Medical Billing PitfallsGoing by the latest reports, things are looking up for ambulatory surgical centers (ASCs). The key factors driving the proliferation of these centers are: high quality outcomes, convenience for both patients and providers, and technological advancements that allow even complex procedures to be performed in ACSs with payer and patient cost savings. These factors are also fueling merger and acquisition activity in the ASC market, according to a recent Beckers ASC Review report. To take advantage of this upswing, ASCs need to manage their revenue cycle effectively by avoiding some common pitfalls. In fact, outsourced medical billing and coding services could be the best strategy in these circumstances.

Let’s take a look at the common billing problems plaguing ASCs according to a Beckers ASC Review report, and how an experienced medical billing company can help them avoid these issues and maintain their financial health.

    • Neglecting insurance eligibility verification and prior authorizations:
      • Verifying patients’ coverage is crucial to understand the type of plan that the patient has and the party that responsible for payment. Narrow and tiered networks are a popular cost containment strategy. ASCs can see declining reimbursement if they are not included in narrow network or tiered products. So they need to verify which patients are in tiered health plan.
      • All aspects of the patient’s coverage should be verified with the payer before the surgery including eligibility of the claim and the claim address. Not sending the claim to correct address will delay payment. ASCs also need to obtain authorizations for the correct procedure and include implants and costly supplies.
      • Some health plans, like HMOs, do not reimburse out-of-network providers at all.If they are working with an out-of-network carrier, ASCs need to understanda case’s reimbursement. ASCs could pre-bargain for uncovered procedures and/or implant(s) and obtain written confirmation.
      • Some procedures require prior authorizations. Without authorization the claim will not be paid.
        The ideal strategy is to have an insurance verification specialist handle the task. Medical billing companies are experts indetermining patients’ coverage and responsibilities before services are provided will reduce the chances of delayed or denied payments.
    • Not addressing local coverage determinations (LCDs): LCD determination is always based on medical necessity. Assimilating the necessary data and providing documentation for proving medical necessity is crucial to get paid.
    • Coding errors: Errors in coding negatively impact reimbursement. Common coding mistakes in ASCs include:
      • Not coding to the highest level of specificity
      • Failure to code bilateral procedures and multiple procedures where allowed
      • Coding wrong anatomical part
      • Using wrong or non-specific diagnosis codes
      • Unbundling or up-coding
      • Not using appropriate and sufficient modifiers
      • Not billing/improper billing for implants
      • Failure to code billable supplies or equipment usage
      • Wrong anatomical part
      • Not use the latest codes

      A reliable medical coding company will have a team of AAPC-certified coders who are up-to-date on CPT and ICD-10 codes. They can ensure that all surgical procedures are coded accurately.

Medical Billing Pitfalls

  • Not having comprehensive patient information: Accurate coding and billing is impossible without complete patient charts inclusive of medical records, payment receipts, payment plan agreements, implant log/invoice, patient identification, insurance identification, and insurance verification and authorization. Coders can assign the most appropriate CPT codes, diagnosis codes, and modifiers only if they have access to medical records, pathology reports, and history and physical documentation.
  • Unreconciled billing: ACSs need to track if all cases are being billed. Moreover, unless they are followed up, claims can remain in “unreconciled”. Failure to monitor rejections and denials through the clearing house is a common issue which can be avoided if the process is handled by an experienced medical billing company.
  • Not maintaining comprehensive patient records: Medical billing and coding companies cannot do their job without comprehensive patient records. To assign the most appropriate CPT codes, diagnosis codes, and modifiers, coders need to review medical records, pathology reports, and history and physical exam documentation.
  • Not posting payments: Payment posting is an important step in the medical billing process. ASCs need to post and reconcile information from Explanation of benefits (EOBs) and ensure that electronic deposits match payment totals. In medical billing companies, payment posters thoroughly review EOBs to understand signs of payment issues or processing errors so that they can be corrected without delay.
  • Not monitoring key performance metrics (KPI): Not monitoring and benchmark KPIs will make it difficult to identify and resolve revenue cycle problems. Charge Lag Over 5 Days and Accounts Receivable (A/R) Over 90 Days are two KPIs that need to be tracked. These KPIs will help determine the sources of delays and lags in revenue, such as unpaid claims, patient balances, or unadjusted accounts, or a lack of follow up and maintenance on the A/R. Indentifying the underlying reasons will make it possible to take corrective action.
  • Not communicating patient payment responsibilities: Patients must be educated on their financial obligations well in advance of their procedure. Also, providing unwarranted or inappropriate discounts should be avoided as it will negatively impact the facility’s revenue and may even result in violation of insurance contracts. Informing patients about their co-pays and out-of-pocket fees in advance will also eliminate surprise bills and improve patient satisfaction. ASCs can offer patients various convenient options to pay their bills.
  • Not having a proper appeals process: Denied claims need to be successfully appealed. This is a time-consuming process that needs special attention. In fact, experienced medical billing companies have a team on the job of appealing denied claims. They will find out the reason for the denial, call up the carrier, and carry through the appeals process in a professional manner. This includes sending appeals letters with all the necessary information: patient name, claim number, date of service, member ID and ASC provider number.

Errors made at any stage of the revenue cycle process can negatively impact a facility’s bottom line. That’s why many ACSs choose to outsource medical billing. An experienced service provider can ensure timely and accurate coding, claims processing, payment posting and collections. With advanced software, strong business intelligent analytics, audits, and billing expertise, medical billing companies are well equipped to helps ASCs get appropriately reimbursed for services rendered.