Struggling Ambulatory Surgery Center Improves its Monthly Collections by 40%
The Client
The client is a state-of-the-art neurosurgery, neurology, and pain management group that operates an Ambulatory Surgery Center (ASC) in Beaumont & Shenandoah, Texas.
Business Challenges
As per Beckers Healthcare, Ambulatory Surgical Centers (ASCs) will be extremely successful in the coming years — thanks to trends like expanding offered procedures, increasing reimbursement for ASCs, growing consumer demand, and migrating care delivery. However, despite the tremendous potential, ASCs face numerous revenue cycle challenges like the time taken to bill services provided, increased denials cases, and failure to follow-up after the submission. Like many ASCs, our client couldn’t realize their true revenue cycle goals, due to an inefficient claims cycle, higher-than-average claim denials rates, improper medical coding, and lack of follow-ups on denied claims, leading to razor thin margins for the facility.
Solutions Delivered
The group sought a partner with proven ASC Revenue Cycle Management expertise to improve medical coding and billing accuracy and reduce denials to accelerate reimbursements. We broke down these complex sets of interrelated challenges into smaller segments to provide a comprehensive denials management and medical and coding billing solution. After an in-depth analysis through our in-house proprietary AI tool, HealthX, we realized three areas that needed maximum attention-
Reducing Lag Days
Reducing Denials
Providing high-quality work across all RCM functions
(coding/billing/AR)
Results in hand, we showed practice leaders what they were collecting and cross-referenced that with what the insurance payers like Medicare and BlueShield typically pay.
A) Finding and eliminating errors: We were seamlessly able to ascertain common errors made in the facility’s billing, such as:
Non-specific diagnosis code
Incorrect modifiers
Incorrect revenue codes
Non-specific supply codes
Using more specific supply codes (e.g., C1713) helped reduce the facility’s high use of unspecified supply codes (e.g., L8699).
Over-coding
Medical billers were using CPT codes included in a larger service, such as decompression codes 63075 with fusion code 22551.
Under-coding
Billers were missing additional reportable services like the application of bone marrow in major procedures (CPT 38220 and 20939) and reporting each additional peripheral nerve injection separately (CPT 64450).
B) Submitting clean claims, the first time: We identified and set up multiple coding and billing edits in the PM system to empower it not to let a faulty claim go out. This immediately impacted on the clean claim ratio and how quickly the practice was getting paid. It reduced lag days and the cycle of submission, rejection, editing, and resubmission that would otherwise create months of delay in payment.
C) Using analytics for payor trend analysis: Using HealthX, we also analyzed the plans and payors who were not paying or underpaying. For instance, for the client, BlueCross/BlueShield (BCBS) – the facility’s largest commercial payor – was denying nearly all claims for one physician. Upon further examination, we discovered that the physician was not in-network for BCBS. After enrolling the physician, they saw fewer denials and improved outcomes for specific procedures.
Outcomes
Through our analytical, data-driven and systemic RCM approach, the Texas-based Ambulatory Service Center showed great results by Q4 2021, like in average monthly collection, lag days and denials rate.
