Medical surgeries cover a wide range of treatments and procedures. Some may be invasive, while others may be minor interventions that don’t require an invasive approach.
One of the common forms of medical surgery is ambulatory surgery.
Ambulatory surgery is a specialized, unique and important area of surgery today in outpatient settings. So it should come as no surprise that ambulatory surgery center billing is highly specialized as well. It has its own web of complexities and procedures. That need to be navigated precisely and accurately – easier said than done!
In this article, we’ll cover everything you need to know about ambulatory surgery center billing. And what makes it so complex. We’ll also look at some of the issues that arise around the billing process, as well as some industry best practices and ambulatory surgery center billing guidelines you can adopt to ensure your business doesn’t face any hiccups on account of ambulatory surgery center billing.
What is ambulatory surgery?
To understand ambulatory surgery center billing, we first need to know what ambulatory surgery is. Surgical procedures that do not require an overnight stay are known as ambulatory surgeries. Due to this reason, they may also be called ‘outpatient surgery’ or ‘same day surgery’.
Such surgeries don’t require a high level of post surgery care, making it possible for patients to leave the clinic or hospital after the procedure. Examples of ambulatory surgeries include carpal tunnel surgery, cataracts surgery, colonoscopy and various ENT (ear, nose, throat) procedures.
What are ambulatory surgery centers?
Ambulatory surgery centers are becoming more and more popular, with patients preferring their expertise and experience over general providers. As ASCs provide more extensive and comprehensive procedures, it leads to an increase in the trust and comfort patients feel.
What is ambulatory surgery center billing?
To put it in simple terms, ambulatory surgery center billing is the process of claiming payment for the ambulatory surgery treatment provided to the patient from their insurance company or other payer. And while the definition of ambulatory surgery center billing may be simple, the process is anything but.
There are many steps involved in preparing and submitting invoices for ambulatory surgery. It requires specialized knowledge of medical codes and staying up to date with regulatory requirements. In addition, ASCs need to maintain complete and accurate documentation of the entire ambulatory surgical process and services provided as that information is critical when preparing claims.
What are the components of ambulatory surgery center billing?
There are several parts to ambulatory surgery center billing:
- Documenting patient information: The process starts as soon as a patient walks into a healthcare center and seeks a consultation. Patient information collected includes personal details and insurance details.
- Insurance verification: The insurance information provided needs to be verified to understand.
- Medical coding: Medical coding professionals must then allocate diagnostic codes to the services provided, before submitting the codes to the medical billing system.
- Generating and submitting claims: Using the codes submitted, a claim is generated. Claims include the personal details of the patient and the cost of the medical services provided by the ASC. The claims are submitted to the insurance provider or other payer.
- Review and processing: Insurance companies will review claims submitted and evaluate whether the claim will be paid in full, part or denied. If the patient is required to pay a portion of the claim as per the policy, the insurance company will send them their portion of the bill.
- Paid claims, Denied claims: For claims that are approved in full or part, the insurance company will issue the payout to the healthcare provider. For claims that are denied in full or part, the insurance company will convey the decision and reasons.
- Appeals: The ASC will need to explore the reasons for the claim denial which could be due to incomplete or inaccurate patient information provided, errors in medical coding, or due to other mistakes or omissions found in the process. These errors or omissions are then rectified and a revised claim submitted.
The above is a brief overview of the ambulatory surgery center billing process. Appeals cause delays and take up valuable time and energy to fix. Denials also affect the efficiency of the organization and cause financial loss.
Common ambulatory surgery center billing and coding errors
Medical coding errors are amongst the chief reasons for claims to be denied. Here are some of the common coding mistakes and other errors ASCs make when processing ambulatory surgery center billing:
- Allocating incorrect codes: Using an incorrect, invalid or outdated code for performed. Procedures, or not providing a code at all will lead to denials. Assigning a code for a procedure that is cheaper than the one provided will lead to under billing. While assigning a code for a more expensive procedure can open up the ASC to claims of fraud.
- Unbundling codes: Ambulatory surgical procedures may be made of several components. Billing these components separately instead of as a single bundled code leads to a larger number of claims being submitted. Which is more time consuming and affects efficiency.
