Docstoc

clicking here - Beckers ASC Review

Document Sample
clicking here - Beckers ASC Review Powered By Docstoc
					1
22
                                                                  3
Case Study reflects financial findings/recommendations only –      3
additional clinical findings/ recommendations are not presented
          • 14 month old ambulatory surgery
            center evaluated because not
            meeting projected revenue
          • Semi-rural area
          • Joint-venture – 7 physicians/
            local hospital
          • Average case volume - 350 month
                                              4
ABC Surgery Center
     • Specialties         • Payor Mix
       - ENT                 - Medicare
       - GI                  - Medicaid
       - Ophthalmology       - BCBS
       - Orthopedics         - W/C
       - Podiatry            - PPOs
       - Pain Management     - HMOs
                             - Indemnity
                                           5
ABC Surgery Center
     •Number of reasons for negative cash flow:
       - Fee schedule far lower than normally
         seen in an ASC
       - Managed care contracts low with
         unfavorable terms
       - Improper billing/coding practices
       - Managers with no ASC experience
       - Inefficient use of staff
       - Appropriate structure and policies and
         procedures not in place                  6
ABC Surgery Center
     Findings
     • Evaluation of the fee schedule revealed
       that most fees were exceptionally low
       low compared to Medicare/BCBS ASC
       fees for this geographic locality
     • Many fees were actually less than
       Medicare allowable
     • Fee schedule had been based on
       physician DRGs
     • No consistency in fees – similar
       procedures had wide variances          7
ABC Surgery Center
         Recommendations
         • Develop fee schedule based on
           percentage of Medicare group rates
         • Carve-outs for higher ticket
           procedures
         • Decide on additional procedure
           discount
         • Sample fee schedule given to Board -
           recommended 500% of current
           Medicare rates
                                                  8
ABC Surgery Center
       Findings
       • Low rates for an area with little
         managed care penetration
       • Some reimbursement methodologies
         varied from market standard
       • Unfavorable terms in contracts
       • Most carriers require accreditation
       • Some contracts were invalid as not
         voted on by Board                     9
ABC Surgery Center
    Recommendations
    • Join local PHO and have them assist in
      recontracting for ASC
    • Cancel five major contracts whose
      reimbursement is based on Medicare rate
    • Great managed care market – suggest
      renegotiate for reimbursement based on
      percentage of billed charges
    • Move toward becoming accredited – mark
      applications as “Accreditation Pending”
                                                10
ABC Surgery Center
   Findings
   • Coder with no ASC or surgical coding
     experience
   • Coding errors included:
      - not coding for bilateral procedures
      - not coding for multiple procedures
      - lack of sufficient modifiers
      - improper or no billing of toe implants
      - wrong anatomical part
      - coding from title – not from body of op note
      - no copy of coding history in patient chart
      - no cross check to ensure coded all cases
                                                  11
ABC Surgery Center
     Recommendations
     • Hire or outsource to certified coder, or
     • Immediate coding certification
       training for current coder
     • Code from body of operative note –
       use additional information when
       necessary

                                              12
ABC Surgery Center
         Recommendations (continued)
         • Rebilling of all claims with coding
           errors that result in differences in
           reimbursement
         • Utilize coding form
         • Utilize schedule to make sure all
           patients have been coded

