When analyzing the many components included in the reimbursement cycle, you recognize that there are two major divisions: prior to and after the procedure is performed. The first part of this article, "6 Areas of Focus for Collecting Full Payment: Critical Steps to Take Prior to Billing," discussed essential steps to perform before the services are rendered to ensure timely and accurate reimbursement.
Part two deals with the steps needed to file and collect the full amount due. It is very important to follow all the steps carefully to avoid denials and incorrect payments whenever possible.
In part one, we left off with the dictation and transcription of the operative note and its importance in filing an accurate claim. Part two begins with using the operative note to determine the fees to be charged.
#1: Coding the procedure – Determining what is owed
Coding is a crucial step in determining the ASC's financial success or failure. The person coding the operative note is deciding the amount to be charged. It is vital this individual is well-versed in interpreting the operative note accurately and assigning all appropriate codes for the procedure(s) and billable implants and supplies. They must also be aware of all OIG billing compliance regulations and managed care companies' specific requirements. Code optimization while remaining compliant should only be assigned to a well trained and experienced certified coder.
#2: Claim submissions – Getting clean claims out the door
Whether this step is done by the coder or by a separate person, don't underestimate the time required to perform this task accurately. Electronic claim submission is just as complex as submitting paper claims. All required information must be inserted accurately and must meet payor requirements. Remember, different states, different payors and different Medicare carriers may all have different requirements.
In order to submit a "clean claim" and avoid delays, use your software's "scrubbing" program to points out errors. Clearinghouses also have "scrubbing" software that checks for errors and returns for correction. Once corrections are made, the clearinghouse should advise you that the claim has been sent to the payor.
#3. Verification of receipt by payor - Putting the ball in the payor's court
Most clearinghouses have the ability to advise when the payor received the claim. Some of the larger payors also have their own clearinghouse or website which may allow you to verify the claim is being processed (accepted with no errors). Some even have information on the status of the claim and the amount approved for payment. It's important to take this extra step so you are sure the claim is there and being processed. This helps avoid getting an annoying CNOF (Claim Not on File) message when you check the status in a few days.
#4. Follow-up – When will the claim be paid?
In most cases electronic claim filing should be followed up 1-2 weeks after accepted by the payor. Many electronic claims are now being paid within two weeks. If your payors have online claim status information such as amount billed, amount to be paid, date check will be issued, etc., often a phone call is unnecessary. Some payors allow you to question the accuracy of the claim online without having to wait for payment to be received. However, a phone call is often necessary in order to get definite answers. Always document fully the answers you receive.
#5. Posting payment – Is it the correct amount?
Allowing for deductibles, co-pays, co-insurance, contract allowances, etc., is the amount that you received the amount you were expecting to be paid? If so, post the payment and reassign the balance to the appropriate guarantor, either patient or secondary insurance company.
If the amount paid does not reflect what was expected, determine the specific reason(s) for the difference, i.e., deductible, co-insurance percentage, procedure codes disallowed, allowed amount differs from contract, etc. and ask for coding review or call payor to question payment discrepancy. Some erroneous payments can be corrected over the phone without having to file an appeal.
#6. Filing a denial – When the phone call doesn't work
After checking to ensure the payment deficiency was not because of a coding or billing error, review the payor requirements to file a denial. Information can be found in the payor's contract or their website. Use requested special forms and include all attachments, i.e., EOB, operative note, invoice, etc. Send to appropriate address. If necessary, take to the highest level of adjudication available.
#7. Collections – Third-party payors: The check is in the mail, CNOF, etc.
The best advice is to be firm and persistent. Enforce state prompt payment regulations. Immediately send any additional information they request and follow-up again within a few days. Document everything, dates, names, promises, etc.
Follow A/R accounts every 30 days minimum. If claim status information is available online, use this method as it is faster. However, questions that are not answered online require a direct phone call. When working your A/R, recommend grouping accounts by payor so you can make one call to the payor and cover all outstanding accounts. Follow up on larger balances first.
#8. Secondary insurance claim submissions – Chasing the balance
When a correct payment is received from the primary payor, move the balance to the secondary payor, in this case another insurance company. If the primary payor did not automatically send the claim to the secondary, send a copy of the original claim and the EOB to the secondary payor immediately.
#9. Patient statements – Asking the primary guarantor for payment
The patient is always the responsible party – this should have been explained to them prior to the procedure and included in your center brochure/handout. After correct insurance payments are received, send a statement requesting payment of the balance in full to the patient right away. If needed and approved by management, utilize the same payment options as provided during financial counseling. Send statements monthly.
These nine steps for ensuring payment in full are common sense. However, in most cases, uncollected balances usually indicate taking short-cuts and not following these steps fully. That is why I recommend step #10:
#10. Internal audits – Guaranteeing the process is running appropriately
Audits are not just about A/R numbers and deposits balancing. They should include checkpoints on the accuracy and efficiency of each area of the reimbursement cycle:
a) Coding — accuracy, timeliness
b) Claims processing — accuracy, timeliness
c) Payment posting — accuracy, timeliness, error follow-up
d) Collections – timeliness, effectiveness, denials
Getting paid in full for services rendered requires a lot of time and effort. Experienced and dedicated employees and management involvement in the process are the keys to your reimbursement success.
Learn more about Serbin Surgery Center Billing.
