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Revenue Cycle Management Archives - Pinnacle III

Apr 09
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ASC billing office process improvement

ASC Billing Office Process Improvement – Conducting a Quarterly Review

By ASC Management, Leadership, Revenue Cycle Management No Comments

The saying goes, “Old habits die hard.” But in the ASC billing office, repeating the same mistakes costs time, money, and resources. Hence, the process of identifying process inefficiencies and areas of improvement is a constant responsibility for an effective ASC billing office. It is generally good practice to conduct a complete billing office process improvement evaluation and plan implementation at the end of each financial quarter. At the close of a quarter, there is enough data to review, identify, and correct negative trends. The start of a new quarter provides a clean slate for tracking the impact of the changes three months from now.

Where to begin?

Start by identifying your weaknesses by analyzing available data. This data can come from your patient accounting system and/or clearinghouse. Error tracking allows you to quantify mistakes that prevent clean claims. Reviewing clearinghouse rejection reports may identify trends. If you regularly find the same rejections, log the incidence as well as the resolution changes you make to help you identify and correct the issue. It may also be beneficial to review adjustment journal codes and ensure they meet your tracking needs in case you need to analyze payment or adjustment trends. These metrics can help you identify training opportunities for your staff at all stages of your billing cycle.

Collaboration

In an efficient billing office, a system of checks and balances establishes itself when billing tasks are departmentalized. The schedulers provide the patient and billing information, verification confirms the feasibility of the case under the provided circumstances, coders translate the visit for delivery to the insurance carrier, data entry qualifies the billing information, and accounts receivable ensures maximum reimbursement for the team’s efforts. Each subsequent person that handles the information relies on the previous person’s understanding of healthcare billing. Every individual’s work is verified, but not repeated, in the next step in the process. When each of these groups of people are housed in the same location, collaboration is as simple as looking over the cubicle wall. If your ASC billing office is off-site, the frequency and timeliness in which front office errors are communicated may impact the ASC billing office revenue cycle. It is important to have timely and frequent communication in this scenario.

Cross-train

Requests should not be put on hold when someone is out sick! Besides needing backup to cover absences, cross-training allows employees to understand how people in other roles manage their time and contribute to the success of the team. Transparency among departments and roles invites accountability. The quarterly billing office process improvement review is a perfect time to identify areas where cross-training is needed to fill gaps and/or back up a role.

Empower

A billing office’s process improvement plan success is dependent on the team’s commitment to the improvements. Encourage staff to participate and take charge of change. They perform the tasks that bring the money in the door. Policies and procedures sound good on paper, but execution can reveal unexpected roadblocks. Your team has ideas of how to prevent issues and improve the process. Implement the solutions that will work best for your team and your center.

Re-evaluate

CMS guidelines, fee schedules, CPT/ICD-10/HCPCS codes, pre-certification lists, and coverage policies – this information changes monthly, quarterly, annually. Subscribe to insurance company newsletters and follow medical societies, revenue cycle resources, and vendors. Assign someone to distribute beneficial information to affected groups of people. This may include surgeons, their billing office, facility administrators, and insurance verification specialists, in addition to your own revenue cycle team. The information released may force you to take yet another look at your revenue cycle needs and adjust as necessary!

Summary of Tips for ASC Billing Office Process Improvement

Make it regular. ASC billing office process improvement review should take place on a regular basis, whether conducted monthly, quarterly, or on another schedule.

Review the data. Reviewing rejected claims logs and other data allows you to identify trends and billing office inefficiencies.

Promote team collaboration. Billing office roles will naturally back each other up when operating in sync with collaboration.

Incorporate occasional cross-training. A fresh set of eyes can provide valuable insight into simple changes that can increase efficiency or reduce errors.

Don’t leave out clinical roles. They have valuable insights that can affect coding and thus reimbursement. Evaluate the use of expensive implants and supplies to ensure you are billing and collecting as your contracts allow.

