Protect Reimbursement 4 Ways as Payers Narrow Payable Diagnosis Codes

For ambulatory surgery centers (ASCs), it’s a “perfect storm” story: the number of Americans with knee osteoarthritis has doubled since the mid-20th century, affecting 19% of those 45 and older, and continues to grow as our population ages. Meanwhile, insurance companies are narrowing payable diagnosis codes for treatment in their drive toward value-based care. Today, surgeons need to prove patients have a very specific diagnosis of knee osteoarthritis before payers will preauthorize surgery, as “knee pain” is no longer an acceptable criterion for approval for many payers.

To help ensure ASCs avoid negative financial consequences of these trends, the experts at Regent Revenue Cycle Management have identified four key steps to protect reimbursement against denied preauthorization and payment when it comes to surgery related to knee osteoarthritis.

  1. Get the Diagnosis Right – As payers narrow the payable diagnosis codes, ASCs need to be aware of payers’ coverage and preauthorization guidelines, ensuring surgeons are aware of and using the acceptable diagnosis codes for each payer to indicate specific diagnoses. Aetna, for example, considers patients with mild-to-moderate osteoarthritis, with knee pain as well as mechanical symptoms, to be candidates for arthroscopic debridement based on medical necessity, but the payer considers the same surgery for persons with osteoarthritis presenting with knee pain only to be experimental. ASCs also should be sure to follow through with claims the physician’s office submits after preapproval so the diagnosis codes match.
  2. Negotiate to Avoid Preauthorization Denial – Since little recourse is possible after a preauthorization is denied, ASCs that include carve-outs for certain diagnosis codes when they negotiate payer contracts are a step ahead. Do this by pulling together evidence-based literature and letters justifying specific procedures and data on their cost and medical necessity to present to the insurance companies during the negotiation. Groups like the American Academy of Orthopedic Surgeons also provide resources on medical necessity and coverage for certain diagnoses. It is also important to stay current on updates to insurance company coverage, and to update your contracts to avoid losing ground.
  3. Track Processed Claims, Audit Payment Patterns — Especially for orthopedic and spine procedures, many orthopedic and spine codes aren’t clearly defined. Know them well, and keep track of processed claims against each. In addition, regular audits can help detect patterns such as minor errors responsible for denials or underpayment, and prevent similar future issues. Be sure to focus on both diagnosis codes used as well as final payment as you audit. Details matter, so consider having a professional revenue cycle management organization like Regent RCM review your contracts and help with the audit.
  4. Bundled payments – As ASCs experiment with new payment models that are directly tied to diagnosis, such as bundled payments, understanding the codes becomes even more important. Recent studies show 80 percent of payers find bundled payments appealing, and providers are beginning to embrace the new model as well. Make sure to stay apprised of any new changes or requirements that occur within the bundles, and the ASC and affiliated physicians are providing the right documentation and verification for the value-based reimbursement — if the diagnosis code is incorrect, the surgery won’t qualify for the bundled payment and the ASC could lose money.

For additional information on protecting reimbursement in today’s evolving healthcare payment environment, call Erin Petrie, Regent’s Director of RCM at (708) 492-0531 or visit www.regentrcm.com.

Focusing on Stewardship: Regent RCM’s R.I.S.E. Program

Regent Revenue Cycle Management’s R.I.S.E. program was created to develop a values-driven culture that helps us stay focused on our goal of leveraging our ambulatory surgery center (ASC) expertise, while providing consistent high-value customer service to clients.  While at the same time creating an environment that sets up our employees for successful and rewarding work.

In a four-part series, we’re highlighting our four corporate valuesRespectful Caring, Integrity, Stewardship, and Efficiency.  In part three of our series, we look at Stewardship, the responsibility to properly utilize and develop our people, property and assets while fostering a safe and secure environment.  This approach is a key part of why we can consistently outperform industry benchmarks and allow our clients to focus on high-value activities.

Stewardship is defined by Regent RCM as the ability to excel in five essential skills.  In summary, these skills are:

  1. Mentor others to promote personal and professional growth.
  2. Regularly provide information to create enterprise understanding around the clinical and economic performance of our business.
  3. Communicate difficult information in any direction to improve our business.
  4. Comply with both regulatory requirements and institutional policies and procedures.
  5. Promote and participate in quality improvement initiatives.

Our value based culture is crucial to ensure we consistently provide innovative, cost-effective billing and collection services for surgery centers.  It guides us in all that we do and is fully incorporated into how we effectively lead our employees.

Are you interested in working with Regent RCM?  Contact us today to learn about how you can join our team and make a valuable contribution to our partner centers.

Learn more about our first two parts of our R.I.S.E. Program:  Respectful Caring and Integrity.

