Maximizing Reimbursement and Increasing Efficiency in the Revenue Cycle


By Maggie Dean and Regina Boore

With the cost of doing business steadily increasing, it is more important than ever to take advantage of every opportunity to maximize reimbursement and increase efficiency in your ASC’s revenue cycle. The following tips can help ensure your facility is on the right track.

Know Your Contracts

Invest the time to educate your coder, biller and payment poster to ensure revenue does not slip through the cracks. Billing staff should be familiar with your payor contracts to maximize your revenue opportunity. If a payor disallows a code, or reimburses it below your negotiated rate, an uninformed payment poster may believe the claim was properly paid. It can be intimidating to call and argue underpayments with insurance companies. Arming your staff with the knowledge of what your facility should be paid for each service is a must. A fee schedule with all your contracted rates is an important reference that should be available to your business office staff. The schedule should also include information such as reductions for additional procedures.

Reassess your contract reimbursement for each procedure annually. Some payors base reimbursement on a grouper system. This methodology may result in costly procedures being reimbursed at a rate significantly less than Medicare and other payors who base their schedule on the Medicare fee schedule. Create a spreadsheet comparing Medicare’s current reimbursement to your other payors' contract rates. This is a good way to identify codes that may be underpaying. Take a closer look at these codes and compare the reimbursement to average cost per case for that procedure. Note any concerns and initiate renegotiations four to six months prior to your contract's renewal date.

Encourage Communication Between Your Billing Staff and Materials Manager

Ongoing communication between these two key players can help identify high-ticket items that may be separately reimbursable. Cost per case, even for the same procedure, can vary based on surgeon preference. Your coder will not be able to glean all of the supply information from the intra-operative record alone. Therefore it is important that expensive supply items are identified and somehow communicated to the billing staff. Remember that even though you cannot bill Medicare separately for these items, some of your contracts may provide reimbursement. If the supply item is not reimbursable, does the procedure payment cover the cost of the procedure including the high-priced supply? If not, try to obtain a carve-out during your next contract renegotiation.

Adding a New Specialty

It is especially important to keep an eye on your contracts when adding a new specialty. Contact the contracting manager at each company to make them aware beforehand. Ask for a fee schedule for the new codes you will be billing. Research what new disposables, supplies and implants will be used and if they are separately billable under your current contracts. If your staff is not familiar with billing the new specialty, try to network to get tips from someone with experience in that field. You will most likely have to renegotiate your contracts at this point. Keep notes of your concerns for each contract and a spreadsheet comparing each contract allowable as a comparison.

Insurance Verification

Insurance should be verified at least five days prior to a patient’s surgery date. As soon as insurance is verified, a patient’s estimated deductible/coinsurance or copay portion should be calculated. A phone call placed at least three days prior to the date of service is courteous and allows time to prepare if the amount is high. In lieu of payment plans or allowing a patient to pay after insurance is billed, consider signing up with a healthcare financing company and offer that as an alternative if a patient states they cannot pay on

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