Ambulatory surgery centers (ASCs) have had to weather the financial storm in recent years, perhaps more so than other healthcare sectors. When the pandemic hit hard, the bottom dropped out of procedure volume. Many centers were forced to furlough staff, including front-end and billing staff.
Then, in 2021, just as demand for elective surgeries started to tick up and the financial clouds began to lift, the talent pool shrank - a lot.
Healthcare has been profoundly impacted by high attrition. The financial pain and administrative burden have been felt deeply in organizations whose most valuable revenue cycle management (RCM) talent has moved on. Some of the most highly skilled medical billers decided that they liked being at home. They learned to live on one income. They pursued alternate paths that offered more flexibility. They didn't come back when ASC volume returned to pre-pandemic levels.
Unfortunately, their departure means the loss of deep, institutional knowledge. There are many things that aren't written down about how this payer operates or how those claims get paid more easily. All the filing, prior authorizations, and coding nuances that prevent claim rejections and denials are learned through experience - and when the experience walks out the door, there's no one left to train the next generation of billers.
With the labor pool as tight as it is, many ASCs find themselves hiring less experienced staff. Less experience means more errors, and more errors mean more revenue leakage. The problems often begin at the front desk: the insurance card presented by the patient is out of date; the patient's name or group number wasn't legible on the paperwork and was entered incorrectly into the system. Whatever the reasons, if patient demographics are not captured correctly at the beginning of the encounter, the risk of claim denial increases significantly.
What about the patient's out-of-pocket portion? Less experienced staff may not know how to look up the patient copay or coinsurance on the payer website and collect it on the spot. Once the patient is out the door, chances of collecting that money drops dramatically.
Inexperience and errors cost ASCs time and money. Mark R. Jones, an RCM industry veteran and President and CEO of EMRJ Consulting, says that without good controls in place, revenue loss is all but guaranteed. "It's a major issue, yet oddly enough, these errors are not always felt immediately. If the ASC is operating profitably and bonuses are being paid, they may not know how much revenue they're leaving on the table."
Savvy administrators should track key performance indicators (KPIs) that can identify revenue cycle issues early so they can take appropriate action, according to Jones. He suggests monitoring these KPIs to discover whether revenue is leaking:
- Accounts Receivable (AR) Aging - The older AR, the more difficult it is to collect within timely filing and timely appeals deadlines. On average, the percentage of AR over 90 days should be less than 20%.
- Denials Management - Tracking denied claims to identify why they were not paid upon first submittal can reveal problems with front-end procedures, coding, specific payers, or even with coverage of certain procedure codes.
- Net Collection Percentage - Net collection percentage combines both insurance payments and contractual adjustments as a percentage of billed charges to measure how successful a practice is at collecting the total amount allowed by the payer. A good benchmark is 97%.
- Days Sales Outstanding (DSO) - DSO is how long it takes to receive payment for a claim. The lower the number, the quicker the practice is collecting for services performed. DSO under 30 days is a good benchmark, with up to 45 days being acceptable.
With highly skilled RCM staff keeping an eye on these KPIs, it is more likely that an ASC will perform at or above industry benchmarks. When staff is less experienced or simply overburdened by high patient volume, however, it can be difficult notice problems or to take the steps necessary to correct them.
Automated AR optimization technology, says Jones, can provide controls that save the day for ASCs. He recommends leveraging robust tools to assist with eligibility, verification of coverage, prior authorization (PA), and deductible monitoring - all of which he says can cause snags in the revenue cycle and adversely impact the patient financial experience.
"The right technology can reduce front-end workload and improve productivity of your staff, regardless of their experience level. Automated solutions streamline the information search process. A best-in-class demographic verification tool will return complete, accurate patient data in seconds. Combine that with automated insurance discovery and verification tools that confirm active, billable coverage, and you're well on your way to submitting a claim that's going to get paid the first time. Solutions like ZOLL AR Boost have all those capabilities, plus automated deductible monitoring that lets you see exactly when the patient deductible has been met so you can appropriately time claim submission to the payer."
Jones advises that ASCs also consider AI-assisted, automated PA tools. It's an investment, he says, that pays dividends in more revenue, less hassle, and better served patients.
"When your staff is spread thin, a tedious, complex process like PA can create problems for both patients and the revenue cycle. Even experienced medical billers hate dealing with PA because it's such a burden. You can ease that burden with technology that will identify requirements based on payers, plans, and groups and determine at the point of care whether the patient meets those requirements. Determination and adjudication are magnitudes faster compared to doing it the old way. Patients get care without delay, and ASCs know they'll receive optimal reimbursement for services provided."
This article is a collaborative effort with ZOLL Data Systems.