Regent RCM Launches New Guide Empowering Surgery Center to Self-Audit Operations

As ongoing consolidation among healthcare payers squeezes surgery center reimbursements, periodic business office audits can be key to identifying a center’s financial stress points, strengths, and opportunities. Regent Revenue Cycle Management (Regent RCM), a leading provider of innovative, cost-effective revenue cycle management services exclusively for ambulatory surgery centers nationwide, recently published a new self-audit guide to help center administrators audit operations to ensure their ASC stays within compliance while producing maximum revenue.

“Conducting a self-audit is the fastest way for centers to get on track and stay on track,” says Erin Petrie, Director of Revenue Cycle Management at Regent RCM. “A routine audit gives your center the mechanism it needs to ask and answer the questions that lead to stronger financial health.”

Revenue cycle management for a surgery center is complex. In the guide, How to Self-Audit and Improve your ASC’s Financial Health, Regent RCM experts suggest ASC administrators examine four areas affecting the financial function of an ASC: reimbursement, coding and billing, staffing, and observation (workflow and process).

In addition, to bring clarity to surgery center billing, Regent RCM’s Petrie suggests centers monitor ASC-specific benchmarks such as accounts receivable days, net collection rate, statement lag and charge lag, for information to trigger a new audit.

“When you notice negative changes in important benchmarks, a business office audit can be the best course of action,” Petrie contends. “A full business office audit examines both quantitatively and qualitatively all components of the revenue cycle process to determine strengths and weaknesses.”

Click here to download the free guide.

Revenue Cycle Analysis

4 Key Areas Analyzed During a Business Office Audit

Ambulatory surgery center (ASC) administrators are charged with improving their ASC’s financial health and periodic business office audits are key to identifying, both quantitatively and qualitatively, a center’s strengths and opportunities.

On the surface, an audit sounds intimidating. But according to Michael Orseno, VP of Revenue Cycle at Regent RCM, it doesn’t have to be that way.

“We want our centers to maximize revenue and a routine audit is the fastest way to get on track and stay on track,” said Orseno. “The audit identifies issues – then working with our partner centers, we implement strategies and processes to correct them; it’s that simple.”

A Regent RCM audit goes beyond a traditional reimbursement assessment by examining four areas vital to the function of an ASC: reimbursement, coding, staffing and observation (workflow and process).

  1. Reimbursement. Regent RCM conducts a thorough review of a center’s billing and reimbursement procedures, including reviewing payor contracts. “Ensuring that an ASC is being reimbursed the full and correct amount per each procedure code for every case is one of the most important billing practices to maximize revenue for the center,” said Orseno. “Due diligence is crucial and for our partner centers, our team of revenue cycle specialists are intimately familiar with every payor contract.”
  2. Coding and Billing. Whether a center outsources its coding services or employs a certified coder, Regent RCM’s audit evaluates coding, determining if cases are coded correctly and billed properly. “We watch for inaccurate modifiers, which can negate or reduce payment on an otherwise clean claim,” noted Orseno, “and when applicable, we pay particularly close attention to implant coding errors.”
  3. Staffing. More business office staff does not always equal more efficiency, and striking a balance is difficult. Regent RCM’s audit diligently tracks business office FTEs in all of its facilities and compares facilities against the gold standard.
  4. Observation. Regent RCM’s expertise comes from exclusively developing, executing and refining revenue cycle management strategies. “Leveraging our collective experience, our team observes business office functions and processes and looks for inconsistencies and efficiencies,” said Orseno. “For example, a front office employee may be spending vast amounts of time verifying insurance benefits when this can be accomplished more efficiently with the use of technology.”

To learn more, read a case study revealing how an audit uncovered coding errors which led to recouping more than $590,000 in additional funds.

A recent blog highlighted what to expect from a business office audit, including Regent RCM’s methodology. Ready to schedule an audit for your center? Call (312) 882-7228 today.

Reasons to Outsource

4 Steps of a Regent RCM Business Office Audit

A Regent Revenue Cycle Management (Regent RCM) audit goes beyond a traditional reimbursement assessment. “The benefits of an audit are clear,” said Michael Orseno, VP of Revenue Cycle at Regent RCM, “and we ensure that facility time commitment is minimal. Our ASC-specific expertise allows us to complete the process in about two weeks.”

This is a quick turnaround, particularly considering the potential upside. In the case of one client, a business office audit uncovered coding errors which led to recouping more than $590,000 in additional funds.

An audit is comprised of four steps:

  • Initial Data Request*. Access to information is vital, and centers will provide a variety of data including but not limited to year-to-date case count and payer mix.
  • Initial Analysis. After collecting and reviewing initial data, Regent RCM selects multiple cases for a more detailed review and analysis.
  • Full Analysis. Pinpointing a number of cases, the Regent RCM team dives deeper using an internal audit tool set.
  • Once the audit is complete, Regent RCM will present findings on-site and provide detailed, strategic recommendations to ASC leadership.

