Achieving Billing Accuracy in Ambulatory Surgery Centers (ASCs)
ASCs have become increasingly popular for outpatient surgical procedures as they offer high-quality and cost-effective surgical care. They are an appealing alternative to traditional hospital settings. However, the rise of ASCs also brings the possibility of billing errors that can result in revenue cycle delays, reimbursement delays, and affect the bottom line.
To be paid for certain procedures by the Center for Medicare and Medicaid Services (CMS), an ASC must meet CMS requirements and sign a contract with the organization. The CMS website provides a list of these procedures, along with information on regional pay variation, covered ASC ancillary services, wage indices, and wage-adjusted payment rates.
It is worth noting that while CMS guidelines can be helpful, ASCs should consult their local intermediary or carrier to address most of their problems related to reimbursement. ASCs must also ensure that they sign a participating provider agreement with CMS to be eligible for Medicare payments. Moreover, for a procedure to be authorized by Medicare, CMS must determine that it does not pose a significant risk of harm or the need for an overnight stay after the treatment.
Despite positive patient outcomes and a strong track record, medical practitioners often struggle to manage medical billing and coding for ambulatory surgical centers due to the existing regulations. Therefore, as an ASC medical practitioner, here are some of the most common billing errors to avoid in your practice:
- Lack of Documentation: ASCs must have accurate and complete documentation for all services rendered, including patient medical records, operative reports, and anesthesia records. Without proper documentation, billing errors can occur, leading to delayed payments and potential audits.
- Incomplete Patient Information: Accurate patient information, including name, date of birth, and insurance information, is critical for successful billing. Incomplete or inaccurate information can lead to denied claims or delayed payments.
- Inaccurate Coding: ASCs must use the correct CPT (Current Procedural Terminology) and ICD-10 (International Classification of Diseases) codes to bill for services provided. Using the wrong codes can lead to denied claims, delayed payments, and even legal trouble.
- Incorrect Modifier Use: Modifiers are used to indicate that a service or procedure has been modified in some way. Incorrect use of modifiers can lead to claim denials and delays in payment. It’s essential to understand when and how to use modifiers correctly.
- Lack of Consistency in Charge Capture: ASCs must have consistent charge capture processes to ensure all services rendered are properly documented and billed. Inconsistencies can lead to lost revenue and inaccuracies in billing. To prevent this, ASCs should implement a charge capture system to ensure all charges are accurately recorded.
- A/R follow-up & Denial Management: ASCs must have an effective Accounts Receivable (A/R) management process to ensure that they receive timely payments for services rendered. This includes following up on unpaid claims, identifying and resolving claim denials, and appealing denied claims when necessary. Failure to properly manage A/R can result in lost revenue, increased expenses, and decreased cash flow. To ensure effective A/R management, ASCs should have a dedicated team responsible for following up on unpaid claims and denials and be well-trained in the use of billing and coding software.
- Lack of Secondary Claims Visibility and Submission: ASCs must review and submit any secondary claims to insurance companies to ensure that they receive maximum reimbursement for services rendered. Failure to submit secondary claims can result in lost revenue, as the ASC will only receive payment from the primary insurance company.
- Failure to Obtain Prior Authorization: Many insurance plans require prior authorization for certain procedures. ASCs must ensure they have obtained the necessary authorizations before providing services to patients. Failure to do so can result in denied claims and delayed payments.
- Using Outdated Fee Schedules: Using outdated fee schedules can lead to underpayments and lost revenue. Make sure that you’re using the most up-to-date fee schedules and that you’re regularly reviewing and updating them.
- Failure to monitor KPI: ASCs must keep track of and evaluate key performance metrics to promptly detect revenue cycle issues and implement sustainable enhancements. Relying on a software (like expEDIum in this case) for reports and other data can prove to be a prudent choice. Failure to access measurable and practical data via robust business intelligence capabilities can impede the timely identification and resolution of the fundamental causes of revenue cycle problems.
- Lack of Patient Collection Management: ASCs must have a comprehensive patient collection management system in place to ensure that they receive payment for services rendered. This includes implementing Patient Responsibility Agreements (PRA) and Patient Payment Agreements (payments as EMI). ASCs should ensure that their billing team is well-trained in patient collection management and that they have effective processes in place to track and follow up on unpaid patient balances.
- Inadequate Staff Training: Staff must be properly trained in coding and billing procedures to ensure accuracy and compliance. Inadequate training can lead to billing errors and legal issues.
It is essential to ensure that your ASC medical billing and coding are free from any errors or negative consequences. This can be accomplished by implementing proper documentation practices, verifying patient information for accuracy, using appropriate coding, obtaining prior authorization, consistently capturing charges, following up on denied claims, and providing sufficient staff training. Your ASC clinic can prevent billing errors and achieve financial success by following these practices.
To identify any workflow weaknesses and eliminate common errors in ASC medical billing and coding, it is recommended to conduct an adequate revenue cycle assessment firstly. If you are still experiencing issues related to medical billing for ASC, please do not hesitate to contact our iTech team, and we will be happy to assist you.