Collections Issues for ASCs

Check the explaination of benefits (EOBs) closely for denial reasons. Correct missing or incomplete information on claims and resubmit claims for reconsideration. If a claim has been denied, proceed with their appeals process. Be aware of the payor’s requirements for submitting “corrected claims” and appeals.

Patient Collections

For patients with poor payment habits, contact them at home or work to discuss owing balances — but remember, in most states it is illegal to make calls after 9 p.m. When patient accounts get too old, turn them over to a collection agency. Have a relationship with a good collection agency, and ship accounts out to them when the account is no older than 120 days, but 90 days is better. The sooner the collection agency receives it, the fresher the information will be and the greater your chance will be of collecting the money. Some cases go all the way to court. The ASC’s board needs to be involved with decisions about collection procedures. Collections procedures should be fair, consistently followed, and must be in writing.

Appeals of Denied Claims

Denied Claims are always an unwelcomed challenge. Just be aware that the insurance company is banking on your giving up. However, it’s just a fact that some claims are going to be denied, and we encourage vigorous appeals when this occurs. Persistence and tenacity pays off. All payors have appeal procedures; however, these procedures can differ greatly from payor to payor. Review the payor’s appeal procedures and follow them to the letter. Pay close attention to timelines. Many appeals are unsuccessful due to not following their guidelines closely or missing deadlines. If your facility does not have a contract with the payor and your claim is denied, your appeal rights will likely be significantly more restricted.

Medicare’s appeal guidelines are as follows:

Start with a reopening request, and if unsuccessful, proceed with the Medicare appeals process:

>>redetermination by Medicare contractor

>>reconsideration by a qualified independent contractor

>>hearing by an administrative law judge

>>departmental appeals board

>>U.S. district court review

With Medicare appeals (as well as appeals to most other payors), it is very important to include some sort of additional documentation to support your position with each higher level of appeal. If your claim has been denied, it is possible that the surgeon’s claim is being denied, as well. Sometimes, if the surgeon writes a letter of medical necessity with more information, it will turn the denial around.

If the denial reason involves the ASC’s procedure coding not matching the coding on the physician’s claim, research what codes the physician billed and see whose coding was correct. If the physician’s coding was incorrect and you feel that your coding is correct, pursue your appeals based on your correct coding. Do not follow the physician’s coding if you know his/her coding is incorrect. The ASC is responsible for their own coding and if the physician is wrong and gets in trouble, the ASC will be safe billing the correct codes.

The collections process can be laborious. However, persistence and tenacity pays off, and it is your facility’s money you are fighting for, which makes it worth the fight.

Stephanie Ellis, RN, CPC, is president of Nashville-based Ellis Medical Consulting, Inc. She can be reached at SEllis@EllisMedical.com.