consideration, it is fair to say that a TJR surgery reimburses approximately 8 to 10 times more than the average case in a typical multi-specialty surgery center. Given the wide-ranging nature of rates for these procedures, it is important to have a skilled and knowledgeable team negotiating your managed care con- tracts. This team will need detailed data at their fingertips to build a case that provides significant cost savings for the payer while simultaneously being highly profitable for the ASC. Because of the dramatically higher dollar amounts for these procedures, ASCs need to establish and train staff members to follow operational and financial processes that are designed with the managed care contract in mind and optimize each step of the revenue cycle. In fact, because the pro- cedures are so expensive, payers are increasingly thorough in their review of these cases and oftentimes more closely scrutinize the coding and bill- ing involved.

In addition to ensuring that patients meet all pre-surgery


front desk personnel must be thor- oughly trained in all aspects of their job, including the following: financial counseling, the pre-authorization pro- cess, insurance verification and eli- gibility, providing an estimation of a patient’s financial responsibility, and collecting in advance or on the day of surgery the deductible, co-pay and co- insurance. There are many nuances to each of these functions, and a mistake in any of these areas could lead to sig- nificant expenses incurred by the ASC without obtaining any reimbursement at all. For example, while getting a pre- authorization for the surgery, it is par- amount to obtain authorization for a range of relevant and possible codes as a surgeon might need to change course after surgery begins. Performing a pro- cedure without the proper authoriza- tion will lead to a denial of the claim. From a medical coding perspec- tive, coders need to be aware of the

relevant codes for each surgery and be cognizant of each patient’s specific health insurance contract and how it reads relative to reimbursement. For example, while the current procedural terminology (CPT) code will be the same under each contract, it is likely that the implant will be treated differ- ently from contract to contract. Billing for these implants is extremely impor- tant, as they cost several thousand dol- lars each, depending on the specific implant used. The cost is much more than the average implant cost for most other procedures. Since large sums of money are at stake, ASC leaders should make sure that all their man- aged care contracts are readily avail- able to their coders. Better yet, leaders might want to create documents that summarize pertinent information from each contract, so coders can easily find the specific information they need. Each managed care contract is

likely to stipulate specifically how an implant should be billed. For instance, an insurance carrier could have an HMO contract in place that stipulates it will pay the ASC a certain amount for the total joint procedure and would include the cost of the implant in that reimbursement. The same carrier’s PPO contract might, however, pay a certain amount for the procedure but

separately reimburse the implant, as well as shipping, handling and tax. The managed care contracts also will

provide insight regarding exactly how each payer needs to receive documenta- tion for the implant charges. Some pay- ers will stipulate that they want to be billed electronically and, subsequently, request the implant invoice if needed. Others will provide a portal where the ASC will need to upload the implant invoice for each case or request a paper copy of the invoice for submission. The sequencing of the codes also is

critical. For example, a contract could state that it will pay 100 percent of the first line procedure, 50 percent of the second and 25 percent of the third. So, if the coder does not sequence the codes optimally, reimbursement will suffer. Mistakes in any of these areas will lead to denials, incorrect pay- ments or underpayments.

Moving Forward

By rethinking current practices and making necessary adjustments, ASCs will put themselves in a position to take advantage of the increased demand for total joint surgeries, the migration of total joint surgeries to the ASC set- ting and the increased likelihood that more payers—including Medicare— will cover total joint surgeries in ASCs in the future.

ASC FOCUS MAY 2019 | 21

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