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Optimizing ASC Revenue and Contract Negotiations: Strategies for Improving Implant Collections

By Scott Allen, Senior Vice President of Managed Care Contracting, nimble solutions

Join nimble solutions President Lisa Rock and Senior Vice President of Managed Care Contracting Scott Allen on Thursday, July 20th at 12pm Central for the Unlocking Implant Reimbursements webinar. Register here.  

Recently, nimble solutions co-hosted a podcast panel discussion on the trends impacting orthopedic ambulatory surgery centers (ASCs). One particular topic that sparked interest was the high cost of implants. Ultimately, our panel expressed that if your ASCs breaks even on implants, you’re probably losing money. This is due to the time and commitment it takes to actually receive reimbursement.  

Securing timely reimbursements for implants is challenging due to payer obstacles that can delay the collections process. This blog post presents my top strategies for overcoming these challenges. 

Streamline documentation and communication with suppliers

One of the major roadblocks to timely reimbursements is incomplete or incorrect documentation from implant suppliers. Imagine conducting a complex orthopedic surgery, only to face a claim denial due to essential information missing from the supplier’s documentation.  

To tackle this issue, establish clear and effective communication channels with your implant suppliers. Ensure that they provide all necessary information ahead of time, including product codes, lot numbers, and any other critical details relevant to the implant. By doing so, you can avoid claim denials and minimize delays caused by back-and-forth communications.

Be proactive: regular audits on implant documentation

Rather than waiting for a claim rejection to identify issues with implant documentation, adopt a proactive approach by conducting regular audits. Regularly review the documentation related to implants and verify that all payer requirements are being met.  

These periodic checks help catch errors and omissions before they transform into expensive claim denials, saving you valuable time and resources. Implementing a structured audit process as part of your administrative routine will also contribute to smoother and more efficient reimbursement workflows. 

Understand payer policies and negotiate effectively

Payer policies and guidelines can vary across different managed care contracts. It’s essential to have access to your complete contracts and thoroughly review the terms with your staff.

Familiarize yourself with the intricacies of each contract, particularly in regard to implant reimbursements including any manual processes, such as circling the actual cost of an implant in red pen. This manual process adds an extra step to the billing process, which can slow down reimbursement and create delays in payment.  

Other terms to look for in your payer contracts what the payer considers “reasonable and customary.” For example, if the cost of your implant exceeds the amount the payer considers to be reasonable and customary, the payer will only provide a partial reimbursement due to previously set managed care contracting terms.

In this case, you may need to provide additional documentation or negotiate with the payer to receive the full reimbursement amount. You can rely on benchmarks, such as the Fair Health database, to justify the cost of the implant to help negotiate a higher reimbursement amount.

Optimize coordination for trailer billing

Trailer billing can create additional hurdles in the reimbursement process, as it requires submitting a separate invoice for the implant used during the procedure.

To minimize delays caused by trailer billing, coordination is key. Ensure that the secondary implant claim is correctly associated with the primary procedure claim, allowing for seamless processing and approval.

Review the terms of your managed care contracts to identify which payers necessitate trailer billing, as this policy can significantly impact your overall cash flow, especially if the implant is a high-cost component of the procedure.

Overcome barriers to medical necessity approvals

In some instances, a medically necessary procedure and related implant may be excluded from a patient’s insurance plan, posing a barrier to reimbursement.

To navigate this challenge, provide comprehensive documentation of the patient’s medical necessity and be prepared to appeal decisions through the payer’s internal review process.

Educate the patient about cost estimates upfront, especially if they will bear a portion of the procedure’s cost out-of-pocket. Offering payment options before the procedure can also improve patient collections and prevent misunderstandings regarding billing.

Stay informed: keep up-to-date with payer policies

The landscape of payer policies is constantly evolving. By staying up-to-date, your ASC can adapt its processes to align with payer requirements, increasing the odds of obtaining full reimbursement for implants. 

Taking a proactive approach and being well-prepared for negotiations will contribute to increased revenue and financial stability for your ASC. Mastering these strategies will pave the way for your ASC to thrive in the competitive outpatient healthcare industry. 

Attending webinars on implant reimbursement strategies is one way to help your ASC optimize revenue and improve collections. 

Are you looking for ways to improve your revenue cycle management? Take the first step towards optimizing your revenue cycle process by requesting a revenue assessment from our team of RCM experts. Request a demo.