- Not complying with coding guidelines: Certain associations and centers have the responsibility for assigning. And updating regulations and guidelines around medical codes. These are regularly updated and failure to keep up and follow. The most recent guidelines will not only lead to claim denials, but can also open up. The ASC to regulatory inspections and penalties.
- Failing to prove medical necessity: ASCs are required to submit documentation that sufficiently proves the patient required the course of treatment provided. Failure to provide documentary evidence supporting the medical necessity can lead to claim denials.
- Incorrect or incomplete patient documentation: If the patient information collected is inaccurate or incomplete, the bill claim sent to the insurance provider will not be processed for payment.
- Seeking proper authorization: Insurance providers have their own guidelines, and policies have their own details. If the policy requires pre-authorization for a particular treatment or procedure and the ASC fails to get the authorization, the claim may be denied.
Each of the above can derail the claim process by themselves. Often, one can have a domino effect, leading to not just one error or oversight, but several errors and omissions which makes the rectification process even more of a nightmare.
Billing Strategies and Best Practices for Ambulatory Surgical Centers
Fortunately, by setting up ambulatory surgery center billing guidelines and processes. ASCs can prevent billing errors and ensure. They receive timely payment in full for the services they have provided.
- The correct code, at the right time: Before a claim is submitted. ASCs should ensure each and every code is checked for accuracy and relevance. This also requires keeping up to date with changes to coding regulations and guidelines. As well as using the correct modifiers. ASCs may need to run staff training and education programs. to ensure they have the necessary expertise to do their jobs.
- Correct and complete documentation: From the very beginning, each and every detail around patient consultation, treatment, medication, aftercare and other elements must be properly documented and on time. Having the proper documentation ensures not only are there no errors in the claim, but also ensures ASCs can provide the necessary documentation to justify the procedures undertaken.
- Claim submission and dealing with denials: Claims have to be submitted on time and may require regular follow ups to ensure the insurance provider or payer processes and makes the payment promptly. In case of delays, reminders may have to be sent. Where the insurance company asks for more information, denies a part or the whole of the claim, the ASC must have an established internal process to assess the situation, provide the necessary information and otherwise deal with it efficiently and without delay.
- Keeping up with regulatory guidelines: As mentioned earlier, medical codes and other regulatory guidelines are constantly changing. ASCs should monitor any changes to the rules and adjust their own internal practices and procedures to ensure compliance. It is important for ASCs to be proactive rather than reactive as preventing errors is much better and efficient than fixing errors.
- Upscaling technology: Several softwares are available for ASCs to modernize and automate their billing and revenue management workflows, support with project management and reduce duplication of work. Tech systems have inbuilt mechanisms to cross check information, automate claim submissions and more. By adopting the right technology for the practice ASCs can have a much faster and more efficient revenue collection system.
- Reviews and audits: ASCs should consider adopting a regular review and audit process that identifies and analyzes key performance indicators (KPIs). And compares them with industry benchmarks. By studying data, ASCs can establish. Whether there is a particular pattern of performance and denials. What steps can be taken to prevent recurring issues, and prevent issues from arising in the first place.
The above are some of the established best practices and procedures that ASCs can use to improve their billing services. In addition to the above and based on their own realities. ASCs can identify and establish their own strategies that further benefit the practice.
Ambulatory surgical centers are an important part of the healthcare service provider universe. These specialist organizations provide comprehensive and extensive surgeries that don’t require overnight stay.
Ambulatory surgery center billing is just as specialized as the procedures themselves. The billing department of ASCs. Need to have knowledge of the complex procedures and must be able to distinguish between procedures. They need to be aware of the relevant codes and guidelines, and always stay on top of regulatory requirements.
By following the best practices provided above, ASCs can prevent common issues that affect numerous ASCs around the country. It should be noted, these suggestions are by no means exhaustive. ASCs should look at their own practice, the procedures they follow and the challenges they face and identify key problems. By finding solutions to eliminate issues, ASCs can have a healthier financial bottom line and be set for success.