mation about authorizations online to electronic filing, Colen says it is often difficult to get individual attention from a payer when you encounter problems. “That is why relationship building

is key,” she says. “Work to develop a relationship with your payer’s provider representative whose job is to act as a liaison with providers. Try to arrange a meeting between this rep and your accounts receivable team to build a closer partnership.” If you receive a questionable denial or underpayment, take

immediate Hold Your Payers Accountable

Educate yourself, develop relationships and act quickly on denials BY ROBERT KURTZ


hether your ASC is in- or out-of- network with a payer, payment denials, payment delays and underpay- ments are inevitable, says Brian Huf- ford, health care attorney with the law firm of Zuckerman Spaeder in New York, New York. “ASCs are typically busy and

focused on supporting their surgeons in providing services to patients,” he says. “They do not want to be in the busi- ness of fighting insurance companies for payment.” Nevertheless, those that fail to pay attention to whether and how much they are paid, could be leaving a lot of money on the table, he cautions. Unfortunately, there is no way to completely avoid denials, says Mar- tha Colen, RN, CASC, administrator of Virginia Beach Ambulatory Surgery Center in Virginia Beach, Virginia. “While this is frustrating, ASCs can- not afford to let these incidents slide.

We must hold carriers accountable and work to ensure they pay us what we rightfully deserve.”

In-Network Strategies One effective strategy ASCs can use to prepare for eventual payment issues is education, Colen says. Provider agreements with commer-

cial carriers outline the provider’s and health insurance plan’s obligations to each other. This includes the required time frame for billing, how to file a claim, the time frame within which payments are to be made, why claims can be denied, the appeals process and when you can balance bill the patient. “Know the specific terms of your con- tracts, follow their requirements to a T and hold the insurance company to these terms,” she says. With greater reliance on electronic communications, from accessing infor-

24 ASC FOCUS MAY 2018 |

action, Colen says. “Reach out to the rep and request assistance in resolving the issue. . . . keep your finger on the pulse of the details.” A helpful exercise is to put your- self in the shoes of insurance carri- ers, she says. “While they have profit margins they are trying to reach, and they can reach that margin faster by not paying for services, they also want to be seen in a positive light so more people buy their insurance.” To avoid, issues, ASCs would do well to make it as easy as possible for their carrier to pay them and their rep to assist them.

Out-of-Network Strategies Be prepared not to treat out-of-net- work claims like in-network claims, says Thomas Force, an attorney and the founder and president of The Patriot Group, a revenue recovery and advocacy company in Lindenhurst, New York. In many cases, out-of-network pay-

ments are sent to patients, he says. “To increase the likelihood of receiv- ing that payment, inform patients in advance that they may receive your ASC’s payment. Provide patients with a pre-stamped envelope and instruc- tions on what to do if this occurs.” If a payment is not sent to a patient

but is delayed, Force advises tak- ing an aggressive follow-up strategy. “Whereas ASCs can follow up on in- network claims often up to 60-plus

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