Revenue Cycle

Top 4 ASC Payer Contracting Practices – Part 1

Ambulatory surgery center (ASC) administrators face a variety of challenges when it comes to successfully managing their payer contract negotiation deadlines.

According to Andrea Woodell, Vice President of Managed Care at Regent Surgical Health, hard-working and well-intentioned administrators and office managers are often too busy balancing numerous job responsibilities to dedicate the needed persistence and focus required to successfully negotiate expiring payer contracts.

In the first of a two-part series, Regent RCM outlines two of four top strategies to ensure seamless payer negotiations.

  1. Incorporate Centers for Medicare & Medicaid Services (CMS) changes into your contracting

There must be ample room in the budget for contractual changes to occur, says Woodell. “You should not rely on the payer to be responsive or have the bandwidth to renegotiate your contract. There’s just not enough staffing to do that,” she advises.

Medicare has been making a series of significant adjustments causing sizable reimbursement changes, Woodell says. “Codes 62310 and 62311 are being deleted and replaced with 62321 and 62323,” she explains. Facilities performing hundreds of these cases will incur cost reductions at $53 apiece, she adds. “This could add up to tens of thousands of dollars – and that’s just under Medicare patients,” Woodell estimates.

Woodell also emphasizes codes 64490 and 64493 will soon take an even bigger hit, decreased under Medicare by $115 each. Woodell therefore recommends budgeting for changes within your current negotiations.

“Not every payer contract pays based off a percent of current year Medicare, some contracts will have language stating the contract is based off 2015 Medicare. Your current rates will remain and will not be impacted,” Woodell says. “But the contracts that are based off current year Medicare will immediately see a decrease.”

“One large payer gave me an eight percent increase for a two-year contract,” she explains. “Subsequent to adjusting for 2017 CMS changes, this eight percent increase then became a 4.7 percent increase. Eight percent from a large payor plan is a slam dunk – but 4.7 for a two-year? Not so much. So, I was right back at the table,” she says. “It’s not done, but I’m fighting the fight.”

  1. Plan for the future with case mix changes

Woodell says more focus needs to be placed on negotiating contracts and planning for the future with case mix changes and updated procedures.

“Most payers are unwilling to open up negotiations during a normal existing contract term,” she says. “Therefore, it’s critical to plan for the future. Even if you’re 9-12 months away, put it in your contract now.”

Adds Woodell, “If you have it carved out already, you can avoid when Medicare releases it and adds it to their list because they’re not going to be generous.”

To learn more about payer negotiations, contact Andrea Woodell. She has negotiated on behalf of health care providers and professionals for over 20 years, working in tandem with business offices to enhance collections.

In part two of Regent RCM’s blog series, Woodell details how to optimize annual contract negotiation increases and what is most overlooked regarding TPA & PPO contracts.

Click here to read part two!

revenue cycle management

3 Secrets to Successful ASC Revenue Cycle Management

Effective ambulatory surgery center (ASC) revenue cycle management can be hard to achieve, particularly as internal and external forces exercise their influence. According to Regent RCM’s Vice President of Revenue Cycle Management Michael Orseno, ASCs that pay attention to three key success factors are well-suited for the challenge.

“The first key success factor is driven by the healthcare industry’s shift toward value-based care,” Orseno says. “While assuming reimbursement risk from payers along with the responsibility to provide quality care has created some uncertainty and challenges for ASCs, managed care is in better hands. ASCs are equipped to both deliver quality care and manage costs more effectively than insurance companies ever were. But to be successful in revenue cycle management (RCM), ASCs need to become more adept at both managing costs and collecting additional revenue directly from patients, many of whom have selected healthcare insurance plans with lower premiums but higher deductibles.”

Another factor is also closely related to the evolution of value-based care. While many ASCs are succeeding at streamlining procedures and costs for procedures new to out-patient treatment, such as total joint replacement, payment bundling and reimbursement declines introduce new pressures. For example, payers are beginning to scrutinize payment of high-cost implant procedures and are driving a hard bargain when it comes to bundled payment agreements. As ASCs assume leadership of these bundles, a second key success factor is careful negotiation along the way. “You need to be diligent – check your costs, factor in economies of scale but also account for patient-driven variation, and renegotiate contracts annually,” Orseno suggests.

