Strategic Approach to Upfront Financial Counseling Proves Success at East Hills Surgery Center

COVID-19 has created cash flow issues for most ASCs due to decreased volume and slower reimbursement. In response, we are working closely with our centers to ensure they are collecting as much of their revenue as possible during this time. And our approach is paying off.

At East Hills Surgery Center, a focused approach to upfront collections has been key to improving revenue cycle management and has resulted in significant improvements, even when New York state had more coronavirus cases than any single country outside the US, in April. Percentage of due collected improved from 16% in 2019 to 36% in 2020, and financial counseling accounted for 36% of upfront collections in 2019, compared to 99% in 2020.

“Basically, it all comes down to having the correct processes in place,” explains Leslie Favela, Regent RCM’s manager of revenue cycle business development. “It’s about making sure that we’re reviewing every single case and ensuring that we’re making the best decisions for the center and the patient.”

Attention to correct processes and disciplined focus have delivered very strong revenue cycle management statistics for East Hills over the past months: The center achieved 149% of its cash goal, and saw a significant decrease in AR days over 90 on the strength of an average for AR follow up over the last three months of 99%.

Favela attributes the success at East Hills to having dedicated staff focused on collections, and a strategic approach to upfront financial counseling.

“Often we find that centers are kind of open-ended on what they’re asking patients to pay upfront,” she says. “We always start with the highest estimate, and then work from there. I think that the centers tend to reduce it right away without explaining the potentially highest amount to the patient. So we start high and then give wiggle room, rather than starting in between and later having to lower it from there. We find then that another result of increasing upfront collections is a drop in AR, so we have less bad debt to write off, and fewer receivables moving into the aging buckets.”

“East Hills reached their cash collection goal,” Favela continued. “The team has been diligent on working on the AR, and then we took advantage of a slower business period to make sure that we touched all accounts to bring in the most money. This has been an effective formula.”

Learn more in our white paper, Proactive Cash Flow Management. Download your copy now.

negotiations

Fact-Based Payer Contract Negotiations Key as ASCs Reopen

A side effect of COVID-19, disrupted contract updates between health insurance payers and ambulatory surgery centers (ASCs) have created a new normal for negotiations. For ASCs, leveraging a thorough understanding of the pandemic business realities for both payers and providers is more critical than ever as the industry recovers.

“Payer resources have been intently focused on their provider networks capacity to manage COVID — whether it was ensuring enough beds or ventilators, teleconference access, physicians’ capabilities, or testing,” says Andrea Woodell, Vice President of Managed Care at Regent RCM. “The virus caused a seismic shift in the payers’ focus. Naturally, we lost momentum in our ASC contract negotiations. Now, 12-16 weeks into it, we’re picking up the discussions again.”

As contract talks resume, Woodell shares observations to keep ASCs’ negotiations focused on the facts:

  1. Costs, But Also Savings: While payers have incurred some new costs due to the pandemic, they also have realized savings that balance out those costs. “The decline in elective cases has resulted in substantial savings for health plans. As a negotiator, we should incorporate the savings which offset new COVID expenses,” Woodell says.
  2. Shifting Payer Mix:COVID-19 has forced a change in payer mix that should be addressed in negotiations. Says Woodell: “Because of COVID, there are 40 million people unemployed now. We’re going to see a spike in uninsured, an increase in Exchange coverage, an increase in Medicaid, and especially in metropolitan areas, we’ll see some commercial coverage migrating from PPO and HMO plans to a lower-paying Exchange product. The impact of these payer mix changes, if not offset during negotiations, would decrease ASC reimbursement for surgeries.”
  3. A Better Site of Care: Woodell says the benefits of moving procedures to the ASC setting have never been clearer. ASCs afford Medicare patients 55% savings over the same procedure at a hospital. And, with hospital space and priorities stretched by COVID, the advantages of a separate location for elective surgeries become even more important and valuable. “I think it’s important to include in negotiations what the spend would be on their managed Medicare product for an HOPD setting versus your ASC setting,” she explains. “Use that. If I have both a managed Medicare product and a commercial product with a certain payer, I quantify the amount saved by moving the case to an ASC versus HOPD setting. We know the Medicare population does not want to go to the hospital right now, and they are unlikely to go there due to COVID. A shift in site of service is great for the payers, but often leaves the ASC unprofitable. My goal is to demonstrate the saving on their managed Medicare lives and shift some of that savings to the commercial cases It is a fair and logical discussion to support long-term success of both the ASCs and the health plans”

Finally, Woodell predicts ASCs will see a quick uptick in volume as things reopen, followed by a plateau or decline as the industry satisfies demand that was put on hold. “The volume will come, but it’s going to come back slowly. In terms of reimbursement and payer contract negotiations short term, if we push the money will be there. ASCs’ value should be recognized and rewarded.”