Re-evaluate and update regulatory information. It is crucial to the essential function of the ASC billing office to maintain accurate and up-to-date records when it comes to CMS guidelines, fee schedules, CPT/ICD-10/HCPCS codes, pre-certification lists, and coverage policies. This should also be a part of the regular ASC billing office process improvement review.

The only constant in the healthcare industry is change. When so many professionals rely on your office for the financial deliverables of their organization, as in the ASC billing office, it is imperative to stay up-to-date with industry changes. Regular review of your internal processes is the best way to keep up.

Bethany Bueno, Director of Billing Operations

May 02
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Revenue Cycle Management Processes: Establishing a Status Quo and Incorporating Input from New Employees

Revenue Cycle Management Processes: Establishing a Status Quo and Incorporating Input from New Employees

By ASC Management, Revenue Cycle Management No Comments

It’s Monday morning and one of your billing office employees walks in with a bizarre patient statement. To make matters even worse, your employee’s work on the statement does not reflect your office’s revenue cycle management processes. Where did this statement come from? How long have your employees employed this process? Where did the communication go wrong?

Perhaps your organization is in growth mode and new staff began implementing experiences and practices from their previous employers. Their understanding of the best way to proceed may not align with your company’s established revenue cycle management processes. Additional education or retraining is necessary.

Perhaps it’s time to re-evaluate your processes to assess if they still meet your business needs. If you’re not auditing your current protocols, how do you really know they are effective?

Consider the following practices to ensure successful communication is being delivered to your billing office employees. These suggestions will also ensure your processes remain relevant and effective.

  • Create, implement, and adhere to a robust onboarding process. This helps managers and trainers provide each new employee with the same foundation. A key onboarding element is spending time in other departments to gain an understanding of how each department contributes to the process. If you don’t have a well-defined new employee onboarding process, you need one. The orientation period is the most important opportunity to position new employees for success.
  • Hold educational boot camps when issues arise. It may be much easier to hold short 15-minute topic-specific meetings to address identified issues, than a 30 minute or an hour-long meeting designed to cover multiple topics. This tactic will allow you to be very detailed in reviewing and educating your team about the specific processes or issues in question. Addressing one topic per meeting leads to a greater chance your team will adopt your revenue cycle management processes. Addressing multiple topics in the same meeting may cause the team to become overwhelmed and lose direction, not knowing what to tackle first.
  • Review your policy and procedure manual. Engage your team members in revamping or creating revenue cycle management processes. Allow them to review existing policies to determine if they are still relevant. Retraining and education naturally occur through this type of employee engagement — a win-win for your team.
  • Allow employees to cross-train or shadow in different departments. Confusion often occurs when multiple departments are part of a process. Allowing employees to cross-train or shadow in departments other than their own will help them understand the process in its entirety. Once they have a clear understanding of the entire process, they are better equipped to problem-solve in areas they can control to help their colleagues. Time spent cross-training or shadowing also allows employees to establish relationships and team build with one another.
  • Audit, and then audit some more. Audits don’t have to be cumbersome. A high-level review can reveal where you need to focus your attention. The issues you discover may apply to only one employee and may not be departmental problems.

Bottom line: don’t bury your head in the sand and hope for the best. When adding new team members, training, education, and communication are your best shots for success to ensure their understanding and continuous use of current, relevant revenue cycle management processes. Allowing new team members to suggest alternate ways of proceeding is a bonus for the organization. Their fresh perspective may lead to improvement of established or outdated processes.

Carol Ciluffo, VP of Revenue Cycle Management

Apr 26
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ASC Business Office Checkpoints: Improving Your Surgery Center’s Bottom Line

ASC Business Office Checkpoints: Improving Your Surgery Center’s Bottom Line

By ASC Management, Revenue Cycle Management No Comments

If your ASC business office is not meeting their performance metric benchmarks, it may be time to re-evaluate your revenue cycle management policies and procedures. Business office personnel who serve on the front-end (scheduling and insurance verification, for example) and those who serve on the back-end (billing office personnel) must work as a team to achieve your ASC’s key performance indicators.

