Avoid reimbursement delays: Accuracy is key
Avoid reimbursement delays: Accuracy is key
You monitor your supply costs; you track your operating room turnover times; and you collect data to enable comparison of your performance against other same-day surgery programs. These all are critical to fiscally responsible management, but are they enough? How closely are you watching your accounts receivables and reimbursement experience?
"There’s no magic to create a good billing process, but it does require development of clear policies that are followed consistently and reviewed constantly," says Andy J. Hetrick, administrator of the Decatur (AL) Ambulatory Surgery Center. The center handles about 3,000 procedures per year and was averaging 90 days between the time a bill or claim was generated and receipt of payment in 1993 when Hetrick arrived. In 1998, the average accounts receivable had dropped to 28-32 days with the help of electronic claims and upfront discussions with patients and payers regarding coverage.
"There is no one thing that we did to create a dramatic drop in accounts-receivable numbers," he says. "We just looked at how we were gathering information and how we were submitting bills and identified areas that could be more efficient and more accurate."
The policies and procedures put into place at Decatur Ambulatory Surgery Center addressed key points of contact at which problems can be averted, says Hetrick. "Most problems can be avoided by taking steps upfront to identify and address potential denials."
Verifying insurance coverage specifics, such as pre-existing condition exclusions and collection of copays, and making sure the procedure is reimbursable in an ambulatory surgery setting are key activities, he explains. (See story on solving reimbursement problems, p. 70.)
Once the front-end verifications and financial arrangements are made and the surgery performed, the accuracy of the claim you submit is critical to avoid denials or partial reimbursements, says Hetrick.
Make sure codes match
A key reason for denials is often a conflicting Common Procedure Terminology (CPT) code or diagnosis codes between the surgeon, the anesthesiologist, or the surgical facility’s claim, says Jeff Ray Gibson, MD, medical director of information services for perioperative and anesthesia services at Scott and White in Temple, TX. A rising number of claim denials a few years ago initiated a closer look at the specific explanation of benefits for each denied claim, he says.
"We discovered that the coding on the claims was not always consistent, and when codes for anesthesia and physician professional fees don’t match the codes for the facility fees, part or all of the claim was denied," he explains.
The key problem at his facility: There was no employee who specialized in coding for outpatient surgical claims, says Gibson. "Because all of the coding was handled in a centralized department with no one person focusing on surgery, it was hard for the coders to spot a potential problem." Now, there is a coder who handles the anesthesiologist and surgeon part of the claims, he says.
To improve communication and make sure the coder can get the necessary information or explanations to file an accurate claim, that employee works in the department of anesthesiology. "This gives the coder immediate access to physicians who can verify exactly what was done in surgery," he says. Because the volume has grown to 771 day-surgery cases per month and the coders also handle pain management and inpatient surgery claims, now there are two coders who specialize in surgery, adds Gibson.
Freestanding day-surgery center staffs already specialize in surgery but need to establish a close relationship that makes it easy for a coder to pick up a telephone and call a surgeon’s office to verify diagnosis and procedure codes, says Hetrick.
Review reports to find problems
Even when you have put the right processes in place, you must review denial reports on a monthly basis, says Gibson. Focus on the procedures that represent the highest volume or the highest number of dollars first, he says.
Hetrick also has gained a new appreciation for electronic claims filing. "We made some changes in our accounting and billing software, and for some reason, we are now unable to file electronically as we have done in the past," he explains. Having to rely upon paper-claims filing has added six to 10 days in accounts receivable, says Hetrick. Reliance on postal delivery and the additional days that third-party payers require to open the mail and scan the information into their system are the reasons for the delays, he explains.
"Denials also have increased slightly because the scanner might pick up a 3’ as an 8’ and create an inaccurate code that causes the denial," says Hetrick. His staff then have to call the payer to correct the error and sometimes refile the claim. The delays in payment, the increased chance for denials in error, and the additional staff time to handle the denials are great reasons for making sure your day-surgery program is capable of filing electronically, he adds.
One of the biggest mistakes managers make when reviewing accounts receivable is to focus on accounts that are 120 or 180 days old, says Hetrick. While you shouldn’t ignore these accounts, the best use of time is to look carefully at your accounts that are 60 and 90 days old, he says. These accounts have a better collection success rate than older accounts, same-day surgery experts point out.
"Your 120-day-old account is already a problem that needs to be solved, but if you spend time on the 60- and 90-day-old accounts, you’ll be able to keep them from becoming problems," Hetrick explains.
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