                                                  13
ABC Surgery Center
       Findings
       • Biller had no ASC/surgical billing
         experience
       • No electronic filing – all paper claims
       • All business office uses same printer
       • Billing for non-ASC services in same
         module – cannot separate in reports
       • No cross-check between coded cases
         and batch report
                                                   14
ABC Surgery Center
           Recommendations
           • Hire experienced biller, or
           • Immediate training for current
             biller including the following:
                  CPT codes     ICD-9 Dx Codes
                Sx Procedures      Modifiers
                      Medicare Guidelines
           • Electronic submission of all claims
             where possible
                                                   15
ABC Surgery Center
          Recommendations (continued)
          • Additional printer near biller to run
            claim forms
          • Purchase separate software module
            to bill for non-ASC services
          • Balance billing batch report to
            coding forms/schedule to ensure no
            unbilled revenue
                                                    16
ABC Surgery Center
    Findings
    • Payment poster not knowledgeable
      regarding managed care contract
      allowances – no copy of contracts
    • Accepts what payor allows – write-offs
      are adjusted to match what is paid and
      not pre-approved
    • Not checking to determine if refund due
    • Not balancing to deposit
                                           17
ABC Surgery Center
     Recommendations
     • Hire experienced payment poster, or
     • Provide payment poster with copy of
       contracts and ASC fee schedule
     • If payment correct, transfer amount to be
       billed to secondary insurance or patient
       and send
     • If not paid correctly or denied, start
       denial process
     • If overpaid, begin refund process
     • Balance payment batch to deposit log     18
ABC Surgery Center
    Findings
    • Collections not being done
      regularly due to lack of business
      office staff
    • No system in place to determine
      oldest accounts and when to place
      with collection agency
        • High dollar amount over 150 days
            old - investigate to determine how
            much collectible
                                                 19
ABC Surgery Center
         Recommendations – Insurance Carriers
         • Use Aging by Carrier report to
           develop collection schedule
         • Check all outstanding balances with
           each carrier, oldest first
         • Remind carrier of state prompt
           payment regulation
         • Resubmit bill and/or additional
           documentation, if applicable
                                                 20
ABC Surgery Center
   Recommendations – Insurance Carriers (cont)
   • Develop tickler system to follow-up on
     promised payments
   • Future collections – follow-up in 15 days to
     make sure carrier received claim
   • Follow-up at 30 days to determine if carrier
     is following prompt payment rule
   • Document in patient’s account

                                                21
ABC Surgery Center
      Recommendations – Patient Accounts
      • Collect deductibles and copays up-front
      • Perform patient financial counseling
        prior to DOS
      • Bill patients monthly
      • Add notes that increase in language as
        account ages
      • Contact patients by phone to determine
        status and offer payment alternatives,
        i.e., credit card, payment schedule, etc.   22
ABC Surgery Center
   Findings
   • Unbilled revenue due to:
     - bilateral procedures–second side not billed
     - billing from operative note title only
   • Sample coding review - 61 charts revealed
     27 errors - estimated loss of allowable net
     revenue – $33,396
   • Review of accounts over 1 year old which
     received no payment and were never
     rebilled - $79,124 gross
                                                   23
ABC Surgery Center
   Findings (continued)
   • 12 patient accounts not paid or rebilled
     ($21,338) – few days short of 12 months –
     rebilled immediately to avoid timely filing
   • Balances never transferred nor billed to
      secondary insurance and/or patient
      responsibility
   • Coding and billing are non-compliant due to:
      - inequity of charges
      - inequity of balance billing
      - errors                                   24
ABC Surgery Center
   Recommendations
   • Check all accounts over one year old to
     determine if can be rebilled
   • Assess all accounts over 150 days to
     determine need for collection, adjustments,
     before exceed statute of limitations
   • It may be more cost effective to outsource
     coding/billing/collections than to retrain and
     oversee current employees while trying
     remain current and recoup old revenue
                                                 25
ABC Surgery Center
        POSITIONS* DIRECTLY AFFECTING
        REIMBURSEMENT (Not Including Mgmt)
        • Scheduler
        • Admitting clerk (receptionist)
        • Insurance verification specialist
        • Patient financial counselor
        • Coder/biller
        • Payment poster/collector

