Business Advisor: Chase Every Dollar

When I founded the Atlas Surgical group of ASCs 15 years ago, we outsourced our billing operations. Our collection rate was about 80%, which was acceptable, but not stellar. I came to realize that outside firms are “one-click wonders” — they’ll submit your claims and get back the easy money that commercial insurers and Medicare are likely to pay anyway. Collecting the other 20% is the key to maximizing your revenue cycle management and requires heavy lifting.

These difficult dollars can include an insurance company asking for patient records before they pay a portion of your claim, payers wrongly contending you’ve submitted duplicate charges, your facility submitting a wrong CPT code or failing to obtain prior authorization before surgery. Insurance companies will pay for these claims, but you need to chase every dollar.

On the surface, working with a third-party billing company make sense. It costs less than employing a full-time billing team, and controlling staffing expenses obviously helps maximize profits. But what about the 20% of the reimbursements you’re not getting back? Getting the remaining amount from payers and patients takes time and effort, and companies getting paid $24 an hour that get 6% or 7% of what they collect often don’t bother with challenging reimbursements. That’s why we moved our revenue operations in-house about 10 years ago. Our collection rate is now at 99% thanks to efforts we made to maximize collections and increase profits:

• Do the upfront work. For every case, follow a set of standardized steps: verify a patient’s insurance, check the benefits that go with their plan and confirm the amount of the deductibles and co-pays and whether prior authorizations are needed for any service you are about to provide. If you skip or miscalculate any of these steps, you’re begging for denials from payers. No case should proceed until all four of these components are completed.

• Submit accurate claims. Most reimbursements consist of the professional fee for the surgeon, the facility fee, the anesthesia fee and sometimes a fourth pathology charge if you’ve taken samples from the patient. When you submit your charges for these services to a clearinghouse, your coder must attach the correct CPT codes or you’ll have trouble obtaining timely reimbursements. You have three months to submit a bill, but we try to get ours out within two days of procedures being performed with the aim of getting the reimbursements back in two to three weeks.

You need to know all the CPT codes for each service line in your facility.

Surgeons must be engaged in the claims process. They need to know the CPT codes for every procedure they’re performing and submit them in their notes to the coders in a timely fashion. I routinely meet surgeons who don’t know even their basic CPT codes, and in the process are losing significant sums of unclaimed revenues. They also need to be well-versed in the distinct aspects of medical management, including billing and collections. It’s much harder to get paid if you miss the 90-day deadline to file a claim. Having surgeons on board to submit their codes as soon as possible after their procedures will ensure deadlines are hit. Your facility’s coders are the ultimate experts and will go back to the surgeons if something doesn’t look right with a claims submission before it gets shipped, but make sure their job is as easy as possible by submitting correct and competent information to them on the front end.

• Get involved. You need to know all the CPT codes for each service line in your facility and oversee the financial aspects of every case on some level. When a patient has an issue with a deductible or co-pay, I get involved because even though that might seem like a task to delegate, it’s not. I’m the one who insists to our business staff, or directly to the patients, that we need to get as much of the deductible up front as possible before a case commences and bill the rest — the smallest amount possible — afterward.

The final aspect of chasing the difficult dollar comes after you identify the last 20% of uncollected amounts. And that is where the combination of good captaincy and diligent staffing comes in. You need to keep going back to each insurance provider on these claims until every account is paid or resolved. 

If you follow these steps, you’ll exponentially increase the amount of easy money you’ll collect and decrease the difficult dollars you’ll have to chase. Having an efficient and streamlined revenue cycle management process will make your life immeasurably easier and your facility that much more profitable. OSM