Updated: Dec 10, 2019
Jorie was engaged by an Ambulatory Surgery Center, operated by a highly regarded neurosurgery, neurology and pain practice in Texas. Jorie was asked to provide an analysis and implement efficient processes to improve billing, collections and maximize revenue for an ASC. Jorie identified several potential areas of revenue leakage.
Addressing front desk processes (registration and insurance pre-verification).
Auditing operative notes to ensure completeness of clinical documentation and capturing charges for accurate coding.
Entering data/billing correctly to maximize revenue by using the correct modifiers.
Diligently following up on billed services to collect more revenue, more quickly from both payors and patients.
A Common Challenge
Like many ASCs, the facility was not realizing revenue goals. Inefficiencies, created by a lack of standardized practices within the Revenue Cycle, caused higher-than-average claims denial rates. Poor coding, a lack of proper follow-up on denied claims and other claims submission errors were creating thin margins for the center.
This resulted in a drag on the center’s average monthly collections and nearly 20% of claims being denied.
Recommendations to Maximize Cash Flow
Jorie was onboard to manage the RCM process in the second quarter of 2018 (Q2 2018). While there are many metrics that can be utilized for measuring RCM performance, after an in-depth analysis, Jorie focused on four areas to increase revenue. After Jorie Health implemented a more accurate, systemic approach to RCM in Q2 2018, the results were quick and drastic.
Interventions that Made a Difference
Increasing revenue for this ASC – and many others – rely on implementing solutions that enhance accuracy and improve efficiency:
Submitting clean claims the first time – Jorie specialists are experts in the nuances of medical billing and commercial medical claims submission data, which helped ensure accurate, detailed claims could be quickly submitted the first time. This reduced lag days and the cycle of submission, rejection, editing, and resubmission that creates months of delay in payment.
Finding and eliminating errors – There were many common errors made in the facility’s billing: 1. Non-specific diagnosis code: reporting back pain with M54.9 when more specification is available (ICD code M54.5). 2. Incorrect modifiers: using certain modifiers (e.g. 59, 76 and 78) improved billing. 3. Incorrect revenue codes: introducing correct revenue codes for supplies to replace incorrect codes led to more accurate billing. 4. Non-specific supply codes: using more specific supply codes (e.g. C1713) helped reduce the facility’s high use of unspecified supply codes (e.g. L8699). 5. Over-coding: billers were using CPT codes which were part of or included in, a larger service such as decompression codes 63075 with fusion codes 22551. 6. Under-coding: billers were missing additional reportable services like the application of bone marrow in major procedures (CPT 38220 and 20939) and reporting each additional peripheral nerve injection separately (CPT 64450).
Using business intelligence for payor trend analysis – Through its propriety business intelligence platform, Jorie Health analyzed the plans and payors who were not paying or underpaying. This tool uncovered that BlueCross/BlueShield (BCBS) – the facility’s largest commercial payor – was denying nearly all claims for one physician. Upon further examination, the physician was not in-network for BCBS. After enrolling the physician, the ASC saw far fewer denials and improved payments for specific procedures.
Many ASCs view outsourcing RCM as an expense. But with a partner like Jorie, it is a profitable investment in:
improving billing processes and minimizing lag days.
coding to the highest specificity for all codes.
accurately capturing all supply and other potential revenue sources often overlooked.
tracking and reducing outstanding A/R.
analyzing payor trends.