For more information on managing ASC payer contracts, contact Woodell here.

improved collections cash flow management

New White Paper: Proactive Cash Flow Management

Ambulatory surgery centers (ASCs) have been severely impacted by the COVID-19 pandemic and experienced a significant decrease in volume, especially after some states postponed elective procedures and imposed stay-at-home orders to decrease possible transmission.

The current environment has been made more challenging with slower reimbursement from payers, which has created cash flow issues for some centers. As centers are back up to 80-90% of total cases, proactive revenue cycle management and cash flow is more important than ever before.

The team at Regent RCM is working closely with its ASC partners to help them collect as much of their revenue as possible during this challenging time.

“ASCs want to collect everything they have available, and that means paying close attention to two buckets in particular,” said Erin Petrie, Regent RCM Vice President. “We look at all aging accounts receivable and on any new cases, we work with centers to maximize what they are collecting upfront from patients.”

A new white paper, Proactive Cash Flow Management: Two Case Studies Highlight How Centers in New York and Delaware Improved Collections in Spite of the Pandemic, explores two instances where the effectiveness of a renewed focus on optimizing cash flow and managing revenue cycle has paid off for two ASCs in particular.

Download our white paper here and please contact us for any revenue cycle needs you may have.

revenue cycle leaks

Tracking Key Reports Helps Repair Revenue Cycle Leaks

Successfully managing ambulatory surgery center (ASC) profitability and cash flow means keeping a tight rein on your center’s revenue cycle. One way many ASCs do this is by carefully tracking against Regent’s revenue cycle management (RCM) benchmarks. But when a potential revenue cycle leak is suspected, a deeper look at three key reports offers problem-solving insights.

“When it comes to revenue cycle leaks, there are three reports in particular that will give you enough insight to be able to tackle most any issue you see. Obviously, you’re looking into this for a reason: maybe it’s because your cash flow is slowing down, or maybe your percent (of Accounts Receivable) over 90 days is picking up,” says Regent RCM Vice President Erin Petrie. “Starting with these reports will give you an opportunity to narrow the scope of what you’re looking for, so you don’t have to go through and look at every single account. It highlights target areas.”

The three leak-sealing reports Petrie recommends are Aging AR by Payer, your ASC’s Unbilled Case Log, and your Denials Report. She explains the power of each:

Aging AR by Payer

While Aging AR is a routine benchmark report, digging into Aging AR data by Payer can be an efficient way to identify trends and potential problems when you suspect a revenue cycle leak.

“If all of a sudden you notice that your Blue Cross 120 bucket just got huge because everything’s rolling over from 90, you can tell that there’s probably an issue with that payer versus if you look at the summary AR report and see that all of the 120 buckets – regardless of payer – are starting to pick up,” says Petrie.

She explains that an uptick in the 120 Days AR bucket across the board may indicate a problem with the biller not following up or sending claims out incorrectly in the first place, whereas if you see that it’s just one payer or a couple payers specifically, that is likely a payer related issue. “If it’s a payer issue, you would then dig into that particular payer’s accounts to see what the notes are on those accounts so you can solve for whatever is going on.”

Unbilled Case Log 

If your look at the Aging AR reports has determined that the problem is more of an across the board performance issue, Petrie recommends a second key report:

“By taking a look at your unbilled case log, you can see if you have a spike in cases that weren’t dictated by physicians or weren’t billed because they’re waiting for an implant invoice or something,” she says. “Obviously you’re not billing those cases without that information, but the date of service remains the same. That means when you do bill them, all of a sudden, those cases are going to drop directly into your 90 bucket instead of your 0 bucket. So that unbilled cases log is a good one to monitor. You don’t want to see wild swings where all of a sudden one month you have like a quarter of your case volume that’s just not dictated.”