There are natural checkpoints built in to revenue cycle management. When striving to meet performance benchmarks, you and your staff can take advantage of these natural checkpoints if you know how to use them. For example, both your patient accounting system and clearinghouse have resources available to help identify opportunities for improvement. Additionally, internal tracking processes, including logs and dashboards, allow you to sort through preventable errors and identify staff members who need additional education and training.

Regular evaluation of revenue cycle policies and procedures on the front and back end of your process can assist supervisors, managers, and administrators address weaknesses, improve performance, and enhance your ASC’s bottom line.

Where do you start?

Begin your evaluation at the initial receipt of patient information. Schedulers and insurance verification personnel are at the front end of your financial flow. Accurate data entry is crucial to proper registration, eligibility, and authorization. Data entry errors, including incorrect policy numbers or failure to obtain subscriber date of birth, may create billing delays. To minimize unnecessary rejections and denials, consider developing and using a scheduling checklist.

A scheduling checklist includes guidelines on information your surgery schedulers must collect to ensure there are no omissions or errors when the ASC billing office submits a claim. This tool can reduce time delays in claim filing and eliminate the need to re-work rejected claims. Regular review of clearinghouse rejections can help you create and add to your scheduling checklist by identifying areas in which staff may be prone to making errors.

Monitoring patient benefits

Schedulers and insurance verification personnel also need a solid understanding of patient benefits. Knowing how to determine a patient’s outstanding deductible, predict coinsurance, pre-collect co-payments, and coordinate patient benefits are essential to success. To automate this process, integrate your clearinghouse whenever possible. Insurance websites also provide free tools that assist in determining patient benefits, eligibility, and financial responsibility. Evaluate the accuracy, efficiency, and effectiveness of your scheduling and verification team by running reports from your patient accounting system. Review the total dollars pre-collected each month and challenge your team to break their record the following month. Celebrate their successes! And ensure you educate staff about when and why to use an Advance Beneficiary Notice (ABN).[1]

Establishing self-pay policies for procedures performed at the facility which are not covered by insurance is also important. Ensure your team is familiar with in-network insurance carriers as well as the procedures and implants those carriers reimburse. Insurance carriers regularly publish and update pre-authorization lists. Track and evaluate denials attributable to no authorization, non-coverage due to place of service, and out-of-network write-offs. Set targets for the ASC business office team to increase collections and decrease denials. When target goals are met, reward your team for their efforts. Motivation and direction make a difference when seeking improvements.

What happens after submitting a claim?

Once a case is billed, use denial tracking to identify areas of education for coders and surgeons. Encourage coding staff to take a second look at medical necessity denials. A simple query to the physician can mean the difference between payment and non-payment. Review this information to identify areas for improvement. Denials related to bundling[2] might mean a coder requires additional education on proper modifier use. Medical necessity denials can indicate operative note templates need to be updated or coding staff need additional access to pertinent patient records.

Educate everyone about the cases that can and cannot be performed in your ASC. National Correct Coding Initiative (NCCI) edits and a list of approved ASC procedures can be found on the Centers for Medicare & Medicaid Services (CMS) website or the website for the facility’s Medicare Administrative Contractor (MAC).[3] Centralize front and back end staff access to your approved procedures lists and assign someone to review and update them on a regular basis.

Another checkpoint technique is separating the duties of your charge entry, payment posting, and follow-up teams. This introduces another layer of accountability. As your accounts receivable (follow-up) personnel work their aging reports, they can identify charge entry and payment posting habits that require education or training to improve accuracy and timeliness of account resolution. Payment posters will provide a second set of eyes on write-offs and can supply additional insight into tackling appeals and securing reimbursement. Accounts receivable personnel can also prevent timely filing issues by following up on accounts as soon as 30-45 days after the date of service. Regular reconciliation of unbilled claims in comparison to cases performed prevents missed cases.

Improving the flow in the ASC business office

There are numerous opportunities to tighten the flow of patient information from scheduling to final payment. Cross-checking information at critical points in the ASC revenue cycle reduces billing delays and preventable denials. Separation of duties among ASC billing office staff allows you to build natural checkpoints into your system, preventing costly errors including unnecessary write-offs. Once areas for improvement have been identified, set achievable goals and timelines for your staff, then celebrate their successes.