        * Number of employees per position
          dependent on caseload
                                              26
ABC Surgery Center
  Recommendations/Findings – Business Office
  • Currently whoever answers main phone line
    schedules patient
  • Suggest dedicated phone line for scheduling
  • Suggest one employee be assigned to
    schedule – others can be back-up
  • Have Business Office Manager learn all
    business office positions and act as back-up
  • Develop business office policies and
    procedures
                                              27
ABC Surgery Center
     Recommendations/Findings – Business Office
     • If maintain billing in-house:
       - Add one FTE to business office staff –
         best choice – receptionist (lower salary
         and less training required)
       - Move current receptionist/biller to full
         time biller
       - Change current coder/biller to coding
         and collections
     • If outsource billing – no additional staff
       needed
                                                    28
ABC Surgery Center
   Recommendations - Business Office Manager
   • Hire experienced ASC Business Office
    Manager, or
   • Educate current BOM in following areas:
     - write-offs
     - adjustments
     - checking for errors
     - collection agency
     - refunds
     - audits
                                               29
ABC Surgery Center
            Findings
            • No counter-check of deposits
            • No auditing of coding/billing
            • Reports invalid as reflect another
              business as well as ASC



                                                   30
ABC Surgery Center
     Recommendations
     • Utilize bank lock-box if available
     • If doing deposit in-house:
       - utilize and balance to deposit log
       - separate payment posting and deposits
       - BOM should check deposit for accuracy
       - BOM or designee make daily deposit
     • Weekly audits of coding and billing
     • Move other business billing functions into
       separate module
                                                31
ABC Surgery Center
               • Governing Body approved and
                 adopted recommendations
               • Hired outside management to
                 institute changes
               • Outsourced coding and billing
                 functions
               • Discontinued secondary
                 business in ASC
               • Made other clinical changes not
                 discussed in this report          32
ABC Surgery Center
     • Within 3 months surgery center in the
       black for first time
     • Gross charges tripled
     • Average gross charges per case doubled
     • Collections increased more than 250%
     • Profit increased more than 400%
     • Net income/case increased more than
       300%
                                               33
ABC Surgery Center
                                                                  34
                                                                   34
Case Study reflects financial findings/recommendations only –
additional clinical findings/ recommendations are not presented
       • 10 month old ambulatory surgery
         center evaluated to determine
         compliance and efficiency and
         evaluate billing process
       • Semi-rural area
       • Solely owned by physician and
           non-physician partners
       • Average case volume – 80-100 month35
                                            35
XYZ Surgery Center
                     • Specialties
                       - Orthopedics – 50%
                       - Ophthalmology – 25%
                       - Pain Management – 13%
                       - Urology – 6%
                       - Podiatry – 6%

                                                 36
                                                  36
XYZ Surgery Center
       • Payor Mix
         - Medicare
         - Medicaid
         - BCBS
         - W/C
         - PPOs
         - Indemnity
       • Contract reimbursement is based on a
         mixture of:
         - percentage of Medicare groups
         - discount off billed charges          37
                                                 37
XYZ Surgery Center
        Findings
        • Sharing practice management
          software with clinic
        • Software does not allow loading of
          contracts
        • Shared schedule with clinic
        • Software does not have place for
          Medicare groups nor APCs
        • Clearinghouse (part of software)
          reports not accurate                 38
                                                38
XYZ Surgery Center
         Recommendations
         • Consider purchasing ASC-specific
           software – need to be able to
           schedule separately and load
           contracts

         • Suggest changing to independent
           clearinghouse

                                              39
                                               39
XYZ Surgery Center
         Findings
         • Evaluation of fee schedule
           revealed that many fees were less
           than some contracts would
           reimburse
         • No minimum fee – some fees as
           low as $200 - $300


                                               40
                                                40
XYZ Surgery Center
         Recommendations
         • May want to review entire fee
           schedule based on evaluation and
           comparison to reimbursement, as
           well as case cost
         • Suggest minimum fee of $1200 to
           $1500

                                              41
                                               41
XYZ Surgery Center
          Findings
          • ASC does not have copy of most
            contracts
          • Contracts not loaded in computer
          • No insurance matrix available to
            determine accuracy of payments

