This year brings new revenue cycle challenges for spine and orthopedic surgeons, according to Lisa Rock, president of National Medical Billing Services. Luckily, with a little foresight, providers can correct course and avoid losing revenue.
At the Becker's 15th Annual Spine, Orthopedic and Pain-Management-Driven ASC Conference in Chicago, Ms. Rock outlined the top pitfalls providers currently face in revenue capture. Here are six things to watch out for this year.
1. Insurance verification. Providers need to understand who is paying their claims at the time of patient registration, according to Ms. Rock. She advises pulling the automated eligibility sheet to identify whether the patient is fully insured or self-funded — direct-employer contracts are considered part of the self-funded group. "If it is a self-funded patient, we need to understand who the employer is because they are paying the claim, and they can change the way they pay the claim frequently," she said. Other items to watch out for during the insurance verification process are tiered or narrow network plans — among both self-funded and fully insured patients.
2. Coding. When working with vendors, Ms. Rock advises getting a second opinion on reimbursement codes to ensure the products are actually reimbursable. This is an issue particularly for implants. Ms. Rock said she sees reimbursements for some implants are coming in at 50 percent of the bill charges. "The contracts I'm seeing today are scary," she said. "You can't sign a contract like that. You are going to lose 50 percent of cost on your claim." She also advised providers to stay up-to-date on payer policies and staff education to reduce the number of denials.
3. Narrow networks. While narrow networks may be nothing new — there is a new breed to watch out for, according to Ms. Rock. These are the employer-direct contracts, which she is seeing crop up all around the country. And as quality and cost information becomes increasingly public, employers have the decision-making power. Employers looking to cut costs are striking deals directly with narrow networks of providers who can offer the best quality care at the lowest price. "You should really have your ear to the ground in your neck of the woods so you know what's going on," Ms. Rock said. "You don't want to be in situation where your competitor just did a deal with a major employer group and you are out."
4. Narrow network language in contracts. Providers who want to set out and strike contracts with employers on their own would be wise to take a closer look at their contracts with major health insurance carriers, according to Ms. Rock. Noncompete language is often baked into the text of contracts with these carriers, she cautions. One such contract forbids providers from engaging in "activities that cause loss of potential members," she said, and includes a 12-month wait clause after termination of the contract. However, this doesn't mean providers can't strike employer contracts; they just may not be as direct. Ms. Rock suggests working with an outside company to manage those employer contracts, so you are not a "direct competitor" to your payers. "There is always a workaround to these things," she said.
5. Bundled payments. Bundled payments are the fastest growing value-based payment model, Ms. Rock said. And while bundles aren't new, they are newer to the ASC industry. She advises ASC providers to again look carefully at the language in their major health insurance carrier contracts, where they may find they have agreed to work with a bundled payment company. In these cases, spine and orthopedic surgeons are given a list of cases they must contract separately for with the bundled payment company. These contracts are often unsophisticated and disorganized — in some cases they have gone back to faxing claims or asking ASCs to write checks to other providers who participated in the bundle, according to Ms. Rock.
6. Patients as payers. The growth of high-deductible health plans, employer contracting and greater out-of-pocket costs for consumers means providers must look at patients as true payers. "It's something we can't ignore anymore," Ms. Rock said. To start, providers should begin developing sound internal collections policies for patient payers. They also should be sure to stay up-to-date on laws that affect patient billing, such as surprise billing laws. These laws offer patient protections regarding in- and out-of-network billing. They protect a patient who undergoes surgery at an in-network hospital, for example, from getting saddled with an out-of-network bill because their anesthesiologist wasn't in-network. For providers, these laws dictate their payment rates. In California for example, health plans pay out-of-network physicians 125 percent of Medicare rates, Ms. Rock noted.
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