1. Increase front-end training for surgery center staff. If your data indicates a high or increasing number of denials, Bill Gilbert, vice president of marketing at AdvnatEdge Healthcare Solutions, says the problem probably lies with your front-end staff. “That means a need for training, maybe some job aides and adjustments to how front end staff are using the system.” He says problems with denials can be caused by a variety of errors, and not understand the billing system can cause problems easily. When your center implements new software, take a few days to coach your staff on the ins and outs of submitting claims. This will save you a lot of time re-submitting denials that arise from a lack of comfort with the system.
2. Employ coders with knowledge of orthopedic and spine procedures. Specialty knowledge is vitally important to successfully billing for a practice, says Monty Miller, president and co-founder of Momentum Billing. Hire coders who really understand how orthopedic and spine procedures are performed because they must recreate the procedure on the claims. In addition to receiving optimal reimbursements for surgeries, this knowledge helps the coders quickly understand errors made on denied claims, and they will learn from these mistakes, says Mr. Miller. The coders also need to stay at the forefront of the industry and have training in billing changes as they occur.
3. Familiarize coders with payor regulations. When a payor rejects a billing claim, the coder must research and pinpoint any inaccurate coding and fix the errors, such as bad modifiers or bad diagnoses, says Courtney Henderson, CPC, CPC-P, billing supervisor for Mu Medical Management. Most payors require a physician’s note verifying elements of the corrected claim. If the physician mistakenly performed a procedure the payor will not cover, the claim is written off. Mistakenly billing payors commonly occurs when payor regulations change, such as when Medicare removed the consultation code, ceasing to compensate for consultation visits. Initially, some physicians forgot and tried to bill Medicare using the consultation code. In order to avoid returned claims, Ms. Henderson suggests visiting company websites and becoming familiar with payor rules.
4. Encourage surgeons to practice simultaneous reporting. Physicians should document each procedure immediately after the procedure. When a physician waits until the end of the week to document their procedures, they risk forgetting the details of the procedure or writing an insufficient report for the coders to create a claim. Detailed reporting is crucial for the coders to accurately bill for correct reimbursement. “Coding is an art, it’s not an exact science,” says Jay Nussbaum, CEO of Healthcare Watchdog, a medical billing and advocacy group with offices in New Jersey and California. “A lot of times, what you’re going to code depends on what the doctors write in the documentation”
Additionally, if a claim is denied because the payor found a procedure unnecessary, detailed notes help physicians defend their choice to follow through with the procedure. “If the physician has taken good notes, they can make a good claim as to why the procedure was necessary to the insurance companies. Making that strong case really can turn a lot of denials into approvals,” says Mr. Nussbaum.
5. Explain a patient’s financial obligations three days before service. By the time your facility calls the patient to explain the payment, the administrative staff should already have insurance and contact information from the physician. This information will tell your facility how much the patient will owe for the facility fee. Since it can be a challenge to reach patients at home, Rob Morris, vice president of marketing and new business development for GE Capital’s CareCredit, recommends ASCs call three days before the procedure to explain the patient’s financial responsibility. “They’re going to need to say, ‘Make sure you don’t drink any fluids, you need to be an hour early, don’t bring any jewelry or your watch, and we just checked over your insurance and you have an obligation of $600 towards the facility fee. How would you like to pay for that?'” The financial obligation should be a prerequisite for service just like the physical requirements.
