The growth of ambulatory surgery centers (ASCs) is a positive trend. Technological advancements have made it possible for a wider range of procedures to be performed safely and efficiently on an outpatient basis. ASCs are also focused on providing cost-effective care. Starting January 1, 2022, The Centers of Medicare and Medicaid Services (CMS) removed more than 250 musculoskeletal surgeries from the “inpatient-only list,” with an additional 1,500 surgeries eliminated in the following year. With the increasing number of patients, ASCs need to have proper medical billing and benefits verification processes in place to get reimbursed appropriately by payers and patients. Confirming each patient’s coverage and benefits prior to the date of the surgery with the help of robust insurance verification services can go a long way in boosting ASC collections and preventing denials and delays.
Streamline ASC Medical Billing with Insurance Verification and Authorization
ASCs render same-day surgical care, including diagnostic and preventive procedures, which can include services rendered by an anesthesiologist, radiologist, or pathologist. Outpatient procedures commonly performed in these centers include hemodialysis, gynecological procedures, gall bladder removal, kidney/bladder procedures, arthroscopic/orthopedic procedures, endoscopy/colonoscopy, cataract surgery, ear/nose/throat procedures, and hernia operations. ASC insurance verification and authorization play a key role in understanding patient coverage for tests, items, and procedures, which can differ among insurers. Getting it right the first time is key to maintaining cash flow and avoid eligibility related denials:
- Perform insurance verification: Check patient coverage before the surgery. Collect the patient’s demographic and primary and secondary insurance information. Verify benefits within 1-2 days of the procedure date, but not more than 2 weeks in advance as benefits can change frequently. This can help ensure the most accurate information and allow collecting the patient portion due upfront. As personal and insurance information can change at any time, returning patients insurance information should be verified at each visit. Details verified include co-pays, co-insurances, deductibles, insurance policy status and effective date, payable benefits and plan exclusions and insurance caps. Other information that needs verifying includes plan type and coverage, lifetime maximum, referrals and pre-authorizations, out of network benefits, primary and secondary insurance, DME reimbursement, code/procedure specific coverages, out of pocket costs, and prior authorization requirements. Eligibility checks are crucial to ensure that the patients’ insurance is active, but checking what exactly is covered is necessary. ASCs should verify the patient’s financial obligation and make sure to notify patients about it ahead of time. If patients are not informed about their out-of-pocket costs before the surgery, it can become difficult for the surgical center to collect the amount. Checking the limitations in the patient’s insurance plan in advance is also critical as if the procedure is performed but not covered, the claim will be denied.
- Focus on obtaining prior authorization: Up to 81 percent of medical groups have seen an increase in prior authorization requirements since 2020, according to a Medical Group Management Association poll conducted in May, 2021. Many plans require prior authorization to reimburse a facility fee for procedures when performed in an ASC. Facilities must contact the patient’s health plan to get prior authorization for the procedure codes. Tips to optimize the ASC prior authorization process and reduce denials:
- Have patient information ready, including demographic details, surgeon’s name, diagnosis, type of procedure and date of surgery.
- Make a list of CPT codes that require prior authorization.
- Understand payer contracts and authorization requirements.
- Be ready to obtain retroactive authorizations. Though CPT codes for planned/documented procedures need preauthorization, changes can occur during an approved surgery if a different approach is used, findings lead to additional procedures being performed, and/or implants are necessary to complete the procedure. In such cases, the surgeon should communicate the change immediately so that a retroactive authorization can be obtained. Some insurers require a retroactive authorization to be submitted within 72 hours while for others this time period could be up to two weeks from the date of service. Some payers require code changes to be submitted during the appeals process. Obtaining the appropriate procedures/codes from the physician and authorizing them in advance can help if a change in approach is required. It’s also important to know payer requirements on how the required information should be sent – by email, phone or using an online form.
- Ensure that the claim includes the authorization number: When an authorization is obtained, include the unique Prior Authorization Number on the claim. This is best practice to reduce risks of denials or delays.
- Out-of-Network Billing: ASCs should assemble and maintain a list that identifies which payers are in network with them, its surgeons and any ancillary providers. On their part, ASCs need to educate patients about their benefit coverage details and collect payment upon check-in. ASCs should determine what aspects of care that a patient is scheduled to receive is in network and out of network, then share this information with the patient prior to the procedure. Patient engagement and transparency can minimize the number of surprise medical bills that patients receive. Along with that, a good out-of-network strategy combined with the right expertise can help increase ASC reimbursement. Even for ASCs that have a very small percentage of out-of-network cases, having a proper billing strategy can maximize collections.
Outsourced insurance verification and authorization services can ensure that these procedures are completed efficiently. Medical billing companies that offer these services have insurance verification specialists who stay on top of payer requirements and can help ASCs avoid eligibility issues when submitting claims.