Bethany Bueno, Director, Billing Operations, Specialty Billing Solutions

[1] An Advance Beneficiary Notice (ABN) is given to patients to forewarn that Medicare may deny payment for their treatment.

[2] A bundling denial occurs when a procedure requires a qualifying procedure be received and covered and the qualifying other procedure has not been performed or adjudicated. A denial related to unbundling occurs when several CPT codes are billed for a service when one inclusive code is available.

[3] A Medicare Administrative Contractor (MAC) is a private health care insurer that has been awarded a geographic area or “jurisdiction” to regionally manage the policies and medical claims for Medicare Part A and Part B Fee-For-Service (FFS) beneficiaries.

Jan 11
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9 Strategies for Upfront ASC Patient Collections

9 Strategies for Upfront ASC Patient Collections

By ASC Management, Revenue Cycle Management No Comments

With the continued rise of co-payments, deductions, and co-insurance percentages, patient balances are quickly becoming the largest payer class for ambulatory surgery centers. This increased financial burden for patients places upfront ASC patient collections front and center for every facility. ASCs who adopt a proactive stance toward patient financial responsibility can significantly shorten their payment resolution cycle and increase profitability.

In an ideal situation – submission of a clean claim and prompt processing of same by the third-party payor – payment from the patient’s insurance company is received approximately 15-30 days following the date of service. Upon completion of a properly processed claim, the facility can then generate a statement notifying the patient of any residual financial responsibility.

In many cases, however, the actual “payment in full” status of an account extends well beyond a 45- to 90-day timeframe, particularly when the balance attributed to patient responsibility is significant.

To avoid becoming a long-term creditor, ASCs can positively impact patient balances by employing the following ASC patient collections strategies in the upcoming year.

  1. Consider hiring a Patient Financial Counselor to serve as your ASC’s primary source of patient estimates. With their solid understanding of how insurance works and ability to relay patient responsibility expectations in understandable terms, your ASC’s upfront patient collections and patient satisfaction will trend in a positive direction.
  2. Pre-verify patient insurance benefits specifically noting deductibles, co-pays, and co-insurance parameters, as well as the portions patients have already met in each of these areas.
  3. Collect co-pays and deductibles on the date of service, prior to patients undergoing scheduled procedures.
  4. Ask for payment in full.
  5. Don’t fall into the trap of extending payment plan terms that will not pay off patient balances owed in a reasonable amount of time (e.g., $10/month on a $500 bill); otherwise, your ASC can easily become your patients’ loan officer of choice.
  6. Establish hard and fast payment plan guidelines. Ensure staff consistently adhere to them when payment plans are required.
  7. Accept credit card payments and offer alternative payment services (i.e., low interest health care loan programs).
  8. Employ the use of a secure online payment portal.
  9. Accelerate your statement process. Gone are the days of monthly statements – it is simply too expensive to carry an interest free loan for your patients. Shorten your statement cycle to daily, weekly, or every 15 days. Ask for payment in full via the initial statement with one final notice generated 30 days later.

Failure to proactively manage patient balances can result in a higher percentage of accounts receivable attributable to individuals than third-party payors and more patient accounts than you can afford to contact. Ensure your patients are informed about their financial responsibility prior to their procedure and actively work with them to secure payment at the time of service. Upfront ASC patient collections can significantly impact your ASC’s cash flow, especially as you move into the new year.

Carol Ciluffo, VP of Revenue Cycle Management

Nov 21
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Patient Billing – Enhancing Patient Satisfaction & Your ASC’s Revenue Cycle Process

Patient Billing – Enhancing Patient Satisfaction & Your ASC’s Revenue Cycle Process

By ASC Management, Revenue Cycle Management No Comments

You may think service to your ASC patients ends upon completion of their surgical visit. The reality is, patient satisfaction extends far beyond their date of service. An effective patient billing and collections process can impact patient satisfaction both prior to and after their visit.

How can your surgery center create a positive revenue cycle experience and improve your patient billing process?

