ASC RCM Quick Tips: 4 Tips to Improve ASC Implant Billing and Collections

By Lea Young, Director of RCM Engagement and Quality Assurance, Surgical Notes

1. Develop payer reference tool. Create a contract matrix your staff can utilize during charge entry, posting, and accounts receivable (AR) follow-up. The contract matrix should contain the following:

• If implants are payable.
  • Implants should be billed per the specific contract requirements (e.g., if the payer will reimburse 110% of cost, that should be the charge amount).
  • If implants aren’t payable, they should be adjusted off as a contractual adjustment at the time of billing.
• If there are threshold requirements.
  • Review the contract to determine if the threshold is in aggregate or individually.
  • If the implant doesn’t meet the threshold requirements, it should still be billed and contractually adjusted at the time of charge entry.
• If implants are reimbursed at a percentage of charge or invoice cost.
  • If the implant is reimbursed at cost, the charge should be the invoice cost.
  • If there are no contract-specific requirements and the implants pay a percentage of the charge, the markup should be greater than 2x invoice cost, depending on the percentage of reimbursement.
• If the payer allows the reimbursement of shipping, handling, and taxes.
  • If the payer reimburses for shipping, handling, and taxes, this amount should be included in the markup.
  • If the payer won’t allow shipping, handling, and taxes reimbursement, the markup should not include these amounts.
• If the payer requires an implant invoice.
  • Determine whether the payer will accept the invoice upon claim submission (if the invoice is available) or if they require the invoice to be submitted with an appeal after the procedure is paid.
  • Best practice is to not hold the claim for the manufacturer's invoice.
• The billing requirements.
  • Some states have specific requirements to get implants reimbursed. For example, New Jersey contracts call their implant reimbursement program "trailer billing." Trailer billing is when the payer will adjudicate the claim and pay the procedure and then require billing of the implant invoice.
  • There may be contract-specific language where implants are considered inclusive, except for carve-outs or case rate procedures.

2. Reduce invoice delays. One of the biggest challenges for centers is when a carrier requires an implant invoice to process and reimburse the claim. Typically, device vendors submit their invoices 2 to 4 weeks following the service date. Claim submission should not be delayed until the invoice is received. Instead, the implant cost can be calculated using the purchase order and the claim submitted for processing. This process will reduce the likelihood of timely filing denials.

3. Avoid unspecified HCPCS codes. Before the claim is submitted to a carrier, or when working an appeal, review your implant HCPCS code. If a generic code was used (e.g., L8699), check to see if a more specific code can be used or ensure you are following the payer's specific requirements.

4. Strengthen workflow. Ensure your staff works on denials, correspondence, and medical record requests daily. Working your claims and denials timely will allow for smoother cash flow and prevent revenue leakage caused by timely filing denials.