Denials Report 

The third report Petrie recommends to ASCs seeking to plug revenue cycle leaks tracks reimbursement denials, offering a view into why payment may be held up.

“The payers tend to change things in midstream,” Petrie explains. “For example, maybe all of a sudden Blue Cross will start requiring a prior authorization when they hadn’t before, so now you’ll see all of these ‘prior auth’ denials and you’ll have to go back in to solve for that, and also figure out how to avoid those going forward.”

Petrie says the denials report is a good place to figure out two key leak-busting tactics: how you can correct everything that’s sitting out there to be collected, and where training and preparation might help you avoid those mistakes again.

Managing to avoid revenue cycle leaks is especially challenging for ASCs because the process can be time and resource intense.

Says Petrie: “It can be overwhelming when you think about how many accounts you have to look at to try to figure out what’s going on. ASC administrators don’t have the time to go through thousands of accounts. And the ASC software doesn’t always have the most robust reporting, just because that comes at a pretty high price tag, so you’re stuck doing lot of manual reporting. But if you take this approach and try to narrow it down so that you’re not looking at every account out there, that might help get you going. If you start with those three reports, they’re broad enough that you should be able to get the data from any system you’re using, and use it to narrow your scope so you’re not searching for a needle in a haystack.”

For more information about investigating revenue cycle leaks, contact us.

Case Profitability

Keys to Case Profitability

This content was written by Erin Petrie and was published in ASC Focus’s August 2020 issue. Please see the original content here.

As the cost of delivering healthcare continues to rise, ASC reimbursement is getting tighter, necessitating even closer cost monitoring and a proactive stance on payer contracts and collection.

While ASCs might have been able to balance a few cases that did not make money within their total case load in the past, today’s healthcare environment puts profitability pressure on every single case. For example, given the nursing shortage, centers now pay nurses as much or more than they would be paid at a hospital, yet the hospital’s reimbursement is 50 percent higher. And that’s just one element driving a need to carefully manage all the factors that impact ASC profitability.

So, where should you start?

Maximizing case profitability comes down to proactively managing two key activities: understanding payers and reimbursement and, of course, controlling costs.

Understanding Payers and Reimbursement

In our practice, we have found a three-step process helps ASCs tackle payers and reimbursement on a case-by-case basis:

  1. Review the case to be scheduled: identify the applicable codes and pin down the overall cost of the procedure, including implant costs.
  2. Verify patient insurance: confirm if the patient’s insurer is a contracted payer and whether the insurance reimburses for the applicable codes. Do they reimburse on the implants? Based on this information, determine potential profitability of the case.
  3. Verify patient eligibility and coverage: review benefits and deductible accumulations to determine the patient’s financial liability and counsel the patient upfront.

Following this process can help ASCs understand case profitability in advance and avoid taking on cases that are likely to result in a net loss. Let’s look at two examples.

The first is a pain management case involving a permanent neuro stimulator implant. The procedure spans three applicable CPT codes, plus implant costs. The ASC administrative team identifies costs to perform the case at $27,000 including the implant, plus staff and supply costs of $2,300 for a total cost of $29,300. The patient has a contracted insurer that reimburses $4,000 plus implants paid at 110 percent for this type of case, with reimbursement expected to be $33,700. The positive variance of $4,400 between the ASC’s cost and the reimbursement make it profitable to proceed with the procedure.

The second example is a bit less straightforward. In this case, the patient needs a total hip procedure and is insured by Medicare. Costs are $6,250 including the implant plus $2,500 for staff and supply costs for a total of $8,750. Contract reimbursement is $8,900, which at first glance looks like a positive variance of $150. However, the recommendation is not to proceed with the case. Why?

With Medicare, the patient would normally be required to pay 20 percent of the $8,900 as co-insurance but in this case, the patient also has Medicaid as a secondary insurer, so they don’t have to pay the co-insurance. Here’s the problem that faces the ASC: as it turns out, Medicaid won’t pay the 20 percent either because the 80 percent paid by the primary insurance is still more than Medicaid would have paid for the procedure. Scenarios like this underscore the need to really understand your payers. In this case, the dynamic between Medicare and Medicaid as a secondary insurer means actual reimbursement to the ASC is 20 percent lower—just $7,120 toward the ASC’s costs of $8,750—creating a loss of $1,630.