A third way to ensure successful RCM is to optimize business office staffing. “The best-run ASCs make sure their RCM staff is motivated and incentivized to aggressively pursue revenue, rather than just remaining content with the status quo,” Orseno says. “If an ASC’s staff is accepting only what the insurer pays and not fighting for what the center is contractually entitled to or higher than ‘usual and customary,’ that particular facility may be leaving a lot of money on the table.”

revenue cycle dashboard

Managed Care ABCs for Day-to-Day Payor Negotiations

While Medicare’s recent changes and emerging alternate payment models are top-of-mind for many in the healthcare industry today, it is equally important to pay attention to the day-to-day management of payor contracts.

According to Andrea Woodell, Vice President of Managed Care at Regent Surgical Health, even as MACRA (Medicare Access & CHIP Reauthorization Act) drives healthcare to performance targets it will take some time for those changes to take full effect. Meanwhile, healthcare facilities can’t lose sight of their routine negotiations. “It’s not magic, it just takes constant attention,” Woodell says. “One of the biggest mistakes that many centers make is not renegotiating contracts annually, or entering into multi-year contracts without factoring in incremental increases each year.”

Many ambulatory surgery centers in the industry do not revisit and renegotiate their managed care contracts annually to maximize their payments. Keeping reimbursement contracts current is critical for ongoing financial health of most centers. “If you’re not getting at least a 3% increase each year, you’re probably falling behind,” Woodell explains. “We advise centers to look at contracts annually. Identify the facility team member with the correct skill set and align their incentive plan to reward annual payer negotiations and go get those increases!”

Even for standalone surgery centers in saturated markets with no hospital partners, Woodell says, it is possible – and important – to negotiate minimum annual increases of 3%. SWB, new technologies and medical instrumentation, and implants drive up the cost of surgery every year. “I am working on a new project with development reviewing a center’s agreements for the lift I can bring; one of the contracts was last negotiated in 2002 and pays well below Medicare. If the agreement had been touched annually their payments could be 40% higher for that payor.”

Woodell outlines two key steps for centers looking to do a better job in this important area:

“One strategy we’ve found to be effective, is to involve a surgeon in the negotiations. Elevating the negotiation beyond your financial counterpart at the payer organization changes the dynamic. If you have your surgeon contact the VP over ancillaries on the payor side, it can completely change the conversation and may have the power to take you from a 3% increase in a contract year to 10 or 15%.”

Another of Woodell’s recommendations is to pay attention to your facility’s relationships with payors. “These relationships are more important than ever,” she says. “If they don’t like you, not only will they not help you, they will hurt you. – A good relationship with a payer means you understand their challenges as much as you want them to understand yours, and you help them help you by giving them good, objective data that they can take on to their interior team to help you achieve what you’re asking for.”

The bottom line in these contract negotiations, according to Woodell, is to demonstrate the value and cost savings that you’re providing to payor organization. Focused attention, surgeon involvement and strong relationships within the infrastructure of payer organizations can improve results beyond the standard response of “No, all I can do is 2%.”

To learn more about payor negotiations and how Regent RCM can help, contact 312-882-7228.

Revenue Cycle

Regent RCM and ZirMed Partner to Improve Revenue Performance

Authored by Vice President of Revenue Cycle Michael Orseno, Regent Revenue Cycle Management (RCM) this week released an article that outlines five ways in which Regent RCM and ZirMed combine to improve revenue performance.

“The ASC revenue cycle is complex and we both know that. Through our partnership, we leverage our expertise and provide ASCs with the support and technology needed to effectively manage the revenue cycle,” said Orseno. “With this article we drill down on five keys to getting paid quickly and efficiently.” Strategies include:

  1. Verify insurance coverage.
  2. Code claims correctly the first time.
  3. Minimize claim denials.
  4. Act quickly against denials.
  5. Arrange for/Collect patient out-of-pocket expense up front.

“Surgery centers need revenue cycle strategies that work and together with ZirMed, we deliver breakthrough revenue cycle management solutions that enable partner centers to collect every dollar they are entitled to,” added Orseno.

