moving them to an outpatient setting represents significant savings for insurance carriers and patients alike, these higher acuity cases can provide a net revenue per case increase of 300-400% over traditional ASC orthopaedic cases.

Other types of extended stay cases well-suited for this arrangement are orthopaedic-spine and neuro-spine.  Specifically, the following:

  • Single and multi-level anterior and/or posterior cervical and lumbar fusions
  • Cervical and lumbar disc arthroplasty

Again, these spine cases may have traditionally restricted physicians and patients to inpatient settings.   Cost-savings for both insurance carriers and patients also occur when these cases move to ASCs with separately licensed convalescent centers.  The result for ASCs can be a net revenue per case increase of 600-700% over traditional orthopaedic cases and 250% above traditional spine cases.

Another advantage of these separately licensed facilities over inpatient hospitals and orthopaedic specialty hospitals occurs in payor contracting.  The value proposition for commercial payors, workers’ compensation, auto insurers, and the general public is significant.  A contracting advantage for surgeons in terms of future health care reimbursement may also be realized.  Future reimbursement will likely include, but not be limited to:  bundled payments, pay-for-performance, at risk contracting, clinically integrated networks, consumer-driven care, and price transparency.

Finally, having the capacity to accommodate higher acuity and higher paying surgical cases enhances surgeon and partner recruitment. With the saturation of “commodity” ASCs, an ASC with an adjoining convalescent care center offers the benefits of a mini-hospital. This is attractive to surgeons who may not otherwise be interested in using your facility, much less investing in it. 

What Value Does a Convalescent Center Represent for You?

Investigating convalescent care center licensure requirements in your state is a worthwhile endeavor if your facility is interested in performing higher acuity cases.  If your state allows these types of centers, conduct a thorough cost-benefit analysis to determine the feasibility of establishing one in conjunction with your ASC. 

If your state does not currently afford ASCs the opportunity to establish an adjoining convalescent center, consider these benefits, network with other facilities, then work together to rally legislative support for them in your locale.

Pinnacle III Leadership Team

Mar 14
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Patient Payment Policies

Are Your ASC’s Patient Payment Policies Hindering Effective Collections?

By Revenue Cycle Management No Comments

According to a recent study by Kaiser Family Foundation, an increasing number of insured Americans report difficulty affording health care.[1]  Are you prepared for the impact your patients’ out-of-pocket costs will have on your facility’s cash flow?   Implementing patient payment policies and corresponding processes goes a long way toward effectively managing a growing financial class – patient responsibility.    

Are you familiar with your ASC’s patient payment policies?  Is your board supportive of those policies?  Does your staff follow the policies?  If you answered “no” to any of these questions, there’s work to be done.  Make sure you tighten the gaps.  Educate and train your staff on how to implement the policies effectively.  Your efforts will be instrumental in avoiding an increase in bad debt due to uncollected account balances.  You will also create a better patient experience with your ASC’s billing process.

Let’s review the components of strong patient payments policies and upfront collections.

Creating an effective collections process starts with determining when you need to receive payment from patients.  Best practice is to collect co-payment and deductible portions owed by patients before or on the date of service.  Post your policy at your front desk and in your waiting room.  For patients who do not have insurance (self-pay), secure payment in full on or before the date of service. 

Do your patient payment policies outline what should occur when patients indicate they are unable to meet the terms of those policies?  If so, what steps need to be taken by facility personnel?  Proactively discuss with your facility’s governing board the types of payment plans they are willing to extend to patients.  Furthermore, decide what mechanisms the ASC will use when individual patient payment needs conflict with established policies. 

Other things you can do to ensure successful upfront collections include:

  • Providing patients with an accurate estimate of their responsibility for upcoming care – review these details with them before their date of service.
  • Relaying the types of payment you accept – cash, credit cards, automatic withdrawal from bank accounts, online bill pay portal, etc.   Provide as many payment avenues as possible and make it easy for patients to pay.
  • Developing a well-defined policy for upfront collections. Statistics reveal patients are 90% likely to pay before their visit, 70% likely at checkout, and only 40% likely to pay after their visit.[2]
  • Training your staff to be comfortable with upfront collections – provide collections scripts, customer service training, and role playing opportunities to enhance their skills.

Before finalizing your policies, establish how you will deal with amounts that are billed to but not covered by insurance and are attributed to patient responsibility by third-party payors.  

Some questions to consider are:

  • How long will you wait for the insurance payment before you involve or bill the patient?
  • Will you bill secondary insurance?
  • Will you bill the secondary policy if this information is provided after you billed your patient?

Determine if you will bill exclusively when the secondary policy is submitted at the time of registration. Look at your statement cycle – statements issued once a month are no longer effective.  Consider the frequency of your statements and the number of statements you will send before referring patient accounts to an outside collections agency.

After determining your upfront collections policies, define what past due means for your ASC.  It’s surprising how many patient payment policies state past due accounts will be turned over to an outside collections service but do not adequately define the term past due.  Is it one day past the due date?  Is it ten days after the due date?  If you state accounts will be turned over to collections, follow through.    Establish a policy on how to handle scheduling of patients who were previously turned over to collections. 

Consider the following:

  • Will you collect all amounts owed from past dates of service before scheduling an upcoming case?
  • Will you collect the patient estimate in full with no payment options due to previous collections activity?

To address the questions above, consider a legal review of your policies.  This will confirm you have thoughtfully dealt with necessary items and considered how to handle any problems that may arise. 

Once you have a refined policy in place, post it in your waiting room and on your website.  Also, include it in your patient packets and review it in person with patients and family members.  Have patients sign the policy and any corresponding payment plan agreements, then provide them with a copy. Lastly, send the agreement to your billing department to assist with collection efforts.  Displaying and consistently following your patient payment policies will lead to better outcomes in your upfront collections. 

In these times of rising out-of-pocket health care costs, your ASC’s patient payment policies and upfront collections practices are important to the well-being of your ASC.  Review them frequently to ensure your upfront collections practices lead to an enhanced billing experience for patients and stabilization of your ASC’s revenue.

Carol Ciluffo – Vice President of Revenue Cycle Management

[1] The Henry J. Kaiser Family Foundation: “Data Note:  Americans’ Challenges with Health Care Costs,” 2017 

[2] McKinsey & Company: “U.S. Health Care Payments: Remedies for an Ailing System,” 2009