Read more guidance from Caryl Serbin:
- 8 Steps to Ensure Payment From Patients With Insurance
- 7 Guidelines for Better Payor Contracts
Part two deals with the steps needed to file and collect the full amount due. It is very important to follow all the steps carefully to avoid denials and incorrect payments whenever possible.
In part one, we left off with the dictation and transcription of the operative note and its importance in filing an accurate claim. Part two begins with using the operative note to determine the fees to be charged.
#1: Coding the procedure – Determining what is owed
Coding is a crucial step in determining the ASC's financial success or failure. The person coding the operative note is deciding the amount to be charged. It is vital this individual is well-versed in interpreting the operative note accurately and assigning all appropriate codes for the procedure(s) and billable implants and supplies. They must also be aware of all OIG billing compliance regulations and managed care companies' specific requirements. Code optimization while remaining compliant should only be assigned to a well trained and experienced certified coder.
#2: Claim submissions – Getting clean claims out the door
Whether this step is done by the coder or by a separate person, don't underestimate the time required to perform this task accurately. Electronic claim submission is just as complex as submitting paper claims. All required information must be inserted accurately and must meet payor requirements. Remember, different states, different payors and different Medicare carriers may all have different requirements.
In order to submit a "clean claim" and avoid delays, use your software's "scrubbing" program to points out errors. Clearinghouses also have "scrubbing" software that checks for errors and returns for correction. Once corrections are made, the clearinghouse should advise you that the claim has been sent to the payor.
#3. Verification of receipt by payor - Putting the ball in the payor's court
Most clearinghouses have the ability to advise when the payor received the claim. Some of the larger payors also have their own clearinghouse or website which may allow you to verify the claim is being processed (accepted with no errors). Some even have information on the status of the claim and the amount approved for payment. It's important to take this extra step so you are sure the claim is there and being processed. This helps avoid getting an annoying CNOF (Claim Not on File) message when you check the status in a few days.
#4. Follow-up – When will the claim be paid?
In most cases electronic claim filing should be followed up 1-2 weeks after accepted by the payor. Many electronic claims are now being paid within two weeks. If your payors have online claim status information such as amount billed, amount to be paid, date check will be issued, etc., often a phone call is unnecessary. Some payors allow you to question the accuracy of the claim online without having to wait for payment to be received. However, a phone call is often necessary in order to get definite answers. Always document fully the answers you receive.
#5. Posting payment – Is it the correct amount?
Allowing for deductibles, co-pays, co-insurance, contract allowances, etc., is the amount that you received the amount you were expecting to be paid? If so, post the payment and reassign the balance to the appropriate guarantor, either patient or secondary insurance company.
If the amount paid does not reflect what was expected, determine the specific reason(s) for the difference, i.e., deductible, co-insurance percentage, procedure codes disallowed, allowed amount differs from contract, etc. and ask for coding review or call payor to question payment discrepancy. Some erroneous payments can be corrected over the phone without having to file an appeal.
#6. Filing a denial – When the phone call doesn't work
After checking to ensure the payment deficiency was not because of a coding or billing error, review the payor requirements to file a denial. Information can be found in the payor's contract or their website. Use requested special forms and include all attachments, i.e., EOB, operative note, invoice, etc. Send to appropriate address. If necessary, take to the highest level of adjudication available.
#7. Collections – Third-party payors: The check is in the mail, CNOF, etc.
The best advice is to be firm and persistent. Enforce state prompt payment regulations. Immediately send any additional information they request and follow-up again within a few days. Document everything, dates, names, promises, etc.
Follow A/R accounts every 30 days minimum. If claim status information is available online, use this method as it is faster. However, questions that are not answered online require a direct phone call. When working your A/R, recommend grouping accounts by payor so you can make one call to the payor and cover all outstanding accounts. Follow up on larger balances first.
#8. Secondary insurance claim submissions – Chasing the balance
When a correct payment is received from the primary payor, move the balance to the secondary payor, in this case another insurance company. If the primary payor did not automatically send the claim to the secondary, send a copy of the original claim and the EOB to the secondary payor immediately.
#9. Patient statements – Asking the primary guarantor for payment
The patient is always the responsible party – this should have been explained to them prior to the procedure and included in your center brochure/handout. After correct insurance payments are received, send a statement requesting payment of the balance in full to the patient right away. If needed and approved by management, utilize the same payment options as provided during financial counseling. Send statements monthly.
These nine steps for ensuring payment in full are common sense. However, in most cases, uncollected balances usually indicate taking short-cuts and not following these steps fully. That is why I recommend step #10:
#10. Internal audits – Guaranteeing the process is running appropriately
Audits are not just about A/R numbers and deposits balancing. They should include checkpoints on the accuracy and efficiency of each area of the reimbursement cycle:
a) Coding — accuracy, timeliness
b) Claims processing — accuracy, timeliness
c) Payment posting — accuracy, timeliness, error follow-up
d) Collections – timeliness, effectiveness, denials
Getting paid in full for services rendered requires a lot of time and effort. Experienced and dedicated employees and management involvement in the process are the keys to your reimbursement success.
Learn more about Serbin Surgery Center Billing.
Read more guidance from Caryl Serbin:
- 8 Steps to Ensure Payment From Patients With Insurance
- 7 Guidelines for Better Payor Contracts