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5 Ways to Maximize Your Reimbursement
How to make sure you profit from your procedures.
David Bernard
Publish Date: October 10, 2007   |  Tags:   Financial Management

Patient care might be your guiding principle, but reimbursement is what makes it happen. According to experts, you can attain better reimbursement by creating and enforcing an organized system, and the sooner this is done, the better.

Here are their tips for helping your reimbursement meet its potential.

Are You Collecting Every Cent You're Due?

Here are 10 tips to ensure you're getting reimbursed fully.

1 Give patients sufficient warning of money owed before surgery.

2 Use certified coders. Give them updated books and software. If you have more than one experienced coder, have them audit each other.

3 Compare each day's posting batch report to daily bank deposit forms to ensure they are in balance.

4 Start a denial log. List denials by category (coding error, form error, non-ASC code, etc.). Review weekly; track denials to determine trends.

5 Review the log at month's end. Go back a month later and prepare a report on denial dispensation. If claims are in appeals, update when the appeal is completed.

6 Run a report of unbilled insurance and patients. Spot-check these, and ask questions.

7 Use an insurance matrix to see insurance contracts and reimbursement rates. Check accuracy of payments and write-offs. If contracts are in your software, run a contract compliance report.

8 Run an aging accounts receivable report. Check that the total dollar amount isn't increasing and that A/R days are decreasing.

9 Develop a report showing volume by financial class to assess trends in payer mix. Run this report by physician to look for trends in case mix.

10 Hire an experienced auditor to comprehensively audit coding, billing and collections yearly.

- Judith L. English

Ms. English (writeMail("[email protected]")) is vice president of business operations for Surgery Consultants of America and Surgery Center Billing.

1 Work together
Tell your staff and physicians they are important to reimbursement, and make sure they act as if they are. Take collections, for example. There are three main components: the physician's office, the surgery center, and the clinical staff and surgeon.

As the entry point for the patient, the physician's office is the primary source of information on the patient, diagnosis, procedure and insurance coverage, all of which must be accurate and timely.

"How much information do they send, and when do they send it?" asks Marie Edler, reimbursement policy director for the Federated Ambulatory Surgery Association in Alexandria, Va. "Do they send it the day before surgery? That's not going to help. You need to know at least a few days ahead of time." Otherwise, she says, missing information or changes might result in delayed or denied payment.

The burden of information also rests on the clinical staff. "Your billers and coders aren't in the OR," says Ms. Edler. "Operative notes and documentation are all they'll have to go on. You want to make sure they tell exactly what went on, so you can submit a bill with the correct codes and modifiers."

The OR staff can't rely on pre-written templates. Situations such as terminated procedures, co-morbidities that increase the surgery's time or difficulty, and implants might change the codes.

2 Prepare yourself
Your business office shouldn't just wait for information and the procedure.

"Consulting with the patient should take place before the patient arrives for surgery," says Mary Pat Johnson, COE, SOMT, CPC, a senior consultant for the Corcoran Consulting Group in Medina, Ohio. Confirm with patients and their insurers whether they've met their deductible and been approved for the procedure.

"Know what's supposed to be paid by whom and what you're supposed to collect for the procedure," says Ms. Edler. "And try your best to get the patient's portion of the bill ahead of time."

Also find the codes that will apply to the procedures so you don't miss anything, she advises.

3 Know your payers
Get your Medicare house in order, and other payers' rules will usually fall into place. But don't neglect becoming familiar with the specifics of all of the payers you regularly deal with, says Ms. Johnson. Otherwise, facilities risk not submitting claims for all that they're eligible for, if payers' rules are slightly different and slightly more generous on certain procedures or implants.

Get your major payers' policy manuals and fee schedules. Keep them handy and refer to them often. Ann Rose, president of Rose & Associates in Duncanville, Texas, recommends you visit carriers' Web sites and join a surgery center society to keep abreast of local medical review policies and other billing guidelines.

4 Follow the rules, then follow up
While it seems elementary, meeting all the payer's requirements and providing them with the information and documentation they need is crucial to getting prompt and complete reimbursement.

Send the bill quickly and use electronic filing, says Ms. Edler.

And don't let the process end there. "Know when you're supposed to be paid, and your method of filing, so you can ensure a clean and prompt follow-up," she says. "If you know you filed electronically, and the payment is due in 14 days, don't wait 30 days to follow it up."

Divide the task by payer among staff members so each can concentrate on a smaller set of billing and payment rules, and supervise the work, says Ms. Edler.

Follow-up should cover individual claims and review the system as a whole. Ms. Rose suggests you focus on documentation accuracy. "Select five or 10 charts per month, per physician," she says. "Document corrective action for any deficiencies and the results."

Among the most common billing errors, she says, are failure to bill for supplies not included in the ASC fee and for incomplete or discontinued surgical procedures, and mistakenly billing one procedure's code when a different but similar procedure was performed.

"A lot of practices are afraid [to audit because] they might find they've been overpaid, and they'll have to send money back," notes Ms. Johnson. "But more facilities are underpaid than overpaid."

5 Go electronic
For many years, reimbursement was all muscle work. "You had to do it all manually. You had to touch every piece of paper," says Niobis Queiro, RHIA, a revenue cycle solutions consultant for Cerner in Kansas City, Mo. Over the last decade, however, computer software streamlined the process, she says.

"It corrects things in the front end for a better return," she says. Among other things, the latest reimbursement software can

  • track expected revenues and compare them against cash returns;
  • monitor costs and outcomes of procedures by physician;
  • link supply billing to inventory control and ordering; and
  • review payers' trends in re-sponding to the bills you've filed.

Value of efficiency
Organization takes practice and is gradual, notes Ms. Edler, but by taking into account the physicians', clinical staff's and business office's views, "you'll collect as close to dollar-for-dollar as anyone can expect to."