DRG Coding Advisor-ID reimbursement problems before they appear
Coding staff can spend a lot of time talking with third-party payers about denied claims, partial reimbursements, or late payments, so it's more efficient to develop processes to identify potential problems before they appear, says Andy J. Hetrick, administrator of the Decatur (AL) Ambulatory Surgery Center.
Identify potential problems when the patient is scheduled for surgery, Hetrick advises. "Our billing and coding people have developed a close relationship with the office staffs of our physicians, so whenever they have a question about a scheduled procedure, they pick up the telephone and call for more information," he says.
One of the potential problems is a procedure that Medicare and other third-party payers don't recognize as a reimbursable procedure for an ambulatory surgery center. "If it is considered minor and able to be performed in a physician's office, we won't be reimbursed," says Hetrick. Even if a lesion is small enough to remove in a physician's office, some of Hetrick's physicians don't have the capability of handling the procedure in the office. When this situation arises, he approaches it two ways. "First, we contact the payer and explain that if it can't be performed in our surgery center, the physician will have to perform it in the hospital at much higher rates. Many times, the payer agrees to allow the procedure to occur in our facility."
However, this approach won't work with Medicare, which will only pay if the lesion is on its list of CPT codes, coding experts point out.
When the payer refuses to reimburse the surgery center for a certain procedure, the billing staff talk with the patient and explain that the procedure is not on the approved list and that the nonreimbursed costs will need to be collected upfront. Medicare patients are given written notice, as required.
A typical situation is that a lesion on the approved procedures list is scheduled along with a smaller lesion that isn't on the list. "The physician doesn't want the patient to come into the office for one lesion removal and the surgery center for the other removal, so the removal of both will be scheduled at the same time," Hetrick explains.
Another key to identifying potential reimbursement problems upfront is to ask the third-party payer the right questions when verifying coverage, says Hetrick. "We don't just ask if the patient is covered. We specifically ask if the patient is covered for the procedure that is scheduled."
This step helps the surgery center staff identify a procedure that is excluded due to pre-existing conditions. "Some plans have anywhere from a 30-day to 180-day waiting period before a pre-existing condition is covered," he says.
Delay surgeries for approval, if possible
If staff discover that the patient won't be covered for another week or month, someone contacts the physician's office to see if the procedure can be delayed.
Frequently, hernia repair and knee arthroscopy fall into this category, says Hetrick. If the procedure is required because a work-related situation aggravated the pre-existing condition to the point that surgery is needed, workers' compensation comes into play and the procedure can be covered. If, however, the payer doesn't agree to cover the procedure and the patient still wants to proceed, the surgery center staff work out a payment agreement, he adds.
When talking with the third-party payer, Hetrick's staff also verify that the surgeon has received pre-certification for the procedure. "If the physician's staff haven't obtained pre-certification, we call the physician's office," says Hetrick. "If the procedure has been pre-certified, we get the pre-certification number and include it in our files in case there is any question about the claim later."
The staff at Decatur Ambulatory Surgery also collect all copays, deductibles, and uncovered charges upfront, says Hetrick. If the patient is undergoing a procedure for which the third-party payer isn't covering any of the charges, a financial plan is arranged that includes an upfront amount and a billed amount that can be paid over an agreed-upon time, he adds.
About 60% of patients are paying all charges not covered by third-party payers upfront, and the remaining 40% of the patients are billed, explains Hetrick.
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