There is a notable trend in the migration of specialized medical procedures from hospital settings to outpatient facilities, such as ambulatory surgery centers. These procedures include complex orthopedic, spinal, and cardiology surgeries, among others. The driving factors behind this shift include cost savings, technological advancements, convenience, safety, and positive outcomes. This transition is benefiting patients, healthcare providers, and payers alike.]
The Centers for Medicare and Medicaid Services (CMS) have issued a new directive that alters the necessity for Medicare beneficiaries to undergo surgeries exclusively on an inpatient basis to qualify for reimbursement. Effective January 1, 2022, over 250 musculoskeletal surgeries will be removed from the “inpatient-only list,” followed by an additional 1,500 surgeries in the subsequent year. The directive offers patients and physicians more flexibility, reduces expenses, and fosters competition between hospitals and ASCs. However, the CMS only partially deserves recognition since it did not modify its reimbursement practices, which could cause many hospitals, surgical practices, and patients to prefer in-hospital procedures. The CMS can remedy this situation by addressing the fundamental policies that underlie reimbursement discrepancies.
Therefore, to boost reimbursement, it is essential to focus on maximizing the value of these complex procedures. This can be achieved by implementing policies that reduce claim denials and improve front desk staffing. Here are five strategic considerations that can aid in measuring ROI for complex procedures and provide a roadmap for maximizing reimbursements in the surgery center.
- Investing in Front-End Processes for Improved Efficiency
It is crucial to allocate resources towards enhancing front-end processes, which represent the initial point of contact between patients and the healthcare facility. The front desk staff plays a pivotal role in capturing patient data and shaping their perception of the quality of care they will receive. Therefore, it is imperative that front end processes are carefully designed and executed to meet the needs of patients. This may involve providing comprehensive training to the front desk staff or adopting innovative technologies. By ensuring that patient demographics and insurance information are accurately captured, healthcare facilities can minimize claim denials and increase overall revenue.
- Ensuring Patients Comprehend Their Obligations
Despite the fact that patients may be required to pay a portion of the cost of their procedures, not all patients have a clear understanding of their insurance coverage, their financial obligations, and the timing of payments. To enhance the patient experience and facilitate prompt payment, it is advisable to designate a qualified individual to educate patients on financial matters and address any concerns they may have.
- Reviewing and Negotiating Managed Care Contracts
It is advisable for Ambulatory Surgery Centers, which carry out both simple and complex surgical procedures, to carefully evaluate and negotiate their managed care contracts. Although managed care contracts for simple surgeries may appear straightforward, performing more complex surgeries increases the possibility of incurring additional costs. Furthermore, such contracts may contain outdated reimbursement rates or ineffective language with respect to procedures involving the cardio, orthopedic, and spinal systems. Therefore, it is imperative to scrutinize these contracts and seek to renegotiate terms that are more favorable. To optimize revenue on complex surgical procedures, it is essential to have managed care contracts that work in favor and to be fully aware of the earnings on every procedure.
- Employing Advanced Analysis Techniques
Employing sophisticated analysis is crucial for surgery centers, especially in the case of complex procedures such as those involving the cardio, orthopedic, and spinal systems. The use of modern analytics software can help to establish benchmarks and interpret data to determine what is working well and what requires improvement. Through data analysis, surgery centers can measure growth and assess the impact of complex procedures on their revenue stream. Revenue cycle analytics can provide detailed reports on the performance of surgery specialties, such as cash per case, denial rates, and outstanding implant payments. This information is critical in enabling surgery centers to make informed decisions and improve their overall performance.
- Ensuring Accurate Procedure Coding
It is essential to ensure that all procedures carried out at the surgery center are accurately coded. This is particularly important for newly introduced procedures and those requiring specialized knowledge. Failing to code procedures correctly may lead to denials, underpayments, or overpayments, which can result in compliance issues. Mistakes related to complex procedures may cause insurance claims to be denied or patients to be unexpectedly billed. Rectifying these errors can also cause significant delays in payment, which may harm the center’s cash flow. Therefore, it is vital to establish a robust accounts receivable process to ensure that accurate coding is maintained.
At present, surgical centers are experiencing a notable period of growth. The adoption of high-margin and high-growth procedures presents a valuable opportunity to increase revenue streams for the ASC. By implementing effective strategies to manage the revenue cycle, it is possible to optimize the surgery center’s capacity to generate revenue.
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