“Maximizing case profitability comes down to proactively managing two key activities: understanding payers and reimbursement and, of course, controlling costs,” said Vice President of Revenue Cycle, Erin Petrie.

If an ASC doesn’t have the bandwidth to dig into the profitability of every single case, a good place to start is with high-dollar cases or anything with an implant. In many instances, payer contracts will not provide separate reimbursement for an implant, bundling it instead within one price. Knowing which payer contracts allow separate reimbursement for implants helps manage profitability, especially on cases where a more expensive implant is needed.

One final point to understand about payers and reimbursement is the trend toward higher deductibles and patient responsibility. Studies from Kaiser PermanenteTransUnion and Advisory Board show that within the next few years, as much as 50 percent of total ASC reimbursements will come directly from patients. As the percentage of the bill to be paid by the patient continues to increase, ASC profitability can be at risk. Centers that are used to collecting primarily from insurers need a different strategy for patient collections and should begin to think about collecting up front and focusing on financial counseling with the patient to avoid bad debt.

Controlling Costs

When it comes to case profitability, the other side of the coin from reimbursement is managing costs such as staffing, supplies and inventory management.

Most ASCs are adept at managing variable staffing by controlling schedules and sending people home when case volume is low. Centers also need to think about optimizing their fixed staffing equation, like the business office staff doing insurance verification, scheduling, calling patients and doing check-ins. An ASC-specific benchmark is 1.5 full-time equivalents (FTEs) per 1,000 cases for business office staff, based on the number of cases a center does in a year, according to the Regent Gold Standard.

To manage profitability well, it is vitally important that ASCs stay on top of the business side of the operation and do all the work to ensure they are not leaving money uncollected. For example, staff should not be so lean that there is not time to confirm that payer authorizations are on file, because more and more codes are moving to requiring pre-authorization and cases will be denied. On the flip side, if there is too much administrative staff, chances are good that it will impact the ASC’s profit margin.

Another important factor in controlling costs is supplies and inventory management and working to get as close to just-in-time inventory on commodity items as possible. Ideally, an ASC should be forecasting needs and putting in supply orders every day to avoid having too much sitting on the shelf, but also to ensure needed supplies are available so every case can be performed on schedule. Every inch of space needs to be productive in an ASC, especially for supplies that are required to be stored in a sterile space. Centers pay a premium to lease space, so ASC leaders really need to make sure they are not overbuying inventory and storing too much.

In terms of implants, it is critical to have a standardized process for handling physician requests. Centers want to do due diligence before honoring a request for a new higher cost item, to make sure there is not a reasonable alternative in inventory or a more cost-effective alternative. Having a process moves the conversation away from personal, directing questions to the practical: “Are there ways that this will save OR time?” or “Are there ways that this could replace other supplies we would normally have to use in tandem with the implant?” These questions go beyond just looking at the bottom line to help uncover different ways a new implant might be more cost-effective.

Getting Started at Managing Case Profitability

Any center already doing any advance modeling of case profitability is ahead of the game. Many ASCs look only at profits in arrears, comparing case profitability to the last quarter or the last month. A good first step might be looking at these numbers on a weekly basis and looking ahead to review the high-dollar cases coming up. With case-by-case analysis, ASCs can identify trends and see if there is opportunity on the cost side. If a center is already tightly managed on the cost side, the next step is improving reimbursements and contracts and, in the meantime, becoming diligent about not taking on cases that will not be profitable.

Contact Erin Petrie at epetrie@regentsurgicalhealth.com or click here.

missteps

ASCs Can Avoid Revenue Missteps with the Right Business Office Structure

Pat 2 of a 2-part Q&A series with Leslie Favela

With some strategic advanced planning, ambulatory surgery centers (ASCs) can put policies and procedures in place, along with tracking mechanisms, to effectively manage their revenue cycle.

For this second blog in a two-part series, Leslie Favela, an eight-year veteran of Regent Revenue Cycle Management (RRCM) and manager of the RRCM Business Development team, sat down to answer some of the most frequently asked questions that RRCM receives from ASC professionals around the country:

Question:

My colleagues and I are trying to find ways to improve our collections and are considering asking for upfront collections from patients. How can we do this without irritating our clientele?