                                               42
                                                42
XYZ Surgery Center
           Recommendations
           • Request copies of all contracts
           • If change software, load
             contracts and adjust contractual
             allowances at time of billing
           • Develop insurance matrix and
             provide to appropriate billing
             personnel
                                                43
                                                 43
XYZ Surgery Center
    Findings
    • Physicians doing procedure coding -
     diagnosis coding done by clinic coder
    • Back-up coder has no formal coding or ASC
     experience – also does billing, payment
     posting, collections for both ASC and clinic
    • No substantiation with operative note
    • Not being done daily
    • Most implant invoices and pathology
     reports not provided to biller
                                               44
                                                44
XYZ Surgery Center
         Findings (continued)
         • Current coding books present – no CCI
          or other unbundling references
         • No coding audits being performed
         • 50 charts provided for coding review
            - 24 charts had errors
            - additional charts had insufficient
              back-up support for implants
            - $4,328 unbilled revenue
            - $5,558 over-billed revenue           45
                                                    45
XYZ Surgery Center
        Recommendations
        • Utilize certified coder
        • Code from operative note
        • Track pathology reports and provide
          to coder
        • Code daily and balance to schedule
        • Subscribe to CCI edits to prevent
          unbundling
                                                46
                                                 46
XYZ Surgery Center
      Recommendations (continued)
      • Separate coding/billing from payment
        posting/collections
      • Audit to check for unbilled revenue or
        over-billed amounts needing refund
      • Continued monthly audits to remain
        compliant
      • Provide information to physicians
        regarding detailed dictation             47
                                                  47
XYZ Surgery Center
       Findings
       • Claims are not being sent until at
         least 7-10 days post surgery
       • Batches are not closed daily
         therefore not able to balance to
         schedule to prevent unbilled revenue
       • Payments and charges are
         combined in same batches

                                                48
                                                 48
XYZ Surgery Center
      Findings (continued)
      • Contract profiles added based
         on what is being paid
      • ASC staff members unaware of
        upcoming 2008 Medicare changes
      • No out-of-network policy in place and
        no advance notification to payors
      • Contractual adjustments not done
        at time of billing
                                                49
                                                 49
XYZ Surgery Center
      Recommendations
      • Separate payment and charge batches
      • Keep necessary back-up of all
      charges
      • Bill electronically wherever possible
      • Develop tracking system to ensure
        billing for all implants
                                                50
                                                 50
XYZ Surgery Center
      Recommendations (continued)
      • Run clearinghouse reports – verify
        claim on file with payor
      • Process all claims within 48-72 hours
        from DOS
      • Notify all carriers of OON status on
        claim
      • Correct all errors/unsubmitted claims
        found on coding review and rebill
                                                51
                                                 51
XYZ Surgery Center
     Findings
     • Payment poster wears all billing hats
        for clinic and ASC – insufficient time
     • A/R is increasing – one week ago hired
        additional collector
     • Payment poster does not have
        knowledge of managed care contract
        allowances – does not have copies
     • Accepts what payor allows – write-offs
        are adjusted to match what is paid
                                             52
                                              52
XYZ Surgery Center
   Findings (continued)
   • Some secondaries have not been billed –
     assigned to patient responsibility in error
   • Undetermined whether OON payments
     going to patient – no attempt to collect yet
   • No way to balance to deposit as payments
     and charges are in same batch
   • Not starting proceedings with denials or
     incorrect payments in timely manner
                                                   53
                                                    53
XYZ Surgery Center
       Recommendations
       • Provide payment poster with copy of
         all managed care contracts and/or
         contract matrix
       • Payments should be posted daily
       • Bank deposits should be made daily
       • Keep necessary back-up of all
         payments received
                                               54
                                                54
XYZ Surgery Center
     Recommendations (continued)
     • Review EOBs and promptly start denial
       process for erroneous payment or no
       payment
     • When posting, compare payment to
       original claim to determine accuracy
     • Credit balances to be reviewed and
       promptly refunded, where applicable
                                              55
                                               55
XYZ Surgery Center
        Findings
        • Collections not being done regularly
           due to lack of business office staff
        • No upfront collections
        • No brochure for patients to outline
           financial policy
        • No policies/procedures on billing or
           related issues
        • No accounts have been placed with
           collection as no follow-ups done yet 56
                                                 56
XYZ Surgery Center
        Findings (continued)
        • No training in Fair Debt Collection
           standards
        • Medicare claims not crossing over
          to secondaries
        • 30 day prompt payment law
        • Days in A/R 79
        • Over 120 – 22% (mostly insurance)
                                                57
                                                 57
XYZ Surgery Center
      Recommendations
      • Review accounts that were denied or
            paid in error and rebill where
      applicable–
            timely filing may become an issue
      • Follow up on OON claims – determine
            which paid to patient and send
            statements
      • Need to audit Medicare and insurance
            payments to detect overpayments –
            correct and issue refunds where
XYZ Surgery necessary
                                                58
                                                 58
            Center
      Recommendations
      • Use aging reports to aid in collections
      • Use tickler files
      • Evaluate/correct problem with Medicare
        secondaries
      • Enforce prompt payment rule
      • Institute upfront collection of deductible
        and copays
      • Establish financial policies/procedures
                                                  59
                                                   59
XYZ Surgery Center
      Findings
      • Administrator has no previous ASC
        experience
      • No business office manager
      • Only two FT business office employees
      • Billing staff leased part time from clinic
      • Few business office policies/procedures
      • Vague job descriptions – no real
        accountability
                                                     60
                                                      60
XYZ Surgery Center
      Recommendations
      • Separate clinic and ASC staff if possible
      • If billing remains in-house, recommend
        hiring full time experienced coder/biller
        for ASC
      • Suggested some changes in positions to
        cover all tasks
      • When caseload increases, recommend
        hiring working business office
        coordinator who can fill any position as
        needed                                    61
                                                   61
XYZ Surgery Center
      Findings and Recommendations -
      STAFFING

