The goals of an ambulatory surgery center’s (ASC) claims process is to submit as many clean claims as possible and increase the efficiency of the RCM pipeline. In a perfect world, there would be no claim denials and all submissions would be clean. Although this scenario would be impossible to achieve 100 percent of the time, Regent RCM Vice President of Revenue Cycle, Michael Orseno, gives insight on how to work, track and ultimately avoid claim denials.
Set a High Standard
There are a number of factors that go into submitting a clean claim — coding the right diagnosis/CPT codes and selecting the correct modifiers for example — and one small oversight could result in a claim denial. Regent RCM strives for 97 percent clean claim submission, the gold standard in the industry. Denials can be avoided by setting up a thorough claims-editing process, leaving ASC administrators to concentrate on other non-business office activities.
The most efficient billing process is to send claims through a robust clearinghouse complete with standard front-end edits that also allows users to setup customized edits. Edits will kick back, or “scrub”, claims not meeting certain criteria, allowing users to easily correct the claim prior to sending to the payer. For example, standard clearinghouse edits will catch a claim that has a Medicare ID number missing the alpha suffix. Customized edits, such as payer-specific modifiers can also be put in place to prevent the same claim denial in the future. If claims are scrubbed before being sent to the payer, it will save your center a 30-day claim denial cycle.
Learn from Mistakes
It has been said that the best way to avoid mistakes is to make sure you don’t make the same mistake twice. Regent RCM conducts vigorous research on denied claims to determine root causes and detect common patterns. Sometimes the back office discovers that a payer is consistently rejecting a specific procedure or implant code. Research concludes that this payer may accept a similar code for the same procedure or implant that another payer may not. This simple but time consuming step is often overlooked, but can prevent the same claim denial in the future.
It is important to foster open communication between front and back office, so when a common pattern is found, it can be communicated and prevented for future claims. In the example above, the back office would notify the front office of the correct way to input a Medicare ID number. Something as simple as a number in place of a letter in an ID can significantly inhibit the claims process. Do the research, find the patterns, and set up edits to prevent future denials.
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