Patients are quickly becoming the top revenue source in ASCs which presents unique challenges. The days of “send me a bill” or “let’s bill your insurance and see what they pay” are long gone – at least they should be if you expect a steady flow on your revenue stream.
With the growth in high deductible health plans, your facility needs to develop and maintain a strong up-front collections strategy. A patient’s out-of-pocket costs for their portion of a health care procedure can easily exceed their monthly mortgage payment. An unforeseen medical procedure can place a significant burden on them.
Although the situation can seem dire, all hope is not lost! There are several things ASC personnel can do to proactively position your facility to collect the allowed reimbursement – from insurance carriers and patients.
Let’s start with insurance reimbursement. When scheduling a patient for a procedure, ideally ASCs should:
- Be in-network with the insurance carrier. If operating in an out-of-network situation, confirm out-of-network benefits are available to cover the planned procedure(s).
- Confirm the scheduled procedure is allowed by the patient’s plan.
- Verify the patient’s plan eligibility and benefits.
- Obtain prior authorization, if required, for the procedure and implants.
Tools available to assist you with gathering patient specific information include payor web portals and eligibility information through EDI clearinghouses or patient accounting software.
Using these invaluable tools enhances efficiency in the authorization process. Take the information you confidently rely on and create your own tools to summarize your unique insurance contract details to serve as easy references for ASC personnel.
Employ features in your patient accounting system to alert facility personnel to nuances that are likely to be encountered. For example:
- Enter your fee schedules or grouper rates. Ensure this information is updated when your contracts change or renew.
- Create reminder pop-up notes to alert schedulers to the need to secure authorizations for specific CPT procedure codes. If this feature is not a component of your current software system, establish your own list of CPT codes requiring authorization and sort it by payor.
Front desk personnel need to be able to calculate a logical estimate of patient financial responsibility and convey that information in understandable terms to their customers. Information obtained during verification and authorization is necessary to accurately calculate patient estimates. Identify the following patient specific details:
- Their annual deductible and how much is remaining to be paid,
- Their co-payment and/or co-insurance responsibility,
- Their out-of-pocket maximums, if those limits have been met, and
- Their in- and out-of-network benefits.
After you’ve collected patient specific details, determine what coverage is available based on your facility’s contract with the payor. Begin by determining if the procedure scheduled to be performed is allowed in the ASC setting. Then document the following:
- Allowable amounts for each procedure code,
- Multiple procedure limits and/or reimbursement reduction parameters,
- Case rate caps,
- Methodology for pricing and reimbursement of implants,
- Carve-out rates, and
- Other pertinent contract details.
Don’t overlook the information contained in payors’ newsletters. This is where they outline policy and reimbursement changes, pre-certification requirements, packaged coding lists, annual fee schedule and grouper updates, etc.
You should now have the information required to create a useful financial responsibility estimate for the patient. Review your estimate in detail with the patient prior to the procedure. Avoid assuming your patient knows the amount of their outstanding deductible or how much they will owe. Be sure to reinforce that, although you have provided them with the most accurate estimate possible, they are responsible for any amount their insurance doesn’t cover. Make sure to answer all their questions to the best of your ability and obtain their signature on your financial responsibility policy.
Once the financial responsibility estimate has been reviewed with your patient, it’s time to collect their payment. Patients are more likely to remit payment at the time of service. Once they’ve left your ASC, the chances of collecting from them are significantly reduced. Try to avoid asking, “How much can you pay?” Instead inquire, “How will you pay for your portion today?” Improve your ability to collect payment by offering a variety of payment options – cash, HSA or FSA debit cards, credit cards, or automatic bank transfers. If the patient is unable to submit payment at time of service, consider offering them a low interest health care loan or short-term payment plan. It is in your ASC’s best interest to only do so, however, if upfront collection options have been exhausted.
If you must offer a payment plan option, have a solid policy in place and adhere to the defined parameters. Your payment plans should be straightforward and manageable. Remember to obtain the patient’s signature on the payment plan agreement, then follow the outlined terms.
Review your facility’s upfront collections processes, tighten them up, coach your staff, and work with your patients to create clarity regarding their financial obligations. Doing this will ensure you maximize collections from your ASC’s top revenue source – your patients.
Carol Ciluffo – Vice President of Revenue Cycle Management