ASC RCM Quick Tips: Denials and Appeals

By Angela Mattioda, Sr. Vice President of RCM Solutions & Client Experience

There are few consistencies in life, but one of them, unfortunately, is that payers are going to deny ASC claims. Whether ASCs have optimized their internal revenue cycle management processes or outsourced to an ASC billing company eventually they will inevitably experience denials.

To help overcome denials and improve the likelihood of appeal success, here are three tips.

1. Update authorizations when a schedule code is changed

To reduce the likelihood of denials, ASCs should ensure that authorizations are immediately updated if there is a change from the scheduled code(s). Track these changes to provide the scheduling physician’s office with feedback on the incorrect code(s) if it becomes a pattern.

2. Perform real-time verification to help avoid ineligible patients

As the calendar flips to a new year, it's not unusual to see an uptick in instances where a payer initially verifies patient eligibility and then denies a claim, with the reason identified as patient ineligibility. The cause can often be tracked back to payers failing to update their systems in a timely manner.

The best way to combat this trend is for an ASC to verify eligibility in real time upon patient check-in. For COBRA plans, ASCs would be wise to request a copy of the patient's COBRA billing statement to confirm patients are current on their payments to avoid any ineligibility issues.

3. Do not race to file a state-level complaint

If you submit a claim and do not hear back from the payer for an extended period, you may feel motivated to take your grievance to the state. But this is likely to be a fruitless effort. Why? You can't file a complaint with a state department unless you have had the claim denied, filed an appeal, and then received a denial for your appeal. Without a copy of the denial to your appeal in hand, a state department will not consider your grievance.

If the insurance claims adjuster isn't responsive, leverage whatever tactics are at your disposal to escalate the issue, including working to get the name of their supervisor. Surprisingly, one of the most successful tactics to getting a response from a payer: persistence.