The article, Regent RCM, ZirMed Work Together to Solve ASC Revenue Issues, appears exclusively online at Becker’s ASC Review. Click here to read the full article.

Regent RCM’s Michael Orseno to Speak at Becker’s Second Annual CIO/HIT + Revenue Cycle Conference

Regent Revenue Cycle Management (Regent RCM) has been selected to participate in this year’s CIO/HIT + Revenue Cycle Conference hosted by Becker’s.

Michael Orseno, Vice President of Revenue Cycle at Regent RCM, will contribute to a timely panel discussion, Addressing High Deductible Patient Plans and the Evolving Role of Patients Becoming Payers, from 1:00 p.m. – 1:45 p.m. on Thursday, July 28.

“More and more, patients are responsible for handling most of the financial responsibility for their medical care,” said Orseno. “Moving forward, it is critical for revenue cycle leaders to focus on high deductible patient plans, and understand how these plans impact the revenue cycle.”

The conference takes place July 27-28 at the Fairmont Hotel in Chicago. Attendees can sit in on a variety of sessions, featuring 175 experts and revenue cycle leaders. Overall, there will be nearly 100 sessions over the two-day conference, with three full CIO/Health IT tracks, as well as three full revenue cycle tracks. Topics include:

  • The Transformation from Volume to Value and the Constant Movement and Impact on the Revenue Cycle—Wednesday, July 27, 8:05 a.m. to 8:45 a.m.
  • Adapting Best Practices for the Revenue Cycle– Wednesday, July 27, 8:50 a.m.-9:30 a.m.
  • Key Thoughts on Improving Revenue Cycle– Wednesday July 27, 9:50 a.m.-10:30 a.m.
  • The Biggest RCM Pitfalls– Thursday, July 28, 9:45 a.m.-10:25 a.m.
  • Post ICD-10—How is the Revenue Cycle Performing? – Thursday, July 28, 1:00 p.m.-1:45 p.m.

For more information on the conference and registration, download the brochure here.

Mike Orseno VP Revenue Cycle

ASC Revenue Cycle Benchmark Video Series–Number Nine: Business Office Audit

With reimbursement rates for ambulatory surgery centers (ASCs) shrinking, it is now more important than ever to know that every dollar available is being collected. Revenue cycle firms across the country offer business office audits, but Regent RCM’s audit is unique: it examines reimbursement, implants, coding, staffing and process flow, and is offered free of charge.

Regent RCM Vice President Michael Orseno recently hosted a series of videos examining nine benchmarks he and his team utilize to determine the health of an ASC’s revenue cycle. The ninth of these industry specific benchmarks is the business office audit, and provides an inside glimpse into where your surgery center stands with reimbursements.

“We’ll take a percentage of claims and determine if you’re being reimbursed properly,” said Orseno.

Not only that, Regent RCM also conducts a full coding audit and ensures all the cases are coded and billed correctly.

Click here to watch the video and learn more about this meaningful tool and the other measurements a Regent RCM business office audit looks at besides reimbursement, such as correct coding, implant revenue, staffing and business office processes.

Regent RCM recently released a white paper describing in detail nine ASC-specific benchmarks to accurately and consistently assess the health of a surgery center’s revenue cycle. Download the white paper here.

 

ASC Revenue Cycle Benchmarking Series Video

Regent RCM Focuses on Net Collection Rate in Webinar Series

In the final installment of Regent RCM’s three-part webinar series on ASC industry benchmarks to determine the health of a center’s revenue cycle, Vice President Michael Orseno and Director of Business Development Ed Tschan examine how to interpret these key performance indicators (KPIs) and what they are really communicating.

“Performance benchmarking continues to be an integral part of the Regent RCM team’s operations and its focus on continuous improvement,” said Tschan, who introduced the webinar and Orseno.

Orseno recapped the five ASC revenue cycle metrics mentioned in the second webinar but went into greater depth, discussing which ones could stand alone and which ones could be manipulated. He added a sixth ASC revenue cycle performance metric, net collection rate, which cannot be manipulated and explained its significance.