In an upcoming blog, Regent RCM will further define the four key components of an audit including reimbursement, coding, staffing and observation (workflow and process).

Ready to get started? Call Regent RCM’s dedicated team today (312) 882-7228 to schedule an audit for your center.

Revenue Cycle Management Solution

4 ASC Revenue Cycle Things to Know This Month

Each month Regent Revenue Cycle Management (Regent RCM) explores the top news and headlines affecting the ambulatory surgery center (ASC) industry. This month in the news: St. George Surgical Center in Utah is committing to price transparency; The number of anterior cervical discectomy and fusion (ACDF) surgeries is rising as a result of the growing elderly population in the country; Four important legislative changes that impact ASCs; and a trio of ways to maximize reimbursement through anesthesia.

St. George Surgical Center is Appealing to Consumers through Price Transparency

As consumers seek low-cost, high-quality care, St. George (Utah) Surgical Center tells patients how much a procedure will cost before it is performed, which may be a trend that takes hold during healthcare’s continuing shift toward value. Click here to learn more.

Outcomes of Spine Surgery in an ASC

According to Dr. Anthony Asher, ASCA board member, director of the Neuroscience Institute at Carolinas HealthCare System and a senior partner at Carolina Neurosurgery and Spine Associates in Charlotte, North Carolina, the number of anterior cervical discectomy and fusion (ACDF) surgeries continues to rise as a result of the growing elderly population in the country and can be performed as safely as in an inpatient hospital setting . Click here to read more.  

Four Legislative Changes Impacting ASCs

CMS is bringing forth some changes that ASC leaders should note including an increase in ASC payment and 10 codes added to the ASC payable procedure list. Click here to read more.

Three Ways to Maximize Reimbursement through Anesthesia

As healthcare continues down the path of value-based care, ASCs take on more financial risk and must find ways to maximize reimbursements by improving performance regarding CMS’ ASCQR measures. Here are a trio of aspects of anesthesia to assess for quality. Click here to read more.

Regent RCM logo

ASC Revenue Cycle October Industry News Wrap-Up

Each month Regent Revenue Cycle Management (Regent RCM) explores the top news and headlines affecting the healthcare industry. This month in the news: The new MACRA final rule released by the Centers for Medicare and Medicaid Services (CMS) contains aspects that will impact ASCs; A new editorial weighs the pros and cons of “condiminiumizing” ASCs; Key specialties coming for ASCs next year; And a Deloitte survey reveals that a large number of physicians are still paid under fee-for-service payment model.

MACRA Final Rule Released

On Friday, October 14, 2016, the Centers for Medicare and Medicaid Services (CMS) released its final rule that established the new Medicare payment methodology for physician services furnished under Medicare Part B, known as the Quality Payment Program (QPP). The rule contains many components that will impact ASCs. The QPP was enacted in 2015 as part of the Medicare Access and CHIP Reauthorization Act (MACRA) and has two participation options for physicians: The Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs). Reporting for the first year of the QPP begins in 2017. Click here to read more.

ASCs: To Be or Not To Be “Condominiumized”

In an editorial, Stephen Sheppard, CPA, COE, reveals the pluses and minuses around the concept of “condominiumizing” ambulatory surgery centers (ASCs). This model involves separating a single physical ASC plant temporally among two distinct legal entities. For example, ASC-A could operate on Monday, Wednesday, and Friday, while ASC-B could operate on Tuesday and Thursday. Sheppard outlines the opportunities and obstacles. Click here to read more.

Key Specialties Coming for ASCs in 2017 

Ambulatory surgery centers are performing higher acuity cases and presenting opportunities for the healthcare system to provide quality care for patients at a lower cost. Paul Eiseman, vice president of business development at Regent Surgical Health, shares insights into specialties that have fared well in the ASC space and what is in store for 2017. Click here to read more.

Deloitte Survey: 86% of Physicians Are Still Paid Under Fee-For-Service Payment Model

Deloitte’s “2016 Survey of U.S. Physicians” survey has revealed that many physicians are reimbursed under a fee-for-service model instead of the value-based system in which providers are paid according to outcomes. Click here to read more.

Regent RCM’s Michael Orseno to Speak at MASA 2016 Education Day

Regent Revenue Cycle Management (Regent RCM) is again proud to support this year’s Michigan Ambulatory Surgery Association (MASA) Education Day conference.

Michael Orseno, VP of Revenue Cycle at Regent RCM, will present, ASC Benchmarking – Business Office Staffing & Revenue Cycle, on Friday, Oct. 21 at 9:45 a.m.

