Exercising Efficiency in the Billing Process

In today’s market of dwindling reimbursement, efficiency in all areas of the billing process is paramount.

You can’t expect random and unsupervised billing and collection procedures to produce a successful outcome. For the best reimbursement results, provide your staff with specific billing guidelines and a well-organized plan.

In the lingo of billers and payors, the term “clean claim” takes on significant meaning in relationship to getting paid promptly and accurately. Clean claim means exactly what it sounds like, a claim that has every “i” dotted and “t” crossed — so clean that the payor’s first line of defense, the automatic denial for errors, is bypassed.

The following suggestions for coding and claim submission will assist your team in submitting a clean claim.

Coding

To begin with, don’t over-economize by not providing your coders with necessary and up-to-date references. As well as CPT and ICD-9 reference books, your coder may need some specialty references to assist in optimizing coding and a product that helps prevent unbundling.

Secondly, the physician has a responsibility to provide explicit documentation in their operative reports to support all procedures performed. Areas that need special clarification include:

• Bilateral or multiple procedures 
• Implants used, complete description 
• Ancillary services (e.g., billable drugs, X-rays, certain therapy) 
• Diagnoses compatible to procedure and specific to contributing factors 
• Specific areas treated (e.g., medial compartment, lateral compartment, etc.) 
• Accurate identification of surgical site in order to apply appropriate modifiers (e.g., fingers, toes) 

Claim Submission

This is the area that provides the final checkpoint for providing a clean claim. The charge poster must be knowledgeable in several areas as they must make sure the claim contains all required components.

• Specific contract requirements for acceptance by payor 
• All numbers are included: NPI, ASC code, physician code, etc.
• Copy of operative note or invoice required 
• Procedure and diagnosis codes are complete with modifiers, etc.

It’s important to recheck the claim once more before submitting and then obtain a receipt from the clearinghouse or payor verifying the claim has been sent.

Just as important as getting the claim out the door is persistent follow-up to get it paid. The need for more aggressive collections have become the norm as payments are often delayed for a myriad of reasons. It’s important to realize that the collection process now takes almost twice as much follow- up and man-hours than in the past.

Collection Phase I

The first step in collection from third-party payors starts within 24 hours of submission. Confirm the payor received and accepted (without error) the claim. In most cases this can be done electronically.

The next step in Phase I is to check the status of the claim. When speaking with a payor representative, remember the following:

• Record their name and ask for payment status — do not accept “it’s being processed” as an answer 
• If claim status is not being delayed for lack of information — ask when payment will be sent 
• If claim is delayed — get specifics. If they need additional information the ASC can provide, send immediately 

As in all areas of the billing process, good documentation is absolutely necessary.

Payment Posting

When payment arrives, determine if payment accurately reflects contract allowance. If payment is wrong or denied, immediately call to resolve this problem. If resolution is reached, ask when payment is to be expected. If no settlement is achieved, start appeals process immediately.

After payment is posted, transfer to secondary insurance or patient guarantor and bill for balance on the same day.

Collection Phase II

The second phase of collections entails following up on all areas of unpaid services.

Third-Party Payers

Follow up on tickler files. All outstanding balances should be contacted at least every 30 days. Be sure and include workers’ compensation, automobile and attorney claims.

When you call an insurance company, save time by checking on all outstanding claims. Track and report any trends to management (e.g., Medicare computer system down for three days, ABC insurance company does not have the ASC listed as a participant, etc.)

Patient Accounts

If your state and your contracts allow upfront collection of unpaid deductible, it is suggested that you do this. Fees not collected in advance are often fees never collected.

Preferably, don’t offer payment plans longer than 90 days. However, if your center finds this necessary, make sure that patients understand the full amount will become due and payable if there is a default in payment arrangement. Be sure all patient accounts are billed every 30 days, including payment plans.

Audits

To ensure that your center remains compliant with insurance and Office of Inspector General regulations, it is important to audit your billing process regularly. Internal audits of coding and billing should be done at least monthly and an external audit annually is also recommended.

Efficiency is key to maintaining a positive cash flow. Hire competent, experienced staff and provide incentives for good performance. Supervision of the billing personnel by a member of management is key to keeping it running smoothly and working at their full potential. Keep an open mind to change and review the process frequently to see if improvements can be made. 

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