Losing money because of denied claims can be incredibly frustrating for a busy ASC. Chris Davis, billing supervisor at MCG Billing Services discuss five critical mistakes ASCs make in the billing process and how they can be avoided.
1. Front desk staff doesn't compare the patient's current insurance with the information on file. Many ASCs make the mistake of assuming the insurance on file in the computer will match up with the patient's current insurance card information, Ms. Davis says. "You have to compare what the doctor has sent over from the doctor's office with the card presented on the day of service," Ms. Davis says. "You may get a denial because the ID has expired and it just wasn't caught on the front end."
In order to make sure the information matches up, simply check with the patient. Confirm name, date of birth and primary guarantor information with the patient prior to surgery. "The patient should be told to bring that information at the time of service whenever possible, so it's as simple as taking that card and comparing it to the information in the computer," Ms. Davis says.
2. Patients don't understand how their insurance works. Ms. Davis says many claims are denied because of general registration errors, such as patients failing to understand the difference between their primary and secondary plan. "If a patient has Blue Cross and Blue Shield and they're still actively working, they may not know if Medicare is their primary or secondary insurance," she says.
She also says patients may not know that ASCs can't file Medicare Part A, which is reserved for hospitals and skilled nursing facilities. "We have a lot of patients who get confused about Part A and Part B coverage, and that's just patient education," she says. To avoid negative repercussions of these common misunderstandings, Ms. Davis says ASCs should verify insurance information seven days before the procedure when possible. Talk to patients about how their insurance works, and don't be afraid to ask clarifying questions if they seem unsure.
3. Implants are inaccurately documented. Many ASCs lose money because of inaccurate implant documentation, and because implants are generally expensive, these losses can significantly hurt an ASC's revenue, Ms. Davis says. "One anchor for a rotator cuff can cost between [three and five hundred] dollars, so if you miss one, that's a lot of money you're missing out on," she says. "You need to keep an accurate tally of implants in an orthopedic procedure. If you miss one, it just won't get paid." Especially for ASCs that perform a lot of high-end orthopedic procedures, proper documentation on implants is essential to receiving accurate reimbursements.
4. Billers don't understand the difference between carrier requirements. Requirements will vary by commercial carrier, Ms. Davis says, especially regarding modifiers and CCI edits. "We have a lot of commercial carriers, and they treat modifiers differently," Ms. Davis says. "Some don't want any, some don't want the -59 modifier, some put it on everything. It's just carrier-specific, and you have to try and remember and keep note of which carriers like specific modifiers." She says these differences also apply to Medicare National Correct Coding Initiatives: While many carriers follow CCI edits, some don't. "It's hard when one commercial payor will unbundle and pay a list of procedures separately, and one will bundle everything and not follow the Medicare edits," she says.
Ms. Davis says the most important thing an ASC can do regarding coding is check carrier websites consistently for updates. "The websites are just amazing, and they have memos that go out monthly or quarterly regarding CPT changes," she says. "Things are constantly changing, and you have to have a little cheat sheet for each carrier." She says she and her accounts receivable staff member hold regular meetings to track and analyze trends. For example, over the last four months, Ms. Davis has noticed that a few commercial payors are requesting H&Ps and diagnostics on certain procedures, such as rhinoplasties. This change means educating physicians about producing that documentation and keeping track of which carriers require it.
5. Staff members are afraid to call the carrier about a denial. In the age of the internet, some administrators would rather spend time searching online for the reason for a denial than pick up the phone to talk to someone. Ms. Davis says because denial codes are often vague, administrators should not be afraid to call a carrier and ask why a claim was rejected. "If you deal with those zero pays as soon as you can, you can cut down on the time it takes to get reimbursed," she says. "If a denial code seems generic or doesn't make sense to you, picking up the phone should be your first option." Make those calls as soon as possible, as a representative may only be able to talk about two or three bills at a time before putting you on hold. The longer you wait to call with clarifying questions, the longer you will wait to receive your reimbursement.
Phone calls can also help when you need to contest a denial. If an insurance carrier rejects a claim that you know has been paid in the past, you may need to fight to receive your reimbursement. "Some professionals don't even know you can appeal more than one claim," says Ms. Davis. "You can't just write it off because the insurance says so. If you know it's been paid before, you need to appeal it."