1. Proactively address financial concerns prior to each patient’s surgery by obtaining and providing thorough information on their behalf.

  • Contact patients prior to their date of service to verify registration information.
  • Perform insurance eligibility and verification to obtain prior authorization, if required.
  • Create a patient financial responsibility estimate for services to be performed.

2. Avoid potential billing misunderstandings by clearly relaying payment expectations upfront.

  • Discuss patients’ financial estimates with them prior to their scheduled appointment.
  • Secure payment from patients or explore payment plan options.
  • Clarify any remaining billing questions patients might have concerning the billing and collections process.
  • Record details regarding any prior arrangements made with patients in your ASC’s patient accounting system. This will assist with future collections efforts, if needed.

3. Improve upfront collections and/or adherence to agreed-upon terms for financing by reviewing patient estimates with them on the date of service.

  • Review financial responsibility estimates and payment options with patients again, answering any remaining questions they may have.
  • Secure signed financial agreements outlining payment plan details.
  • Collect payments that are due at time of service. Your patients are more likely to pay their bill when you review financial expectations and proactively involve them in the estimation and payment process.

4. Make it easy for your patients to remit payments.

  • Offer an online payment portal accepting ACH debits from bank accounts, a variety of credit cards, and payment plan options.
  • Provide patient friendly statements.

An efficient insurance verification process allows claims to move through the third-party payer system. The result? Timely reimbursement. Conversations with your patients regarding their anticipated financial responsibility ensure they are informed ahead of time. If you’re communicating well, they are able to understand and follow the ASC revenue cycle process.

The goal is a positive patient billing experience from referral all the way through to a zero balance on their account. Patient satisfaction, timely revenue collection, and recommendations of your facility to other patients seeking quality care and a smooth process is a win-win for all!

Carol Ciluffo, VP of Revenue Cycle Management

Sep 06
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Patient Registration Issues? Consider a Front Desk Audit

Patient Registration Issues? Consider a Front Desk Audit

By ASC Management, Revenue Cycle Management No Comments

Inaccurate patient registration can quickly derail a facility’s revenue cycle management efforts. Delayed reimbursement is costly. If your ambulatory surgery center is experiencing patient registration issues leading to lost or delayed reimbursements, consider conducting a front desk audit. Audit results often help identify training, communication, and process gaps that, once addressed, can get your center back on track.

When conducting your front desk audit, review how facility personnel collect the following items from patients:

  • Are scanned copies of patients’ insurance card(s) obtained and retained for future reference?
  • Does data entry in the patient registration sections of your patient accounting system match the scanned insurance card(s) on file? If not, what variances occurred?
  • Were the proper benefits eligibility and verification checks performed prior to the date of service?
    • Were eligibility and verification activities performed via a phone call or online?
    • If verified by phone, were the following elements – phone number, person spoken to, and reference number – recorded in patients’ accounts?
    • Were eligibility and verification details noted in patients’ accounts?
  • Were co-pay, deductible, and co-insurance details obtained and noted in patients’ accounts during the eligibility and verification process?
    • Were patients’ copays and deductibles collected on or before the date of service?
    • If not, were explanations recorded in patients’ accounts?
  • If required, were prior authorizations obtained before the date of service?
    • If not, was there information listed in patients’ accounts explaining why?

Recording audit results in a simple spreadsheet will provide you with an easy tool to assess your findings and identify trends.

Consider having staff members perform front desk audits on each other. Involving them in the assessment, education, and training aspects of patient registration auditing often yields lasting process improvements. Perhaps your ASC will realize the added benefit of a team inspired to collectively work towards an error free patient registration process.

Share this formula with them: Error free patient registration = clean claims = faster reimbursement = patient satisfaction = happy investors and staff. That’s a win-win for all involved!

Carol Ciluffo, VP of Revenue Cycle Management

Aug 30
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Diagnosis Please: It Pays to be Specific!

Diagnosis Please: It Pays to be Specific!

