Q&A with Ann Marie Thom, Client Service Manager, and Brandy Hente, Revenue Cycle Manager, for Surgical Information Systems
Ann Marie Thom, Client Service Manager, and Brandy Hente, Revenue Cycle Manager, for Surgical Information Systems (SIS), recently hosted a webinar on "Keeping the Money Flowing: Improving Your ASC Revenue Cycle Processes." During the program, they provided an overview of the ASC revenue cycle process and its workflows, explained what enables ASC revenue cycle workflow success, identified common problems that disrupt revenue cycle workflows and stifle performance, and shared recommendations for addressing shortfalls and improving workflows.
The audience was engaged and asked great questions during the Q&A portion of the program. Below are the audience's questions and Ann Marie's and Brandy's responses, edited for readability. The webinar can be viewed on-demand.
Q: What is a good way to monitor the types of claim denials received by our ASC to ensure the appropriate front-end and quality control measures are in place?
A: Start by leveraging your clearinghouse. Through your clearinghouse, you should have the ability to monitor and categorize denials. Break down your denial types, like coding errors, missing information, and pre-authorization. Then use subcategories to drill down further. For example, if you have coding errors, could it be a particular CPT code that is causing the issue? If so, track the trend.
Create a system that logs the denials by category reason, and make sure you have one or more staff members that can pull that data for you and help you monitor and address the problems.
Also, track your denials over time. Use a dashboard to track the frequency and the types of denials. Are you seeing a certain increase in denials and why? Then identify the root cause of those denials. Is there an internal process creating the denial? If so, work to determine how to resolve it.
Q: How frequently would you recommend ASCs undergo a third-party revenue cycle audit?
A: The answer will depend on your facility. If you have a new facility, you probably want to consider scheduling an audit between 60 and 90 days after opening. For any ASC, you should never go six months without securing an audit. That is a good amount to review. A year's worth of data is a lot of information to assess.
When undergoing the audit, make sure the auditor is drilling down into the appropriate processes for your ASC. Be mindful of the fact that the external auditors don't know your team. Let the auditors know your workflows. You could have a situation where your operative notes largely dictate your coding. You may not use history and physicals (H&Ps) for your initial coding, but maybe you use them for local coverage determination. Conversations with auditors about your workflows and processes are key.
The key takeaway: Do not put off an audit. If you do, you may find that your ASC was out of compliance for a long time. Those audits are a good way to find and resolve compliance issues.
Q: Given the number of steps in the ASC revenue cycle process, how can we best audit all of them?
A: The key step here is to create a systematic and risk-based approach to ensure that an audit won't be a burden to your team. Sometimes when you're compiling data, it can take your team out of their normal workflow as they need to pull documentation. If you're still doing paper charting, and if you need to get all this information together to get the audit process going, someone's work is going to be impeded. Do your best to make sure that work is not a burden to them. Break down your revenue cycle services in phases. For example, the first phase is your pre-claim submission. That includes your patient scheduling, registration, insurance verification, and your authorizations.
The next could be your claims submission process. That would include your charge capture, coding and claim submissions, post-claim submissions, and then your payment posting, denial management, and accounts receivable (A/R) follow up.
Lastly, your patient collections, which are key. That would include your patient billing and collections processes.
Then you need to create a risk-based audit plan. What that would do is identify high-risk areas that are prone to errors or those that may have great financial impact for you, such as the coding authorization process or denial management. Set priorities for these areas, and rank each of those priorities based on their risk level. Then look back at your historical performance for your facility.
Higher risks need to be audited more frequently. Create metrics to evaluate performance. For example, with insurance verification, what's the timeliness of their process? What is the timeliness of authorization denial issues? This is all key to ensuring you can audit them.
Auditing is not going to be a cookie-cutter process, but at least you can bite off small pieces at a time so that you do not feel overwhelmed by the experience.
Q: How far in advance should we verify and re-verify patient insurance information?
A: Benefits are always changing, so a good rule of thumb for the initial verification is to avoid going out past two weeks in advance of the procedure. Ensure your insurance verifiers stay within that two-week window for the initial verification. Any further out than that and you increase the likelihood of running into other claims processing which could change the patient's benefit total and reduce the amount you can and should collect from the patient.
Concerning reverification, I would go at least two days prior to that procedure because you want to allow yourself time to resolve any issues that may arise if something changed since the initial verification. If you are reverifying the morning of or at 5:00 p.m. the day before the procedure, you are not giving yourself much time to address the issue.
Q: What should we do if one of our physicians is the cause of revenue cycle bottlenecks?
A: Data here is the key. Identifying that a physician could be your bottleneck is great, but then you need to determine how you will have that conversation with them. What you do is provide reporting data. Perhaps it's a physician who never gets their dictation done within a week, or you're always chasing them, or you're always having to walk into their office and ask them to sign something before they leave for the day. It's important to share the data. Your days to bill, which is a big metric for the ASC revenue cycle, is going to be one of those components you can share with the physician and let them see over the month how long it's taking for their office to provide you with a dictation.
Remember: The sooner you can get the dictation, the sooner that case gets coded and then billed. Industry standard for days to bill is anywhere between four and five days. Internally at SIS, we try to do it between three and four days, and sometimes we've even had days to bill come in lower.
Back to the challenging physician. Your goal is to communicate the data and quantify it. Having a sit-down conversation with a doctor is great, but if they can see how the bottleneck they are causing is impacting the ASC and its revenue, that will help drive the conversation with them and help them make necessary changes.
Q: How can we establish reasonable expectations for our ASC business office staff?
A: It starts with defining those goals and communicating them to your team. You don't want anybody to assume they're doing a great job — that they're hitting all of their goals and that you have no problem with their work — if they are not. You also want to also make sure that they've received the proper training and resources that should enable them to hit their goals.
Encourage your team to give you feedback. How are they feeling about their training? Their goals? Their expectations?
The big thing about setting goals is to try to be realistic. Make sure staff are challenged to their full potential, but they're not completely overwhelmed. Doing regular check-ins can also be helpful. Set aside time to discuss goals.
Also bring your teams together. If you have an A/R team, bring them together and discuss issues like where you are with your KPIs (key performance indicators) and any shortfalls. Then work to determine how to address problems. This collaborative process can help build trust with your staff and better make those adjustments and fixes as needed.
Q: Do you have any cross-training tips to share?
A: Every role should have at least one or more individuals who are available to back up that role. To do so requires you to be proactive. Make sure you're planning ahead in the event that someone's out of the office unexpectedly. It's important to have your team understand that they're part of a larger process. It's not just about their individual contribution. It's about the success of the ASC as a whole. If they can learn another facet of the business, this not only helps the surgery center, but it helps increase their job knowledge.
For those team members who are not quite sure where they fit into your organization, you can leverage that to your advantage. Asking them to engage in cross-training tells them that you trust that they're able to learn something new and can be a person you can lean on for further help.
Cross-training can also help staff if they have goals for their career. Maybe they eventually want to manage. Cross-training will help them see the business from start to finish.
For cross-training to be successful, the people in the current role doing that job need to have a "site spec" document that explains how they do that job, and the document needs to be regularly updated. Even if you have someone who's cross-trained, if they have not had the opportunity to fill that role for a while, they may need a refresher.
It's great when the person who's the subject matter expert has all the knowledge needed in their brain, but that's not going to help anybody if they need to be out of the center. Encourage and work with those who are filling your key roles to create and maintain a site spec. This document should enable anybody to jump into and help fill that role through just using the information in that document. Audit those documents regularly as well to ensure they are current and easy to follow.