Answer:

There are several ways to sustain the goal of improving collections overall, and we have had several successes with centers starting to do the upfront collections. In another recent blog, we addressed some of the myths out there, but on a high level, before you start upfront collections, education is key. It is critical that you begin by educating your surgeons, educating the center staff, and educating the patients on exactly what it means and why collecting upfront is the right thing to do. For us, a big focus has been advising the patient and educating them on their financial liability for their healthcare. Once they understand that piece of it, I think that definitely takes away the irritation.

Within our industry, times have changed. Now, we have the capability to really know how much a patient is estimated to pay for a given procedure. So, step one is making sure the patient understands that information: what their deductibles are, what their liability is. The same thing is true for the surgeons: they can prep the patients on their end by telling them “Hey, we can save you time and money by doing the surgery you need at the surgery center instead of at a hospital. We’ll help you understand your deductible and the percentage of the total cost you’ll need to pay, and we collect that upfront.”

Question:

Last year my center merged with two other surgery centers and it has been so hectic that I am worried some administrative chores may be falling through the cracks. Do you have any suggestions on how we can ensure nothing gets missed?

Answer:
Yes, merging two surgery centers can definitely be hectic, but establishing standard policy and procedure helps. At RRCM, we follow a check list that details what reports we should be running on a monthly basis and helps ensure that all of the critical work of revenue cycle management gets done. Self-audit is really key here, whether it’s you who’s completing the tasks or managing someone else who is implementing. It’s all about making sure that once you have the process in place, you follow through on all of your business office policies and procedures, and that you tend to them each month.

“It all comes down to advance planning,” Favela says. “Overall, the secret is really focusing on revenue cycle management and working to ensure that you have an effective structure in place within your business office. In addition, centers should educate everyone from the staff to the surgeons to the patients on standard operating procedures for the center and overall expectations. With those things in place, it’s all about doing regular self-audits to make sure you’re doing everything right and catching any issues early.”

For more information about effective revenue cycle management, contact Favela.

RISE Award Recipient

Shining a Light on RISE Award Recipients

Regent Revenue Cycle Management created the RISE program to develop a values-driven culture that helps the team stay focused on the goal of leveraging ASC expertise while providing high-value and high-touch customer service.

Recently, we recognized three RISE award recipients: Vanessa Herrera, Luz Renteria and Vanessa Soto. Each recipient was nominated by fellow employees for going above and beyond.

Vanessa Herrera, Patient Account Representative, is a one of our newest Regent RCM employees and started right before we made the switch to working remotely due to COVID-19. Despite the unique challenge of beginning a new job while being remote, she never fails to impress. Vanessa was nominated for a RISE award for Respectful Caring for her thoughtful approach when working with patients at the centers she covers.

Luz Renteria, RCM Manager, supports seven centers, two of which are new implementations, and somehow, she makes it seem effortless. She was nominated for a RISE award for Stewardship for doing an excellent job overseeing the business office implementations. Luz has also been handling the day-to-day billing at one of the centers since February because of the hiring and training constraints from the COVID-19 pandemic.

Vanessa Soto was Regent RCM’s first Patient Account Representative and was nominated for a RISE award for Stewardship. Vanessa had a sudden increase in workload and where others may have felt overwhelmed, she stepped up and figured out a way to manage both centers successfully. As of last week, one of the centers she oversees was on pace to hit 166% of historical upfront collections.

“We are always very proud of our employees who go above and beyond,” said Vice President of Revenue Cycle Management, Erin Petrie. “These three team members exemplify what our corporate values stand for and we are happy to recognize them for their hard work.”

 

3 strategies

3 Strategies for Getting Your ASC Paid on Time

The financial health of your ambulatory surgery center (ASC) depends on accurate, efficient revenue cycle management – which is difficult to maintain in an increasingly complex insurance environment. Submitting clean claims to payers is an important step in decreasing delays and denials, but it is only one part of the equation. To ensure your ASC is paid properly and promptly, take a proactive approach to streamlining your revenue cycle.

Here are three ways to improve your ASC’s revenue cycle management and work toward your profitability goals.

