network allowed amount, be it based upon a Medicare formula or hopefully a usual, reasonable and customary (UCR) formula, he adds. Hufford notes that plans typically pay based on a percentage of Medi- care or on UCR rates. These rates are derived from databases such as the one maintained by Fair Health, which he says reports on what providers are charging for services. “Many plans say they will pay based

on UCR, but we have found that payers are often paying below that amount,” Hufford says. “The insurance compa- nies must follow their own plan.” To further support your argument for a higher payment, Force recom- mends getting a copy of insurance plan documentation, preferably from the employer/plan sponsor directly and not from the insurer. “This documen-

tation will tell you how the plan ulti- mately allows out-of-network benefits. This is important to hold the insurer accountable to the actual plan.” Watch for potential mistakes con-

cerning the bundling of CPT codes, Hufford advises. “The American Med- ical Association outlines when codes

should be bundled. Payers can some- times improperly bundle codes. If you do not catch these errors, they can have a substantial impact on your payment.”

Remain Vigilant Always have someone assigned to monitoring and following up on incomplete payments, Hufford advises This follow-up responsibility may

fall to your business office associ- ates, Colen says. “This can feel like a thankless job but their role is essen- tial to getting your ASC paid what it deserves. Let them know they serve as your ASC’s eyes and ears. Pro- vide them with the education and resources they need to speak the insurance language. When you can empower these members of your team, expect improvements in your bottom line.”

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Find out what over 700 medical facilities and 10 million patients already know. © 2017, One Medical Passport, Inc. All rights reserved. 26 ASC FOCUS MAY 2018 |

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