By ASC Management, Revenue Cycle Management No Comments

Payors often update their clinical policies in ways that modify how ambulatory surgery centers and physicians must document their interactions with, and sometimes even how they treat, their patients. Staying informed of these updates is crucial to an ASC billing team’s success in obtaining the expected reimbursements. As surgical procedures proliferate, payors are demanding an increased focus on diagnosis specificity. Physicians, surgery schedulers, coders, and billing departments all have a role in expeditiously implementing payor clinical policy changes to ensure reimbursement losses are minimized when policies change.

For example, Aetna’s Clinical Policy Bulletin #0673 changed how ASCs approach meniscectomy cases – procedures billed via CPT codes 29880 and 29881. From Aetna’s perspective, meniscectomies billed without a current injury diagnosis are deemed experimental and investigational (not reimbursable). Therefore, at time of scheduling facility personnel should be able to anticipate whether the meniscectomy case will result in payment or denial based on the patient’s history. Surgeons who add time parameters and other adjectives to the patient’s post-operative notes can clarify the type of tear to ensure medical records and letters of medical necessity do not need to accompany the claim.

The time parameters acute, chronic, acute on chronic, and recurrent are important documentation factors in ICD-10-CM. The difference between billing a specified and an unspecified code may rely on one of these time parameters. Additionally, the distinction in the operative note between an old and a new injury assist coders with proper diagnosis specificity. The indications heading of the operative note is the ideal section to include details regarding injury, trauma, acute, chronic, recurrent, or degenerative conditions.

For example, without knowledge of the patient’s medical history, the postoperative diagnosis “right knee medial meniscus tear” is coded as “M23.231 – Derangement of other medial meniscus due to old tear or injury, right knee.” According to ICD-10-CM coding guidelines, if acute or chronic is not specified, the default diagnosis – chronic – must be assigned. Your surgery center coders should query the physician to obtain greater diagnosis specificity and to gain access to the History & Physical or other parts of the patient’s medical record that clarify the condition.

Ideally, a stand-alone diagnosis reads “medial meniscus tear of right knee, current injury” with a sentence in the indications section of the operative note such as: “The patient is an 18-year-old male who suffered an acute injury to his left knee while playing basketball.” This example yields diagnosis code “S83.231A – Complex tear of medial meniscus, current injury, right knee, initial encounter.”

Other key descriptive words to include about meniscus tears in post-operative documentation are:

  • Lateral, medial, bucket handle
    • Complex, peripheral, bucket handle

Sample key descriptive words to include in post-operative documentation about rotator cuff tears include:

  • Complete, incomplete, traumatic, non-traumatic, capsule

On average, it takes payors two weeks to issue a claim response (payment or non-payment). When the diagnosis specificity in the operative note is lacking and the carrier requests medical records, an additional 30-60 days is tacked onto the carrier’s payment processing time.

To improve claims processing efficiency, maintain open, direct communication between the patient’s record keepers and the ASC billing department. Regularly review medical necessity denials in the context of clinical policies and operative note documentation. Doing so ensures you are well apprised of payor clinical policy updates and minimizes reimbursement losses.

Bethany Bueno, Director of Billing Operations

Jun 05
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Claims Issue Log

The Claims Issue Log – Not Just Another Spreadsheet

By Revenue Cycle Management No Comments

Claims issues arise daily in the health care billing and collections arena.  If your accounts receivable personnel are repeatedly relaying the same issue, refrain from merely commiserating and determine the scope of the problem.  Is that recurrent theme of inaccurate payments, for example, affecting two or twenty claims?

I’ve found the most effective way to identify trends is to create a claims issue log.

I know what you’re thinking – “I don’t have time for another spreadsheet.”  When used effectively, this spreadsheet can create efficient communication with your payor.  Ultimately, it can lead to timely resolution of issues and correct payment of claims.

What is a claims issue log? 

A claims issues log is a tool that identifies specific details of claims impacted by the same issue with a given payor.  Items on the log may include, but are not limited to:

  • Patient account number
  • Patient and/or subscriber ID
  • Claim number
  • Date of service
  • Network/Plan
  • Total billed
  • Reimbursement due
  • Amount paid
  • Balance due
  • Date billed
  • Billing comments
  • Payor comments

So, you have all this data – now what? 

