Welcome to the new Outpatient Surgery website! Check out our login FAQs.
Secrets to Getting Reimbursed Every Time
Get paid more quickly with this straightforward approach.
Vickie Axsom-Brown
Publish Date: June 9, 2008   |  Tags:   Financial Management
When we submit our claims correctly and in a timely fashion, we expect to be paid in 30 days. Of course, it doesn't always happen that way. The reality is that about 60 percent of our claims are paid in 30 days, another 30 percent in 60 days and the last 10 percent in 90 days.

But compared to some other surgery centers, I would call this 60-in-30, 30-in-60, 10-in-90 breakout an efficient reimbursement timetable. Facility managers often talk about timely payment in terms of 40 to 50 percent of their claims paid in 30 days, 10 to 15 percent paid in 60 days and the balance (as much as 50 percent!) dragged out to 90, 120 or more days. The sad truth is that some claim payments are held up so long that they don't get paid at all or your collection costs take a huge bite out of whatever reimbursement you finally receive.

Other businesses don't wait to get paid for three months or more after providing goods or services, and neither should you. By taking these six straightforward steps, you can drastically improve reimbursement to your surgical facility.

Focus on reimbursement.
Provide your coding staff with defined collections goals and use these to challenge the staff's performance. Help them understand why you don't just pay them to submit claims. Although that's part of the job, there's a more important mission: to get accurate and complete payment in a timely fashion. If the claims aren't reimbursed, the surgery center won't have money to pay its own bills.

Make sure the staff understands that claims must be filed in a timely manner. To us, this means no later than five days from the date the surgery is performed. Yes, you will have to work with the surgeons to ensure timely dictation and receipt of necessary records to accurately code and submit the claim. For every post-surgical day that there is a delay in submitting the claim, you lose money. Forget the idea of "designated billing days" - your staff should be billing every single day to maximize your returns. Most contracts specify a billing period maximum (45, 60, 90 days, for example) "from date of service," and we take them at their word.

Claims must also be filed correctly so payers have no excuses not to pay you on time. To make sure the coding is correct, you need an entire system that's attuned to insurance billing concerns, from the front desk to the clinical staff and straight through to the coding department.

Get to know the payers.
Your coding staff must get to know the payers and find out how they want their claims filed. Make sure you get as much information as possible about code(s) bundling, use of modifiers and how the payer determines what is a "clean and accurate claim." Every one of these issues can have an impact on whether you get paid on time.

That might sound like an overwhelming job, and it can be. We deal with 30-plus payers, so we can't know everything about every one. What we do is focus on our "top 10-15" payers (by surgical volume and reimbursed dollars).

A word of caution about directions from payers. If a payer requires you to code something that's inconsistent with the AMA CPT coding guidelines, be sure to question such direction. Ask payers why they want or need you to do things that are not consistent with coding guidelines. The concern here is that if you follow payers' suggestions that are inconsistent with the CPT guidelines, you may not receive the correct reimbursement, or get paid at all. There's a case like this in litigation here in South Carolina.

Review the trends.
If you haven't undertaken a study of your center's reimbursement patterns, it's time to do it now. Look back over two to three months' worth of claims and ask:
  • Were claims submitted in a timely fashion (per your facility's defined goals)?
  • If not, how long after the date of service were they sent - and what is the root cause of the delays? You'll need to fix these.
  • Were claims coded correctly?
  • If there are coding errors, can you spot a trend? You'll need to address these with the coders and/or physicians.
  • What does your claims' aging report look like for each of your top payers? Are you close to the desired payment goals (60% paid under 30 days, 20% paid under 60 days, etc.)?
  • Did your staff correspond in a timely fashion with the payer to resolve incorrect payments?
  • If so, did the payer correct the errors temporarily or permanently?

What's Causing Those Late Claims?

Look inside.
If you find a trend of untimely reimbursement, first investigate your internal operations - don't "blame" the payer for reimbursement inaccuracies until you have evidence to support your claim. Take the time to look inside at how your center is handling claims from the start of the case to the finish.

Here's an example: When we schedule cases, our staff reviews the insurance information. We make sure we know whether eligibility verification and precertifications have been completed and that the necessary information is on file. You should address this before the patient walks into your center.

Of course, throughout the case, our staff is looking through the patient chart to make sure services are being documented. Each chart has a charge sheet that reflects these services, and our coders work from the charge sheet and the supportive medical record documentation. This is one more reason why coders should be familiar with the payers - so that they can follow their guidelines when filing the claim.

Check and double-check.
When our coders receive the charge sheet, they double-check the chart to make sure documentation is there. They make sure the final diagnosis is noted on the operative report. If a biopsy was done, they look for the pathology report. They locate whatever's missing prior to coding. Our staff also works closely with the surgeons' offices to make sure they are coding the case consistently. The last thing you want is to have two claims come in for the same patient with different diagnosis codes or other inconsistencies.

Make the payer an ally.
Once you're certain that the problem is not internal, it's time to discuss the problems with the payer. But do so in a tactful and business-like fashion. Be careful not to put payers on the defensive, because a bad relationship can significantly impact your reimbursement timeliness, too. For states with prompt payment regulations, this may be a lesser problem if you follow the correct processes for identifying and addressing failure to perform in accord with state regulations.

I invite my representative to come in, look at what we're doing and tell us what we're doing wrong. When payers do this, they often will recognize for themselves that the problem is more likely to be with their procedures or organization. The problem usually gets addressed, and everyone saves face.

Ms. Axsom-Brown ([email protected]) is the president of Practice Resources, LLC, a consulting administrator for two outpatient facilities in South Carolina.