Evaluate & Update Payer Contracts  

Review all of your current payer contracts and fee schedules. Are payers sending appropriate reimbursements as agreed upon in your contracts? Have any payers updated or waived certain costs or processes because of COVID-19? When was the last time you renegotiated contracts with your most common payers? If you haven’t revised a contract in some time, you may not be receiving the best rates.

Track Key Payer Metrics

To gain a better overall view of your ASC’s financial picture, collect information on claims and reimbursements, and grade major insurance payers on key metrics. Start by asking these questions about each payer:

  • What do they pay for a procedure?
  • How fast do they pay?
  • What percentage of claims do they deny?

Use this data to understand how common denials are and how much time your staff is spending to collect from each payer. Can you pinpoint any trends associated with delays or denials? Are you including all of the information needed for a claim? Are you submitting clean claims and still having to appeal incorrect denials? If you notice that your team frequently battles with a payer over correctly billed claims, resulting in hours of lost staff time, you can use this information to push for changes or contract renegotiations.

Follow Up Quickly

Establish a schedule of follow-up practices for outstanding claims and erroneous denials, and remember not to accept the payer’s first payment. Calculate your ASC’s average days in A/R, and set a goal for following up on claims to reduce that number. If your ASC receives a denial where the payer is at fault, set a timeframe – such as 24 hours – in which your staff must resubmit the claim or file an appeal.

Effective revenue cycle management requires diligence and consistency. Partnering with ASC revenue cycle experts can transform your center’s financial health. Get in touch with Regent RCM to optimize reimbursement and solve problems in your revenue cycle.

quarterly award

Congratulations to our Q1 Award Winners

Regent Revenue Cycle is pleased to present our Distinguished Performance Award recipients for Q1. Each recipient met or exceeded all Regent Gold standard performance benchmarks including:

  • AR follow up
  • Decrease in % of AR over 90 days
  • Highest quality audit results for Q1

Our revenue cycle specialists provide consistent high-value and excellent customer service to our clients and are dedicated to delivering exceptional quality.

“The whole team is proud of this group of employees,” said Vice President of Revenue Cycle Management, Erin Petrie. “These individuals go above and beyond to deliver excellence and exemplify our R.I.S.E Values: Respect, Integrity, Stewardship, and Efficiency.”

Congratulations Rebecca Johnson, Dacia Aviles, Mayra Casco, Lorena Gonzalez, Celia Kulis, Lilia Casas, Maria Murguia, Gabriela Alcaraz, and Angie Valentin.

Updated Gold Standard: A/R over 90 Days

In 2017 we introduced ASC-specific benchmarks. And since then, we have routinely leveraged data and industry trends to review and revise the benchmarks, making updates in order to improve our own processes and approach and ensure our centers capture all the revenue they are entitled to.

In 2020, we’re updating A/R over 90 Days: today, our gold standard is below 25%.

“If a center is getting lower than 25%, it would likely mean that someone is taking write-offs versus exhausting appeals to those claims,” explained Regent RCM Vice President Erin Petrie. “Originally, we were aiming for a gold standard of 20% but when we standardized our data over two years, we saw that the percentage was closer to 30-35%. Since then, we have been digging in to better understand why the percentage is higher and when it might be a sign that the center’s revenue cycle is healthier as a result.”

There are couple of variables that centers should note:

Patient Responsibility & Financial Counseling – Up-front collections are a contributor to A/R over 90 and if a center doesn’t have an up-front collections process in place, it is very unlikely to get to 20% for A/R over 90 Days. Why? Because patients can be responsible for as much as 30% and that takes time to collect.

“When patients lack financial counseling, it often results in the patient being unprepared to pay copayment, deductible and/or co-insurance amounts,” explained Petrie. “This contributes to unsecured debt and drives up days in A/R. We work with our clients to operationalize upfront patient financial counseling and collections and we are seeing dramatic results.”

Quality Auditing – Audits help identify where education is needed among staff and assist in finding gaps and leaks in the revenue cycle. Petrie noted: “By conducting an aggressive appeal the first time, the percent of A/R over 90 Days automatically goes down. High-performing ASCs will inevitably experience claims denials, but during an audit we take an in-depth look at the center’s appeal process, that helps us get to the root of the issue and correct it.”

 

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