Learn more about MCG Billing.
1. Front desk staff doesn't compare the patient's current insurance with the information on file. Many ASCs make the mistake of assuming the insurance on file in the computer will match up with the patient's current insurance card information, Ms. Davis says. "You have to compare what the doctor has sent over from the doctor's office with the card presented on the day of service," Ms. Davis says. "You may get a denial because the ID has expired and it just wasn't caught on the front end."
In order to make sure the information matches up, simply check with the patient. Confirm name, date of birth and primary guarantor information with the patient prior to surgery. "The patient should be told to bring that information at the time of service whenever possible, so it's as simple as taking that card and comparing it to the information in the computer," Ms. Davis says.
2. Patients don't understand how their insurance works. Ms. Davis says many claims are denied because of general registration errors, such as patients failing to understand the difference between their primary and secondary plan. "If a patient has Blue Cross and Blue Shield and they're still actively working, they may not know if Medicare is their primary or secondary insurance," she says.
She also says patients may not know that ASCs can't file Medicare Part A, which is reserved for hospitals and skilled nursing facilities. "We have a lot of patients who get confused about Part A and Part B coverage, and that's just patient education," she says. To avoid negative repercussions of these common misunderstandings, Ms. Davis says ASCs should verify insurance information seven days before the procedure when possible. Talk to patients about how their insurance works, and don't be afraid to ask clarifying questions if they seem unsure.
3. Implants are inaccurately documented. Many ASCs lose money because of inaccurate implant documentation, and because implants are generally expensive, these losses can significantly hurt an ASC's revenue, Ms. Davis says. "One anchor for a rotator cuff can cost between [three and five hundred] dollars, so if you miss one, that's a lot of money you're missing out on," she says. "You need to keep an accurate tally of implants in an orthopedic procedure. If you miss one, it just won't get paid." Especially for ASCs that perform a lot of high-end orthopedic procedures, proper documentation on implants is essential to receiving accurate reimbursements.
4. Billers don't understand the difference between carrier requirements. Requirements will vary by commercial carrier, Ms. Davis says, especially regarding modifiers and CCI edits. "We have a lot of commercial carriers, and they treat modifiers differently," Ms. Davis says. "Some don't want any, some don't want the -59 modifier, some put it on everything. It's just carrier-specific, and you have to try and remember and keep note of which carriers like specific modifiers." She says these differences also apply to Medicare National Correct Coding Initiatives: While many carriers follow CCI edits, some don't. "It's hard when one commercial payor will unbundle and pay a list of procedures separately, and one will bundle everything and not follow the Medicare edits," she says.
Ms. Davis says the most important thing an ASC can do regarding coding is check carrier websites consistently for updates. "The websites are just amazing, and they have memos that go out monthly or quarterly regarding CPT changes," she says. "Things are constantly changing, and you have to have a little cheat sheet for each carrier." She says she and her accounts receivable staff member hold regular meetings to track and analyze trends. For example, over the last four months, Ms. Davis has noticed that a few commercial payors are requesting H&Ps and diagnostics on certain procedures, such as rhinoplasties. This change means educating physicians about producing that documentation and keeping track of which carriers require it.
5. Staff members are afraid to call the carrier about a denial. In the age of the internet, some administrators would rather spend time searching online for the reason for a denial than pick up the phone to talk to someone. Ms. Davis says because denial codes are often vague, administrators should not be afraid to call a carrier and ask why a claim was rejected. "If you deal with those zero pays as soon as you can, you can cut down on the time it takes to get reimbursed," she says. "If a denial code seems generic or doesn't make sense to you, picking up the phone should be your first option." Make those calls as soon as possible, as a representative may only be able to talk about two or three bills at a time before putting you on hold. The longer you wait to call with clarifying questions, the longer you will wait to receive your reimbursement.
Phone calls can also help when you need to contest a denial. If an insurance carrier rejects a claim that you know has been paid in the past, you may need to fight to receive your reimbursement. "Some professionals don't even know you can appeal more than one claim," says Ms. Davis. "You can't just write it off because the insurance says so. If you know it's been paid before, you need to appeal it."
Learn more about MCG Billing.