ASC Billing - Out of network facility claims

​ASC Billing for Out of Network Facility Claims

When you are an out of network Ambulatory Surgery Center, it is always a struggle to get paid and have your claims get processed appropriately. It upsets the patients and much more, the ASC loses revenue.

This blog post is about ASC Billing. And I am going to give you some ASC Billing Scenarios and how to tackle them.

It is always wise that you have a system in place in the practice. Because I will tell you, ASC Billing is not easy. But once you understand the process, its not really too bad. 

These tips can be used for any practice services. Mostly I kept these in mind for our clients Pain Management Billing, Anesthesia Billing and Orthopedic Spine Billing.

ASC Billing Tip: We should always remember, if the Professional Services are not Authorized, it's unlikely the ASC Facility will get paid/processed for their portion. 

In the perfect world of ASC, the ASC always relies on the Providers' services being verified and authorized. They have to work together, hand in hand.

So here are my ASC Billing Tips for an Out of Network Facility:

• Always Verify if the Professional Services (this is for the Rending Physician) will require Prior Authorization (Commercial Payers, Motor Vehicle and Workers Compensation)
• If Yes it requires Prior Authorization, make sure you obtain the Prior Authorization with ASC as place of service (very important to take note!). 
• Obtain Pre Determination if Prior Authorization is not required - they may refuse not to process the Predetermination, but we always tell the insurance payers, we want an approval for Pre-Determination based on Medical Necessity
• Have a dedicated team in your practice who will only be doing just Prior Authorization/Predetermination so the practice will be successful in getting paid for the ASC claims. We should always remember, if the Professional Services are not Authorized, it's not possible the Facility will get paid/processed for their portion. In the perfect world of ASC, the ASC always relies on the Providers' services being verified and authorized. They have to work together, hand in hand.

Why is this so? Here's the rationale: if you have an Authorization obtained for the Professional Services with ASC, most likely:

• Your ASC claims will be processed based on the Rendering Physician's prior authorization approval that was obtained.

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NEXT; ASC Billing tip:
Educate your patient about the Ambulatory Surgery Center being out of network. Because your dilemma will be, the patient will likely get the check because the payer may send it to their members! I can name some of the Insurance Payers that does this!
So it is always wise to let them know checks might be directly sent to them by their insurance company. All they have to do is to endorse (sigh the back of the check) and send the check to the practice. And also don't forget to let your patient know about their out of network benefits (deductible & coinsurance). It's very important that your patients knows what to expect about the ASC being an out of network facility.

ASC Billing Claims Submission tips:

• Use HCFA 1500 form, MOD SG POS 24 (ASC) as your primary modifier. Remember your ASC billing codes and the use of HCFA 1500 is the same as how you bill under POS 11 (Office) or POS 22 (Outpatient Hospital)​​
• You can only report the PRIMARY CPT code for the ASC Billing (for example CPT 64635 only)
• DO NOT report each additional code (for example CPT 64636)
• You can report the supervision and guidance with $0 amount for the TC (Technical Component) - because these are bundled into the code based on the CPT Coding guideline
• Submit the spinal stimulator trial electrodes (L-code) when performed at the ASC
• Submit the DME Durable Medical Equipment (Home) when dispensed at the ASC
• Moderate Conscious Sedation (CPT 99152, CPT 99153) are not billable at the ASC
• Use HCFA 1500 form, POS 24 (Professional) - Physician's claim if you are submitting ASC Billing for the Physician or Professional Component
• Use exactly the same codes for the Primary Procedural codes and the Diagnosis Codes
• Scrub your claims before you finalize the claims for submission. CMD cannot fully do this for you due to POS 11 versus POS 24. (CPT, DX, Billing Facility, Billing Provider, HCFA 1500)

So what's next for ASC Billing when claims are Denied, Rejected or Inappropriately Processed?

You don't want to miss that revenue opportunity for the Out of Network Facility Fee. Out of network fees are always based on UCR (Usual and Customary Rates) based on your location. Normally I have seen up to 300% or (even more!) of Medicare Fee Schedule. At times, you will also be negotiating fees with 3rd party claims repricing companies. So be careful when negotiating your fees. You can call our office and we can guide you how to negotiate your fees. Don't be fooled. Remember, they are not the insurance company, they are just the claims repricing companies. If you don't agree with what they want to negotiate with you, send it back to the patient's primary insurance company. You can always call us if you need help in negotiating out of network fees. Contact us here.

What we should do for all our UNPAID Claims:

• Understand how the claims were processed, it may be unpaid because everything was applied towards the patients out of network responsibility; bottom line, find out what exactly happened with the claims and how it was processed;
• Connect with the Payers
• In network versus Out of Network
• Payments sent to the patient
• Claims that are not actually “denied” but are just being rejected for coding or medical documentation requirements
• Appeal the Claims that were denied for NO Prior Authorization obtained
• Appeal claims that were inappropriately processed (in network versus out of network usual and customary fees)
• Corrective claims due to ASC Billing and Coding
• Respond to Medicare Records requests

I mean, you need to know the determination that was made on your claims and then you can take action.

But moving forward, just make sure you have a team in your practice that only does Patients Access and Prior Authorization.

References Source:
https://www.cms.gov/Center/Provider-Type/Ambulatory-Surgical-Centers-ASC-Center
Commercial Payers Public Domain Websites
​CPT Coding Guidelines through the American Medical Association
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