The economic success of your ASC relies heavily on your reimbursement policies and procedures. Many payors (including Medicare) require ASCs to have written policies regarding their payment policies. These policies must follow OIG compliance guidelines for government carriers and must be enforced equally for all patients. To be enforceable, your policies need to be:
The following are brief descriptions of 14 policies needed for most reimbursement situations; however, you may wish to add more of your own that are specific to your ASC.
1. Collections of copayments and deductibles (Upront collections)
Most patients will owe a co-pay, deductible, co-insurance or the full fee at the time of service. Your policy should outline what portion of this patient financial responsibility is expected to be paid prior to surgery. Review private payor contracts and/or state regulations regarding allowable amounts to be collected in advance.
2. Self-pay
Self-pay is where the individual has agreed to pay in full. Your policy should stipulate if a cash discount is allowed, the amount of the discount and if it is based on being paid in full prior to surgery. It should also explain requirements for patient payment plans (i.e., promissory note).
3. Medicare/Medicare HMO
If your ASC is a participating provider with Medicare, you have agreed to accept Medicare's fee schedule for payment. Most ASCs bill the patient (or their secondary insurance) for the deductible/co-insurance amount. Include required patient forms, i.e., ABN (NEMB) and Medicare as Secondary questionnaires. Deductibles, co-payments and filing requirements for Medicare HMOs may vary by carrier. Specific guidelines for non-covered Medicare procedures should be included in this policy.
4. Medicaid/Medicaid HMO
State Medicaid participating providers have agreed to accept Medicaid's fee schedule for payment in full (some states have a patient minimal copayment). Some states' Medicaid programs are administered by an HMO or Blue Cross/Blue Shield. Your Medicaid policy should list state-specific billing and authorization procedures that must be followed.
5. Commercial insurance
Private insurance which may have been contracted directly by the patient or may be a group plan acquired through the patient's employer. Outline patient financial responsibility regarding deductibles and co-insurance and convey information to patient prior to date of surgery. Most ASCs will submit claim as a courtesy to patient, however, patient should understand they are ultimately responsible for payment.
6. Workers' compensation
The patient's employer or workers compensation carrier is the responsible party. Payment for medical services due to a work-related injury is generally not billable directly to the patient. The WC policy should specify the state's position on controverted claims or treatment of conditions which are found not to be work related. Reimbursement guidelines and fee schedules are usually available from the state Workers Compensation department.
7. HMO/PPO
HMOs and PPOs are insurance companies that engage in contractual relationships with specific providers, thereby committing to them a large pool of patient volume, in return for discounted services. The policy should outline the general requirements of HMO/PPO plans regarding co-pay and deductibles.
Most HMOs contracts do not permit collecting outstanding amounts from patients except a co-pay mandated by the plan.
8. Blue Cross/Blue Shield
In most cases, if your ASC is a participating provider with Blue Cross/Blue Shield, you are contracted for all of their products, i.e., Medicare, HMO, PPO, etc. Blue Cross and Blue Shield have specific billing and collection requirements. Your BC/BS policy should outline the basic requirements.
9. Liability (Auto/Litigation/Lien)
A liability account is one for which the facility accepts a letter of protection from an attorney. This situation arises when a patient has filed a suit related to an injury or other condition that causes the patient to require the procedure. The policy should indicate the patient remains financially responsible. If the case is won, the facility will be paid out of "available" awards for any medical services rendered. The policy should also outline the necessity for determination of benefits available for liability/auto cases as they are often exhausted prior to the ASC's claim being received.
10. Other financial classes
This catch-all category includes CHAMPUS, local contracts or capitation accounts. All payors for these types of accounts have specific pre-verification, billing and collection requirements. Your policy (or policies) needs to provide information specific to the type of contract.
11. Secondary insurance
Secondary insurance is coverage a patient may have which may cover services, copayments and/or deductibles not covered by the primary payor. The policy should include required procedures for verification and coordination of benefits requirements for the secondary insurance.
12. Courtesy discounts
This is the granting of discounts and write-offs to patients for individual reasons. The decision whether to allow courtesy discounts is made by the board. This necessitates full understanding of federal regulations regarding discounts and waiver of co-pays/deductibles.
13. Charitable consideration
Charitable consideration is the provision of services to patients who meet the criteria for reduced fees. Usually there are stringent guidelines to meet these criteria. The board must establish the criteria and the amount of reduction allowed. The policy should be very clear on how the reductions are decided. In some cases, if the ASC has a hospital joint-venture partner, the hospital can provide the basis for this policy.
14. Out-of-network
Many states and/or payors are changing their rules on allowing facilities to treat patients out-of-network. Whether accepting routine out-of-network patients or only accepting out-of-network patients rarely, the way the deductible, co-pay and coinsurance are treated should be clearly outlined. It is recommended that this policy be reviewed by the ASC's healthcare attorney.
When completely developed and properly instituted, these policies include the basic elements necessary to fully cover most, if not all, the multiple reimbursement situations your ASC may encounter. The keys to successfully establishing these policies as part of your reimbursement program are staff education and enforcement, as well as patient awareness.
References:
Business Office Manual – Serbin Surgery Center Billing
www.cms.gov/manuals
www.oig.hhs.gov/fraud/complianceguidance.asp
Learn more about Serbin Surgery Center Billing.