  • Review your data for accuracy. The first, and most crucial step is to confirm the accuracy of your data.  Another pair of eyes, perhaps those of a manager, is essential at this point.
  • Once you confirm the accuracy of the data, notify your contracting department.  Alert them to the issue.
  • Forward the claims issue log to your provider representative with a clear explanation of the issue. Set expectations.  Outline what steps are required to resolve the problem.  Underscore payment of the balance due must occur as well.
  • Set meetings with all involved parties to track progress. Items to cover may include:
  • Does the payor have a specific format for this process? If so, obtain and use their form.
  • Why is the issue happening?
  • What is the plan to resolve the issue?
  • What is the timeframe for issue resolution?
  • When can you expect to receive correct reimbursement?
  • Will the payor use the claims issue log to reprocess all affected claims?
  • How often will updates be provided on all the above?

Bottom line

A pattern or trend of inaccurate reimbursement is the last thing you want to discover when working claims.  Unfortunately, it happens often.  Prepare for this inevitability by having a process that organizes, tracks, and resolves claims issues with maximum efficiency.  It’s never too early to identify a trend.  Hop on it as quickly as it rears its ugly head.  You don’t want to lose out on revenue because you failed to connect the dots.

Carol Ciluffo – Vice President of Revenue Cycle Management

May 11
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IT Software Conversion

Managing Your ASC’s A/R During an IT Software Conversion

By Revenue Cycle Management No Comments

Your ASC has decided to take the plunge and transition to a new patient accounting system.   This is no small task.  It requires thoughtful research and planning to make sure the transition is as smooth as possible. 

Plan for a six to nine month exploratory process to research and demo systems designed to meet the needs of your facility.  Involve as many different stakeholders as possible to assist in making an informed decision.  Determine what system will meet your business needs and accommodate employee workflow. 

From a billing perspective, your primary goal is to avoid a decrease in your center’s cash flow.  To achieve this goal, carefully consider the following: 

Electronic claims/statements

  • Will you continue with your current clearinghouse or switch vendors?
  • What will your new electronic data interchange (EDI) testing process entail? When will testing begin?  How long will the testing process take?
  • If your electronic funds transfer (EFT) arrangement is new, will you enroll online or via paper?
  • Will you stagger payer enrollments based on approval timelines to avoid cash flow lag?
  • Is your statement process paper or electronic? How will the process be affected by the change?
  • Are there any modifications required to accommodate your online bill pay system?

Training needed in advance of the go-live date

  • Coding
  • Charge entry/billing
  • Cash posting
  • A/R management
  • Administrative reporting
  • Is the user manual available and up-to-date?
  • Is there an on-demand training option available for current and future staff?
  • How is training scheduled? On-site or via webinar?   What is the course content and how often is it offered?

Strategy for your legacy system

  • How long will it take to work the outstanding A/R in the legacy system?
  • What will the impact be on staff productivity if they need to maintain dual systems for a predefined period?
  • What type(s) of report(s) will you provide to your accountant to convey the A/R being worked in both systems? Will both systems produce comparable A/R data?  If one system reflects gross receivables and the other reflects net receivables, how will you account for the difference?
  • How long will you maintain the legacy system?

Post go-live support and training options

  • Is additional training available?
  • Does online training exist? How robust is the content? 
  • How responsive are system support personnel?
  • How often are system updates rolled out?

The process of moving to a different patient accounting system can be daunting if you don’t do your homework.  In fact, it can feel like a second job.  Prepare your team by keeping them involved throughout the process.  Employee acceptance is a key component to a successful transition. 

Change is hard, but it is rarely without benefits.  You will likely learn a thing or two about your current processes amid the change.  Embrace the opportunity to tighten things up.  Explore better methods to accomplish tasks in the new environment.   Don’t let anxiety run this project into the ground.   Spend the time required upfront to ensure the transition is a smooth one for your surgery center.

Carol Ciluffo – Vice President of Revenue Cycle Management

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