By Angela Mattioda, Vice President of Revenue Cycle Services
Verifying eligibility, insurance verification, and obtaining authorization
are the first steps in better ensuring the viability and profitability
of a case. It is imperative that ASCs understand the importance of these
front-end processes and the overall effect on their bottom line.
By prioritizing benefit verification and authorization, ASCs will put themselves
in a better position to ensure they collect all the money owed for services
rendered. Here are six tips to help you perform these valuable processes.
1. Ensure your policies and procedures are current and adhere to best practices
Develop a list of your frequent payers' CPT codes that require authorization.
Don’t simply accept verbal confirmation from a payer representative
that an authorization isn’t required. It’s critical to do
your due diligence. That means those staff members tasked with completing
authorizations should understand your payer contracts and authorization
requirements. It is also best practice for a performing surgeon to understand
the codes that are authorized for a case in the event the surgeon performs
additional medically necessary procedures that were not initially authorized.
When this occurs, ask the surgeon to communicate the change to your staff
so you can immediately obtain a retroactive authorization. This is a great
way to help reduce denials and further optimize your process.
Finally, ensure you have a policy that clearly spells out the expectations
for patient financial responsibility.
2. Automate front-end processes for efficiency and accuracy
Some of the best outcomes for our clients come from using patient eligibility
and verification software to automate the verification and authorization
processes. If you use such an automated system, you will have the ability
to recheck benefits within 1-2 days of the procedure date. This will better
ensure the most accurate upfront collections from patients.
Automation also allows for a more streamlined process of sending notifications
to patients prior to surgery and providing them with options to pay for
their care in advance. Typically, a well-designed patient software system
will have the capability to track which patients opened their text/email
communications and which patients have prepaid their deposits.
Depending on your center's practice management system or clearinghouse,
it may be possible to leverage automation and use the solution's eligibility
verification and patient responsibility estimation tools. Be sure to obtain
all the necessary information and authorization requirements as these
systems do not have authorization capabilities.
3. Leverage authorizations to better ensure timely reimbursement and avoid
needing to rework the claim
There are some automated patient software systems that are making headway
in automating the authorization process. However, this still largely remains
a manual process.
In most ASCs, authorizations are typically obtained by the physician’s
office. Even when insurance verification and authorization are performed
by the physician’s office, it is still the responsibility of the
ASC’s business office to confirm benefits and authorization. If
there are issues with the information received from the physician’s
office, a conversation is necessary.
4. In the final coding, check if the CPT code changed from what was scheduled
It’s important to understand payer-specific requirements concerning
authorizations. Some payers will allow a retroactive authorization if
there is a change in CPT codes. Some payers require a retroactive authorization
to be completed within 72 hours while others may permit up to two weeks
from the date of service. Other payers require any code changes to be
handled during the appeals process. If a payer requires a retroactive
authorization and it’s not obtained within the allotted timeframe,
the claim will likely be denied and there will be little chance of getting
this denial overturned.
5. Make sure the authorization number is reported on the claim to avoid
Even when a case is properly authorized, there can be denials that delay
cash flow. Best practice is to include the authorization number on the
claim to help avoid delays with unnecessary denials.
Understand that obtaining an authorization does not guarantee payment.
There could be
clinical policy requirements that must also be met. Providing these requirements to the physician is
a vital part of ensuring successful and complete collections.
6. Aim to collect 100% of the patient expected out-of-pocket responsibility
without harming the patient’s experience
Give patients options when informing them of their required pre-procedure
deposit. These can include online access to pay the deposit, prompt-pay
discounts, funding options, and well-defined payment plan options. If
you have a high-dollar procedure and the patient chooses to pay via payment
plan, set up an auto-payment plan through your clearinghouse or credit
Hopefully these six tips help improve your ASC's success with verifying
eligibility, insurance verification, and obtaining authorization. Here
are a few more quick tips. First, allocate the time required for staff
to effectively check benefits and authorizations previously performed
by the physician’s office. Failure to perform this check or doing
so in a rushed manner increases the potential for mistakes that could
result in denials and a significant loss of revenue. Second, ask your
revenue cycle management provider to communicate any issues they observe
that relate to verification and authorization processes to help you make
any necessary improvements. Finally, it is advantageous to track denials/denial
reasons, patient upfront collections percentage, backend patient balances,
and refunds to help further identify where improvements can be made.