Regent Surgical Health’s Partner Centers

Case Study: RCM audit provides pivotal step to greater financial performance

SITUATION

In February 2014, Regent RCM conducted a revenue cycle audit of one of Regent Surgical Health’s partner centers. During the process, a representative sample of cases was selected according to the specialty and payer mix of this particular ambulatory surgery center. A full review of the ASC’s billing and reimbursement procedures and practices was also conducted.

Taken together, these findings typically provide a comprehensive snapshot of an ASC’s overall billing, collections and reimbursement performance. On this occasion, the process also identified an important clue as to why this center was underperforming financially and opened the door for significant RCM improvements to be made.

Billing for surgical centers

SOLUTION

During the RCM audit, Regent discovered a claim that included a modifier billing error. Upon further review, Regent also discovered that the error not only impacted the reimbursement of the specific case in question, but likely many more.

Based on these preliminary findings, Regent developed the following strategy for identifying and correcting the issues:

Contract review: Many insurance contracts have payer- specific billing provisions that an ASC must follow. In this case, no such provision existed within the payer contract.

RCM process review: The ASC’s billing staff was interviewed to determine if any extenuating circumstances contributed to the error. For example, was this a simple mistake? Or a larger training issue that must be addressed?

Conduct expanded review: To determine if a billing error was an isolated mistake, the audit was expanded to include all claims that were billed with the errant modifier.

Educate staff: After reviewing more than 20 cases, the error was identified as a training issue with the billing staff. Select employees were provided the appropriate training and new procedures were established moving forward.

Review previous cases: An equally important step is to review old claims that also may include the modifier billing error. Each payer contract was reviewed by Regent to determine if corrected claims could be resubmitted. Regent also provided a list of recommendations to the ASC’s administrator for refiling these claims.

RESULTS

Within two business days, the ASC’s staff corrected and rebilled for the cases that included the error – all during the course of regular working hours. Regent also continues to monitor the ASC’s modifier usage, proactively setting the stage for the quick resolution of billing errors and fewer claims corrections.

To date, the ambulatory surgery center has collected more than $590,000 in additional funds as a result of this audit and rebilling effort. Spot-check audits also have yielded an additional $130,000 in unclaimed revenue.