“It’s nearly impossible for office staff to manipulate the net collection rate,” said Orseno. “That’s why we sometimes refer to it as the great lie detector. All the other metrics we discussed previously can be manipulated. The only way this metric can be manipulated is by the person doing the calculation.”

Multiple attendees of the three-part webinar series commented that they plan to immediately incorporate ASC revenue cycle benchmarks to improve the health of their ASC.

“I think it was an awesome series with so much helpful information,” said one attendee. “I couldn’t believe all the insight our center can gain from utilizing these metrics. We’re running reports right now to see where we stand.”

Tschan stressed the importance of a revenue cycle audit that utilizes these recommended metrics to allow a center to confidentially capture existing performance metrics and get a solid sense of where they stand.

“What we’ve found historically is that most centers don’t have the luxury of having a strong financial contact that has performed revenue cycle audits before,” said Tschan. “We recommend that a center looks for an auditor specifically in the ASC community to provide relevant qualitative and quantitative insights.” He went on to explain how to find the right auditor, including four key areas that should be part of the audit and what to expect at the end of the audit process.

Orseno finished up the webinar by putting ASC revenue cycle benchmarks in perspective, noting that they are a valuable tool, but only part of the picture.

“We want to make sure that you have the tools in order to measure these metrics and to be able to identify how these metrics can be manipulated,” said Orseno, “but I think the most important message we want to put out is not to be blinded by these metrics, either one by one or altogether. Use them as a tool but ultimately, focus on the revenue due to the center.”

Click here to listen to the full webinar with detailed information on assessing the validity of these ASC revenue cycle benchmarks and how to be mindful of those that can be manipulated.

ASC Revenue Cycle Benchmarks Defined

Regent RCM Webinar Series Addresses Five ASC Revenue Cycle KPIs

In the second of Regent RCM’s three-part webinar series, Vice President Michael Orseno examined five ASC industry benchmarks or key performance indicators (KPIs) that measure the health of a center’s revenue cycle.

“Focusing on these industry benchmarks has been an integral driver of our team’s success and in the continuous improvement cycle of our partner centers,” said Director of Business Development, Ed Tschan, who introduced Orseno.

Tschan added that many revenue cycle conversations with ASCs frequently include questions regarding recommended metrics to drive the financial health of a center, whether metrics operate independently or in an integrated manner, what metric tracking capabilities exist and how to leverage the information to benefit the center.

Orseno addressed these questions while discussing five of the ASC industry benchmarks: Days Outstanding/Days in A/R, % of A/R greater than 90 Days, Denial% and Clean Claim, Charge, Claims Lag, and Statement Lag. He explained how to calculate the metrics, why the information is useful, the Regent gold standard for each of these metrics, and why keeping a center’s numbers within target parameters will maintain a healthy revenue cycle.

“Once your center is measuring these benchmarks, they should be monitored monthly, at minimum, possibly weekly,” said Orseno, in response to an attendee’s question. “For collections, a standard should be set as a goal each month and metrics should be looked at weekly. Other metrics, such as days in A/R should be monitored monthly.”

Click here to listen to the full webinar with detailed information on these benchmarks and answers to more questions on how to utilize them. To register for the final webinar in the series, held May 3, click here.

Regent RCM

Managing Overpayments

Vice President of Managed Care Andrea Woodell negotiates payer contracts on behalf of Regent RCM’s clients, attaining aggressive gains for both existing and new partners. For 20 years, Andrea has negotiated on behalf of health care providers and professionals, working in tandem with business offices to enhance collections. In this blog post, Woodell offers insights on how best to manage overpayments from payers.

Contrary to popular belief, overpayments are not welcome and can put a burden on billings and collections. “Surgery centers don’t want to be overpaid,” advises Andrea Woodell. “The accurate payment amount has to be determined and the difference has to be agreed upon and returned to the payer. It’s time consuming and costly to keep touching the claims.”

Woodell stresses to clients that overpayments are critically important because many of the contracts have language stating that if they are overpaid it should be reported to the payer and paid back within 30 days. Even if the payer doesn’t request a refund, the majority of contracts require a refund be issued.