“One of the toughest challenges for any surgery center is determining if your revenue cycle is performing well,” says Orseno. “Until now, there wasn’t a comprehensive list of ASC-specific benchmarks, and how they should work together. We solved that challenge for our industry and we’re looking forward to a great exchange with center leadership teams. Not only will we focus on the nine benchmarks themselves, we’ll go deeper and discuss  how outside forces impact the numbers, how the benchmarks work together, and when the numbers lie.”

The conference takes place Oct. 20 and 21 at the Soaring Eagle Resort in Mount Pleasant, Mich. Attendees can sit in on a variety of sessions, with four breakout tracks: Administrative, Clinical, Billing and Coding, and Materials Management. For more information on the conference and registration, click here.

To learn more about ASC-specific revenue cycle benchmarks, stop by Regent RCM’s booth during the show. Click here to access Regent RCM’s video and webinar series, including instructions on how to calculate and measure what Orseno refers to as “the great lie detector,” the net collection rate.

To download your copy of Regent RCM’s white paper, Using ASC-Specific Benchmarks to Assess Revenue Cycle Health, click here.

Meet the Team: Kristina Bahula

In our ongoing Meet the Team feature, we introduce the many members of our team who make Regent RCM so successful. In our last post, we learned more about revenue cycle specialist  Ana Hernandez. Today we’ll shine the spotlight on:

Kristina Bahula

Hometown: I grew up in Downers Grove, a western suburb of Chicago.

What do you do at Regent RCM?

As a Revenue Cycle Specialist, I leverage my industry knowledge and ASC-specific training to lead all aspects of billing, payment posting and accounts receivable for a surgery center located in the Midwest. I diligently monitor ASC-specific benchmarks to ensure revenue cycle efficiency.

How long have you been working at Regent RCM?

Prior to joining Regent RCM in May 2016, I worked in the business office at North Central College in Naperville, Ill. for 10 years. I enjoyed working with students and helping them navigate complicated tuition payments, tax forms and reporting. In that role, I was able to hone my financial counseling and customer service skills which I use every day at Regent RCM.

What is your favorite part about working at Regent RCM?

Regent RCM encourages continuous learning for all employees, and challenges us to delve into all aspects of the healthcare industry in order to understand its intricacies. In particular, I’ve learned so much about the ever-changing field of health insurance, and I am grateful for that opportunity. Additionally, our corporate values RISE program teaches our team respectful caring, integrity, stewardship, and efficiency; these values benefit not only our team, but our partner centers and their patients.

What has been your greatest professional achievement?

In my career, I have always strived to be a committed, reliable and positive employee who goes above and beyond what is expected. My financial expertise has garnered many successful outcomes for clients and I look forward to learning and achieving even more as I continue to grow here at Regent RCM.

What is one fun fact about yourself your co-workers don’t know?

I have a slight obsession with sea otters! Not only are they adorable, but they are able to live in the ocean and walk on land. The life lesson that I’ve learned from the otters: It is important to be versatile!

Monitor

ICD-10, One Year Later: What’s the Impact on Revenue Cycle Management?

Healthcare providers went through a massive change in billing operations last year, as the shift from ICD-9 to ICD-10 went into effect on Oct. 1, 2015.

The new coding system brought with it not only an increase in diagnostic codes (from about 14,000 to over 68,000) and procedure codes (from 4,000 to 87,000), but also an increase in operational concerns for providers. Even though the ultimate goal of ICD-10 was to improve quality reporting and outcomes measurement, and also to bring efficiency to reimbursement processes, providers around the country feared the shift would cause productivity to plummet, as well as increased denials and reduced revenue.

Other developed countries such as Canada, Australia and various countries throughout Europe transitioned to ICD-10 years before the United States, and had a rough go of it. Canada’s healthcare system, for instance, reported a 50% drop in coder activity after the implementation of ICD-10 in 2001. 

But in the United States, the numbers did not suffer nearly as much. Initially, the industry reported a decrease of only 25% in charts coded per hour. And a year after implementation, coding productivity has stabilized and now providers report only a 10-15% decrease.

Optimally-trained billing staffs reduced the chance of negative impact on healthcare facilities. To that end, Regent Revenue Cycle Management (Regent RCM) provides tenured, proven revenue cycle management to ambulatory surgery centers (ASCs) with the skills to handle ICD-10 efficiently.

“Our team understands how ICD-10 can impact each segment of the revenue cycle from claim denials to days outstanding/days in A/R,” said Michael Orseno, VP of Revenue Cycle at Regent RCM. “It has been a year since ICD-10 implementation and our team has mastered the changes and updates. Your center may have a solid business office in-house who can sufficiently handle RCM; but if not, consider transitioning to outsourced RCM services with an external provider that is fully prepared.”

If you’re considering outsourcing to optimize your center’s revenue cycle, Ed Tschan and the experienced team at Regent RCM are available to your answer questions, explore a revenue cycle audit or discuss a cost benefit analysis. Ed can be reached directly at 312-882-7228.

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