Ambulatory surgery centers play an important role in the healthcare industry by providing patients with a convenient option to the traditional process of surgery.
These facilities are designed to offer same-day surgical care, which means patients can undergo a procedure and return home within just a few hours. They do not have to stay for days in the hospital after their surgeries, reducing their medical charges while making their treatment journey easier.
Over the years, ambulatory surgery centers have been increasing as many patient are opting for their services when they need minor surgeries. As they grow, insurance companies and government payers are imposing stricter policies, especially in documentation and pricing.
These requirements are implemented to ensure providers are paid the right reimbursement and prevent billing fraud. The result: complexities in urgent care billing that require expertise and understanding of compliance regulations to avoid billing errors.
Ambulatory Surgery Explained
Ambulatory surgery is a kind of procedure done in a medical center or hospital, but the patient does not need to stay there overnight. This means the patient can arrive in the facility for the surgery in the morning and be discharged in the evening.
The concept of ambulatory surgery is to make healthcare faster, reduce recuperation periods, and make it less expensive for patients without compromising on safety or quality. It also protects patients from infection and disruption of their daily routine or schedule.
However, every surgical operation does not fall under this category. Major surgeries, such as organ transplants, cancer treatment, and cesarean section, require longer post-operative healing and monitoring.
Understanding Ambulatory Surgery Medical Billing
Ambulatory billing is the process whereby providers running an ambulatory surgery center submit medical claims to insurance companies and collect reimbursements for the procedures or services they perform.
The billing process often takes so much time and can feel confusing because of the steps and accuracy involved. Therefore, it is important for providers to work with billing experts or outsource to Ambulatory Surgery Coding Services to ensure proper documentation and billing of services, thereby avoiding payment delays.
The Step by Step Process of Ambulatory Surgery Medical Billing
Behind the success of every surgery done in ambulatory surgery facilities is a complex billing process to ensure doctors get paid by the insurance company.
Here is a step-by-step guide of the entire process:
Patient Registration and Insurance Verification
When a patient visits an ASC, the first step is to record all their personal and insurance details.
Why is this process necessary?
- To confirm if the patient have insurance
- and if their surgery is covered in the insurance plan.
- To confirm if the payer requires a pre-authorization before the surgery
- If the patient needs to cover part of the cost, under which category (deductibles, co-pays, or coinsurance)
Documentation of Procedure and Diagnosis
Throughout the patient journey, the ASC documents accurately what was done. This is translated to standardized code during the billing process to make it easier for insurance companies to understand. It also determines the sum of money providers are going to be reimbursed.
Different types of codes used:
- CPT Codes – Describe the specific surgical procedure
- ICD-10 Codes – Explain the medical reason for the surgery
- HCPCS Codes – These may be used for certain supplies, medications, or equipment used during surgery.
Using the wrong codes or not following the insurance policies throughout the billing process will lead to claim rejection or denial.
Submission of the Medical Claim
After filling in the necessary information and adding important documentation, the medical claim is then sent electronically to the insurance company. The insurance company then reviews it by looking at the following details
- They check if the patient’s plan was active on the date of surgery.
- They confirm the surgery is covered under the patient’s insurance plan.
- They review the coding to ensure the reason for surgery matches the procedure.
- They check that the ASC followed all required steps (like pre-authorization and regulations).
Insurance Review and Reimbursement
Insurance company review the medical claim that was submitted for approval or denial. If the claim is approved, the provider will be reimbursed, and the patient will be sent a bill if the insurance only covers part of the service.
Claim Denial and Appeal
When an insurance company denies a claim, the first step is to find out why it happened. Once the reason is clear, the billing team corrects the error and sends an appeal with additional information or documents needed. Many insurance companies have strict deadlines for appeals, so be sure to send everything within the allowed time.
The Challenges of Ambulatory Surgical Billing Compliance
Medical Coding Difficulties
Insurance companies often have different medical coding rules, which can be confusing when dealing with multiple payers. Common mix-ups, use of wrong modifiers, and upcoding can result in denials and penalties.
Constant Change in Legal Requirements
Industrial regulations are constantly changing, with new coding and/or billing rules and requirements introduced every year. Keeping up with the latest legal requirements at both the federal and state levels is tough when you are working with a small team.
Insurance Company Policies
Insurance companies and government payer policies can be very different. For example, what does not cause denial from one payer may prompt a denial from another.
Bundling and Unbundling Confusion
Bundling is when an insurance company groups certain services or procedures into a single payment instead of paying for each separately. For example, the cost of surgical supplies might be bundled into the main surgery fee. Some anesthesia services are included in the facility fee instead of being billed separately.
When providers bill separately for a bundled item, the claim will likely be denied. Also, when they bill for services that should be separate, they lose out on the actual payment.
Payment Delays and Cash Flow Problems
Even when claims are submitted perfectly, payments can take weeks or months to arrive. While some insurance companies process quickly, others take weeks to respond.
Denials and resubmissions also take more time to review, creating a slower cash flow for providers. It also affects staff salaries, equipment costs, and facility bills.
Best Practices for Accurate ASC Billing
- Start with Accurate Patient Registration
- Verify and Obtain Pre-Authorization
- Maintain Complete Documentation
- Use Correct and Specific Medical Codes
- Understand Bundling Rules
- Submit Claims Promptly
- Review Claims Before Submission
- Track Payments and Follow Up on Denials
The Final Thought
Ambulatory surgery centers are equipped with advanced medical technology, highly trained staff, and a streamlined approach that focuses on patient safety, efficiency, and faster recovery times. They cover a wide range of procedures, making them a trusted choice for millions of people seeking timely, high-quality surgical care.
However, providers need to understand the inherent complexity in ASC billing.to drive revenue growth. Eminence RCM is a billing company that offers Ambulatory Surgery Coding Services.
As a well-established billing service, we help providers submit accurate claims and achieve operational stability. Our expertise in billing makes us the perfect partner to handle every aspect of your ambulatory surgery billing.
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