ASC RCM Quick Tips: In-Network Payments and Medicare Sequestration

By Angela Mattioda, Vice President of Revenue Cycle Management Services

In this quick tips piece, I discuss in-network payment accuracy and provide an update and guidance concerning Medicare sequestration.

In-Network Payments

Experiencing problems with in-network carriers paying their correct rates? A one-off underpayment isn't unusual by any means. However, contracted payers not paying correctly according to their contracts has become a bit of an epidemic.

When there are more than a few incorrect payments, it should be considered a pattern — one that requires communication with the insurance contracting representative to address the issue and help ensure it does not continue. Understanding the ins and outs of contracts is critical for ASCs to collect all they are owed for services.

If you encounter such a pattern, the first step you should take is to call the carrier. Then, escalate your issue to a supervisor to discuss the contract they have on file so you can better understand how they are processing your claims. It's very likely that you will need to file an appeal, but it's ideal to request the claims be sent back for reprocessing without having to submit one. It's critical to follow up within a two-week period to track the progress of the claim reprocessing.

If the claim doesn't reprocess correctly or the appeal is denied, the next step you should take is to get into contact with the contracting representative that owns the relationship with your facility. It will be necessary to put a spreadsheet together with all the cases that were underpaid along with a copy of the explanation of benefits and any other correspondence or denials associated with the reprocessing and/or appeal. The contracting representative should be able to confirm the understanding of how claims should be processing and help with getting your ASC's claims to adjudicate correctly.

Medicare Sequestration

In March, I discussed Medicare sequestration and the importance of ASCs addressing this in their contracts. As I noted, the 2% payment reduction is officially suspended through the end of March 2021. However, there is now a bill pending approval that would extend the cut through the end of 2021. ASCs should have their rates loaded without the sequestration to ensure they are properly netting down their accounts receivable to the current expected amount. It is anticipated the sequestration suspension will extend since we are still in the middle of the pandemic.