Read more insight from Caryl Serbin:
- 10 Ways to Improve ASC Profits Immediately
- 7 Quick Guidelines to Follow for Successful Collections
- 6 Areas of Focus for Collecting Full Payment: Critical Steps to Take Prior to Billing (Part 1)
- 10 Steps for ASCs to Collect Full Payment After the Procedure is Performed (Part 2)
- Written and board approved
- Fully explained to the staff
- Conveyed to the patient via brochure and/or financial counseling
The following are brief descriptions of 14 policies needed for most reimbursement situations; however, you may wish to add more of your own that are specific to your ASC.
1. Collections of copayments and deductibles (Upront collections)
Most patients will owe a co-pay, deductible, co-insurance or the full fee at the time of service. Your policy should outline what portion of this patient financial responsibility is expected to be paid prior to surgery. Review private payor contracts and/or state regulations regarding allowable amounts to be collected in advance.
2. Self-pay
Self-pay is where the individual has agreed to pay in full. Your policy should stipulate if a cash discount is allowed, the amount of the discount and if it is based on being paid in full prior to surgery. It should also explain requirements for patient payment plans (i.e., promissory note).
3. Medicare/Medicare HMO
If your ASC is a participating provider with Medicare, you have agreed to accept Medicare's fee schedule for payment. Most ASCs bill the patient (or their secondary insurance) for the deductible/co-insurance amount. Include required patient forms, i.e., ABN (NEMB) and Medicare as Secondary questionnaires. Deductibles, co-payments and filing requirements for Medicare HMOs may vary by carrier. Specific guidelines for non-covered Medicare procedures should be included in this policy.
4. Medicaid/Medicaid HMO
State Medicaid participating providers have agreed to accept Medicaid's fee schedule for payment in full (some states have a patient minimal copayment). Some states' Medicaid programs are administered by an HMO or Blue Cross/Blue Shield. Your Medicaid policy should list state-specific billing and authorization procedures that must be followed.
5. Commercial insurance
Private insurance which may have been contracted directly by the patient or may be a group plan acquired through the patient's employer. Outline patient financial responsibility regarding deductibles and co-insurance and convey information to patient prior to date of surgery. Most ASCs will submit claim as a courtesy to patient, however, patient should understand they are ultimately responsible for payment.
6. Workers' compensation
The patient's employer or workers compensation carrier is the responsible party. Payment for medical services due to a work-related injury is generally not billable directly to the patient. The WC policy should specify the state's position on controverted claims or treatment of conditions which are found not to be work related. Reimbursement guidelines and fee schedules are usually available from the state Workers Compensation department.
7. HMO/PPO
HMOs and PPOs are insurance companies that engage in contractual relationships with specific providers, thereby committing to them a large pool of patient volume, in return for discounted services. The policy should outline the general requirements of HMO/PPO plans regarding co-pay and deductibles.
Most HMOs contracts do not permit collecting outstanding amounts from patients except a co-pay mandated by the plan.
8. Blue Cross/Blue Shield
In most cases, if your ASC is a participating provider with Blue Cross/Blue Shield, you are contracted for all of their products, i.e., Medicare, HMO, PPO, etc. Blue Cross and Blue Shield have specific billing and collection requirements. Your BC/BS policy should outline the basic requirements.
9. Liability (Auto/Litigation/Lien)
A liability account is one for which the facility accepts a letter of protection from an attorney. This situation arises when a patient has filed a suit related to an injury or other condition that causes the patient to require the procedure. The policy should indicate the patient remains financially responsible. If the case is won, the facility will be paid out of "available" awards for any medical services rendered. The policy should also outline the necessity for determination of benefits available for liability/auto cases as they are often exhausted prior to the ASC's claim being received.
10. Other financial classes
This catch-all category includes CHAMPUS, local contracts or capitation accounts. All payors for these types of accounts have specific pre-verification, billing and collection requirements. Your policy (or policies) needs to provide information specific to the type of contract.
11. Secondary insurance
Secondary insurance is coverage a patient may have which may cover services, copayments and/or deductibles not covered by the primary payor. The policy should include required procedures for verification and coordination of benefits requirements for the secondary insurance.
12. Courtesy discounts
This is the granting of discounts and write-offs to patients for individual reasons. The decision whether to allow courtesy discounts is made by the board. This necessitates full understanding of federal regulations regarding discounts and waiver of co-pays/deductibles.
13. Charitable consideration
Charitable consideration is the provision of services to patients who meet the criteria for reduced fees. Usually there are stringent guidelines to meet these criteria. The board must establish the criteria and the amount of reduction allowed. The policy should be very clear on how the reductions are decided. In some cases, if the ASC has a hospital joint-venture partner, the hospital can provide the basis for this policy.
14. Out-of-network
Many states and/or payors are changing their rules on allowing facilities to treat patients out-of-network. Whether accepting routine out-of-network patients or only accepting out-of-network patients rarely, the way the deductible, co-pay and coinsurance are treated should be clearly outlined. It is recommended that this policy be reviewed by the ASC's healthcare attorney.
When completely developed and properly instituted, these policies include the basic elements necessary to fully cover most, if not all, the multiple reimbursement situations your ASC may encounter. The keys to successfully establishing these policies as part of your reimbursement program are staff education and enforcement, as well as patient awareness.
References:
Business Office Manual – Serbin Surgery Center Billing
www.cms.gov/manuals
www.oig.hhs.gov/fraud/complianceguidance.asp
Learn more about Serbin Surgery Center Billing.
Read more insight from Caryl Serbin:
- 10 Ways to Improve ASC Profits Immediately
- 7 Quick Guidelines to Follow for Successful Collections
- 6 Areas of Focus for Collecting Full Payment: Critical Steps to Take Prior to Billing (Part 1)
- 10 Steps for ASCs to Collect Full Payment After the Procedure is Performed (Part 2)