Conversely, not refunding habitual overpayments can quickly add up to hundreds of thousands of dollars. Many states allow payers to go back three to five years to collect overpayments. A payer may hire an outside auditor to look for cash in the form of overpaid claims, typically attributed to the payers’ inability to administer their own contract terms accurately. No one wants to be on the receiving end of a letter stating they owe $250,000 back to Payer xyz and recoupments will begin in 30 days. “It’s a manpower intensive business,” said Woodell, “and when ASCs lack expertise or staffing, or don’t have the protocols and processes in place to manage overpayments, it’s a lose-lose situation.”

  1. Determine if the overpayment request is legitimate – “When a payer requests a refund, do your research,” advises Woodell. “Initial research is required to determine if the refund request is legitimate.” It is not uncommon for a self-funded group to hire a repricer who in turn requests a discount or refund not contractually supported. They just ask, and a facility with inexperienced staff may refund the monies accepting the request as legitimate without performing their own due diligence

The refund request may be appealed by the facility if a payer sends it because a claim was missing required authorization for service or was deemed medically unnecessary. In such cases, the center can provide supporting documentation to the contrary.

If the refund request is considered legitimate, Woodell summarizes the next two steps centers should take prior to returning overpayment:

  1. Determine if the overpayment amount is accurate – Start by calling the payer. “Ask the payer to explain how they determined the payment amount,” said Woodell, “then find out if the payer processed the claim correctly.” While we have made significant improvement in cleaning up the language in fee schedules, many still have verbiage that is confusing, misleading and open to multiple interpretations.
  2. Get the correct paperwork – If the payer confirms that they overpaid through a written request, and your contract supports their logic, then send the refund back to the payer within the appropriate timeframe per contract requirements. “Whether we’re dealing with clients, patients or payers, open communication always goes a long way.”

Determining overpayment is one issue, but according to Woodell, getting to the root of the matter is another. “I am currently working with a center that has overpayment concerns. I am modeling what they are being paid, what contractually we think they should be getting, and then working with them to get a new contract that tightens up the language and absolves them from recoupment,” said Woodell.

While there are consequences for non-payment, Woodell maintains that refunds don’t have to be difficult. “It’s all about establishing protocols,” added Woodell, “and at Regent RCM we have them in place for overpayment to ensure that we stay compliant and continue to foster long lasting relationships with payers.”

Is your center struggling with overpayments? Regent RCM can help. Call us today 312-882-7228.

 

ASC Collections

Diligent Appeals Process Accelerates ASC Collections and Minimizes Premature Write-offs

Revenue Cycle Supervisor Vianca Bautista has helped shape Regent RCM’s diligent appeals process designed to accelerate ASC collections and avoid premature write-offs. She supervises four revenue cycle specialists, while managing her own ASC client, so it’s no surprise that Bautista is highly skilled at getting claims paid. In the following post, Bautista shares her insights about successful insurance appeals, details about the Regent RCM appeals process and how diligence pays dividends for ASC clients.

“When a claim isn’t receiving reimbursement according to the contract or if it is underpaid, this triggers our diligent appeals process so we can get to the root of the problem and then pursue the expected payment immediately,” said Bautista. “Our process begins with a phone call to the payer and that takes place the very same day or the day following receipt of an underpayment.”

If the claim can be reprocessed with additional information, it’s sent back and Regent RCM’s revenue cycle specialist will then follow up 30 days later.

“These automated triggers, along with immediate follow-up fix most, but not all problems,” Bautista adds.

If the claim cannot be reprocessed, a first appeal is sent out and if the payer still maintains their position, Regent RCM will send a second appeal, and, on rare occasion, a third.

While no one can achieve a 100% clean claim rate, proper coding and using a robust clearinghouse to scrub claims prior to submission bolster success. The Regent RCM gold standard is less than 5% denials and a 98% clean claim rate.

“If there is a secret to our success, it is consistency. Our automation catches issues and we have steps in place that will get revenue cycle back on track,” stated Bautista. “We are determined to recover every dollar for our clients and write offs are a last resort.”

Are you interested in learning how Regent RCM revenue cycle specialists can leverage appeals to accelerate ASC collections and avoid premature write-offs? Call 312-882-7228.

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