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  • Case Study reflects financial findings/recommendations only additional clinical findings/ recommendations are not presented3

  • 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 monthABC Surgery Center

  • Specialties - ENT - GI - Ophthalmology - Orthopedics - Podiatry - Pain Management Payor Mix - Medicare - Medicaid - BCBS - W/C - PPOs - HMOs - IndemnityABC 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 placeABC 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 localityMany fees were actually less than Medicare allowableFee schedule had been based on physician DRGsNo consistency in fees similar procedures had wide variancesABC Surgery Center

  • Recommendations Develop fee schedule based on percentage of Medicare group ratesCarve-outs for higher ticket proceduresDecide on additional procedure discountSample fee schedule given to Board -recommended 500% of current Medicare ratesABC Surgery Center

  • FindingsLow rates for an area with little managed care penetrationSome reimbursement methodologies varied from market standardUnfavorable terms in contractsMost carriers require accreditationSome contracts were invalid as not voted on by BoardABC Surgery Center

  • RecommendationsJoin local PHO and have them assist in recontracting for ASCCancel five major contracts whose reimbursement is based on Medicare rateGreat managed care market suggest renegotiate for reimbursement based on percentage of billed chargesMove toward becoming accredited mark applications as Accreditation PendingABC Surgery Center

  • FindingsCoder with no ASC or surgical coding experienceCoding 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 casesABC Surgery Center

  • RecommendationsHire or outsource to certified coder, orImmediate coding certification training for current coderCode from body of operative note use additional information when necessaryABC Surgery Center

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

  • FindingsBiller had no ASC/surgical billing experienceNo electronic filing all paper claimsAll business office uses same printerBilling for non-ASC services in same module cannot separate in reportsNo cross-check between coded cases and batch reportABC Surgery Center

  • RecommendationsHire experienced biller, orImmediate training for current biller including the following:

    Electronic submission of all claims where possible ABC Surgery Center

    CPT codesICD-9 Dx CodesSx ProceduresModifiersMedicare Guidelines

  • Recommendations (continued)Additional printer near biller to run claim formsPurchase separate software module to bill for non-ASC servicesBalance billing batch report to coding forms/schedule to ensure no unbilled revenueABC Surgery Center

  • FindingsPayment poster not knowledgeable regarding managed care contract allowances no copy of contractsAccepts what payor allows write-offs are adjusted to match what is paid and not pre-approvedNot checking to determine if refund dueNot balancing to depositABC Surgery Center

  • RecommendationsHire experienced payment poster, orProvide payment poster with copy of contracts and ASC fee scheduleIf payment correct, transfer amount to be billed to secondary insurance or patient and sendIf not paid correctly or denied, start denial processIf overpaid, begin refund processBalance payment batch to deposit logABC Surgery Center

  • FindingsCollections not being done regularly due to lack of business office staffNo system in place to determine oldest accounts and when to place with collection agencyHigh dollar amount over 150 days old - investigate to determine how much collectibleABC Surgery Center

  • Recommendations Insurance CarriersUse Aging by Carrier report to develop collection scheduleCheck all outstanding balances with each carrier, oldest first Remind carrier of state prompt payment regulationResubmit bill and/or additional documentation, if applicableABC Surgery Center

  • Recommendations Insurance Carriers (cont)Develop tickler system to follow-up on promised paymentsFuture collections follow-up in 15 days to make sure carrier received claimFollow-up at 30 days to determine if carrier is following prompt payment ruleDocument in patients accountABC Surgery Center

  • Recommendations Patient AccountsCollect deductibles and copays up-frontPerform patient financial counseling prior to DOSBill patients monthlyAdd notes that increase in language as account agesContact patients by phone to determine status and offer payment alternatives, i.e., credit card, payment schedule, etc.ABC Surgery Center

  • Findings Unbilled revenue due to: - bilateral proceduressecond 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 grossABC 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 - errorsABC 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 revenueABC 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 caseloadABC Surgery Center

  • Recommendations/Findings Business OfficeCurrently whoever answers main phone line schedules patientSuggest dedicated phone line for schedulingSuggest one employee be assigned to schedule others can be back-upHave Business Office Manager learn all business office positions and act as back-upDevelop business office policies and proceduresABC Surgery Center

  • Recommendations/Findings Business OfficeIf 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 collectionsIf outsource billing no additional staff neededABC 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 - auditsABC Surgery Center

  • Findings No counter-check of deposits No auditing of coding/billing Reports invalid as reflect another business as well as ASCABC 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 moduleABC Surgery Center

  • Governing Body approved and adopted recommendationsHired outside management to institute changesOutsourced coding and billing functionsDiscontinued secondary business in ASCMade other clinical changes not discussed in this reportABC Surgery Center

  • Within 3 months surgery center in the black for first time Gross charges tripledAverage gross charges per case doubledCollections increased more than 250%Profit increased more than 400%Net income/case increased more than 300%ABC Surgery Center

  • Case Study reflects financial findings/recommendations only additional clinical findings/ recommendations are not presented34

  • 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 monthXYZ Surgery Center 35

  • Specialties - Orthopedics 50% - Ophthalmology 25% - Pain