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FEATURE


days from the date of bill submis- sion, ASCs should follow up at 15-day increments when an out-of-network payment is delayed.”


When submitting an appeal letter to payers concerning payment delays, he recommends ASCs attach several forms. He also advises including pre- authorizations to avoid wrongful deni- als based on a payer’s claims that ser- vices were not pre-authorized and a copy of the patient’s driver’s license and member identification card to avoid an insurer claiming it cannot locate the member. “You should include an enforceable assignment of benefits form,” Force says. “This helps avoid a denial based on a payer’s claim that the ASC or their representative is not an authorized rep- resentative of the patient. Also include a summary plan description authoriza-


Know the specific terms of your contracts, follow their requirements to a T and hold the insurance company to these terms.”


— Martha Colen, RN, CASC Virginia Beach Ambulatory Surgery Center


tion form so you can obtain the health plan summary plan document. This may be necessary if your ASC needs to hold the insurer accountable to plan provisions, such as the payment meth- odology and appeal provision.” If you receive a denial to your appeal, do not consider it the end of the road, Hufford says. The denial will fre- quently note that there is another level of appeal. “Gain an understanding of


the reason for the denial,” he recom- mends. “In many cases, there is a basis for challenging the denial. Always exhaust your appeals, especially if you intend to go to litigation.” An effective and thorough appeal is also necessary when an ASC receives an underpayment for out-of-network services, Force says.


One step that is vital to a success- ful appeal of an underpayment is fol- lowing a thorough up-front patient eligibility process, he says. “This is where you verify benefits pre-service to obtain a reasonable estimate of what the plan will allow for an out-of-net- work service, which will enable you to collect the up-front cost for coin- surance and deductibles owed by the patient.” It is important to obtain from the plan administrator or insurer how the health plan calculated the out-of-


D. Brian Hufford: Advising and representing health care providers on insurance reimbursement issues.


BALTIMORE | NEW YORK | TAMPA | WASHINGTON, DC Attorney advertising. Prior results do not guarantee a similar outcome.


www.zuckerman.com ASC FOCUS MAY 2018 | www.ascfocus.org 25


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