How a Nebraska ASC manages prior authorization regulation, prevents revenue loss

Carly Behm -

As prior authorization requirements grow in the outpatient space, ASC administrators have to find ways to balance finances at their centers. For one administrator, communication with physicians and payers has helped the center manage prior authorization rules.

Brooke Day, administrator and business office manager of Hastings (Neb.) Surgical Center told Becker's ASC Review her center's strategies.

Note: Response was edited for style.

Question: How much do you estimate prior authorization to impact revenue at your center?

Brooke Day: Prior authorizations can have a significant impact on our business. We implemented procedures a couple years ago that continue to be changed as unique situations occur. We are in constant communication with our physician office schedulers regarding the authorization of their procedures, specifically orthopedics and gynecology cases. We are recommending physicians authorize specific code sets depending on the procedure due to the amount of work required to obtain payment after the procedure has been performed.

Our scheduler is also verifying that these codes are on our contract with insurances and with specific insurances we are calling to verify the codes are a "covered benefit." We have found with specific codes that they are not always on the patient’s specific medical plan so verifying coverage is an important step in our process. We also verify that the scheduled codes are on the fee schedules for Medicare and Medicaid. If a specific code is not on their fee schedule the case is scheduled in another facility where it will be covered or the patient is required to sign an advanced beneficiary notice prior to the procedure being performed.

We have several procedures in place that can prevent a loss of revenue due to a lack of prior authorization but the cases that are more likely to have this occur are higher cost procedures and could result in a loss of thousands of dollars in supplies. We are fortunate enough to only have this occur in a rare circumstance due to the processes we have implemented.


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