Caryl Serbin, president and founder of Serbin Surgery Center Billing, offers the following 12 best practices for analyzing business terms in proposed ASC payor contracts.
1. Make sure contract has language identifying terms such as:
- member;
- clean claim;
- covered service; and
- payment policies.
2. Establish multiple procedure discount.
3. Make sure there is no limit on number of procedures per case.
4. Determine reimbursement rates for more complex procedures (i.e., discectomies, laparoscopic procedures, etc.).
5. For reimbursement based on percentage of Medicare reimbursement:
- determine if crosswalk and rates that the payor is using are based on current Medicare rates. Most payors are using the 2007 Medicare crosswalk with nine or 10 groups. Under 2007 or older Medicare rates, some specialties are paid less (orthopedic, podiatry, general surgery, retina) and some are paid more (pain management, GI, ophthalmology); and
- make sure rates are appropriate for your specialty mix and market.
6. If reimbursement is based on a percentage of usual and customary rates, request copy of UCR schedule.
7. If reimbursement is based on payor-devised fee schedule, request a copy.
8. Have a coder or someone familiar with Medicare groupers analyze the proposal to determine whether CPTs are linked to the same groups and reimbursement structure.
9. You may have to move high cost procedures to higher reimbursement group.
10. Ask how CPT codes which do not have an assigned group are paid.
11. Identify all procedures to be done at ASC and ascertain coverage/reimbursement.
12. Avoid unfavorable terminology:
- MCO definition of "cases" — other fees may be included in fee (i.e., anesthesia/surgeon).
- Termination, rate changes, amendments by written notice only — demand the right to negotiate.
- Maximum reimbursement clauses (i.e., caps).
- Requirement to submit annual financial statements.
- Allowance for automatic fee decrease if CMS fee schedule changes.
Learn more about Serbin Surgery Center Billing.
Read more insight from Caryl Serbin:
- What to Audit When You Audit Your ASC's Billing Process
- 5 Ways ASCs Can Improve Coding
- 8 Ways ASCs Can Improve Patient Collections