      • Information flow is fragmented
        between clinic and ASC – recommend
        evaluation and change

      • Need specific business office policies
        and procedures and job descriptions

                                             62
                                              62
XYZ Surgery Center
   Findings/Recommendations – COMPLIANCE
   • Not enough separation between Clinic & ASC
   • Billing and payment posting should be
     separate and done by different employees
   • Three members of business office staff
     should review deposits
   • No Business Associate or confidentiality
     agreements
   • No financial policy information available to
     patients
                                                    63
                                                     63
XYZ Surgery Center
        Findings and Recommendations –
        2008 MEDICARE CHANGES
        • Administrator attended educational
          seminar on 2008 Medicare changes
        • Suggest share information with key
          personnel and billing staff
        • Evaluation team provided copy of
          proposed reimbursement to ASC
                                               64
                                                64
XYZ Surgery Center
           • Governing body approved and
             adopted recommendations

           • Outsourced coding and billing
             functions

           • Made other clinical changes not
             discussed in this report

                                               65
                                                65
XYZ Surgery Center
       • Outsource date - January 1, 2008
       • Average caseload 100/month
       • Accounts receivable decreased 25%
       • Over 120 decreased from 22% to 8%
       • Average Collections increased from
         $160,000 to $250,000 per month
       • Average Gross Charges increased from
         $353,860 to $584,055
       • Days in A/R decreased from 79 to 44
                                                66
                                                 66
XYZ Surgery Center
• Inadequate fee schedule
• Poor managed care contracts
• No copies of managed care contracts
• Insufficient staff
• Wrong staff
• No good policies/procedures in place
• Compliance issues
• No consistency in billing practices
• Not billing for implants regularly     67
                                          67
   Caryl Serbin
  239-482-1777
cas@surgecon.com
                   68
                    68

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:10
posted:3/10/2010
language:English
pages:68