Get Correct and Timely Payments for Implants

Implants often require a significant investment, and in an ASC, missing an implant payment can quickly turn a profitable procedure into a financial loss. For surgery centers to be able to continue to offer procedures involving expensive implants, negotiating and capturing appropriate reimbursement for those implants is critical.

How can ASCs better ensure they get paid appropriately and quickly for implants? Consider these recommendations.

Receive prior authorization. Commercial payers are increasingly requiring prior authorization, which can include authorization for implants. Failure to receive prior authorization for an implant can lead to a denial or penalty. Payers might permit an ASC to request retroactive authorization for the implant following the procedure, but this may come with a significant reimbursement penalty compared to what a center would have been paid for the implant had it been pre-authorized.

Use your inventory module properly. Theinventory module within a practice management system is where an ASC's materials manager can document the implants and supplies used in a case. The inventory module should be used consistently, with documentation entered properly. Doing so provides an ASC with a way to generate an implant log that can be sent to its coders. They should use this information to ensure everything about the implant that needs to be captured in coding is complete.

In addition, the inventory module allows ASCs to reconcile their implants and use this information to verify that all implants, as well as billable supplies and biologics, are being captured and billed correctly to avoid revenue loss.

Emphasize detailed implant dictation. Surgeons might provide a high-level dictation about the implant used in a procedure that lacks important details about the device. Missing details might include the specific count, manufacturer or description.When coders receive a dictation without this information, they might not properly code the implant, which can cause denials or loss of reimbursement.

Include implants in the patient estimate. When verifying benefits, a center might input the procedure code that is anticipated per the scheduling order but not include the code for the implant. Then, when a patient estimate is generated, the cost of the implant is not included, reducing the amount the ASC should collect up front. Situations like these lead to more work on the back end as the ASC must try to collect what a patient owes for the implant.

Ensure the billing team has access to all necessary information and documentation. To properly bill implants and reduce the likelihood of denials and payment delays, the billing team needs access to key documentation. Those sources will likely include copies of invoices, purchase orders, an implant log and the surgery center’s inventory module.

Encourage open communication between the billing team and the materials manager. Commercial payers often establish rules concerning the minimum amount an implant must cost to be payable (i.e., threshold) or the rate an ASC is allowed to bill for an implant (for example, 100 percent or 110 percent of cost). Surgery centers need to focus on ensuring their billing team and materials manager understand the most effective ways to communicate about implant-related issues so the billing team can easily retrieve the information it needs to properly bill for implants.

Craft detailed appeals. When a claim is denied due to missing or incorrect implant-related information, verify what documentation the payer requires to bill for implants. That could include a manufacturer invoice and/or implant log.

If a payer requires the invoice, do not send a purchase order instead. In general, payers will not accept a purchase order in place of an invoice.

Review codes and confirm billing is correct. Different commercialpayers often follow different coding and billing rules concerning implants. For example, one payer might require the billing of three screws using HCPCS C1713 on three different line items, and another payer might require you to bill for these three screws on one line item with three units.

As another example, Medicaid might require all implants be billed with HCPCS L8699, whereas commercial payers typically require the use of a C-code, such as C1713.

Certain unlisted HCPCS codes for implants, like C1889 and L8699, might be interchangeable. Depending on the payer, you might find that one of these unlisted codes will get you paid while another will result in a denial or lower payment.

Check contracts for implant payment methodology. Payers tend to have varying rules for how they expect to be billed for and how they will pay for implants, and ASCs need to follow these rules. As discussed earlier, some payers will reimburse implants at cost or cost plus a certain percentage, or they might not reimburse implants at all.

An ASC could also encounter thresholds where the payer will not reimburse an ASC if the cost of an implant is below a certain figure. For example, if a payer has a $500 minimum threshold and an implant costs $490, the payer will not reimburse an ASC for that implant.

Another important reason to understand implant payment methodology: Following the correct billing rules up front will make it easier for you to determine whether you are paid correctly or incorrectly.

Factor in implant invoice delay. Certain commercial payers, and most workers' compensation payers, require an implant invoice to process and reimburse a claim. Typically, implant vendors submit their invoices two to four weeks following the service date.

Claim submission should not be delayed until the invoice is received. Rather, the implant cost can be calculated using the purchase order and the claim submitted for processing. This process will reduce the likelihood of timely filing denials. When the invoice arrives, have a process in place to expedite its submission to the payer.

Negotiate contracts that cover costs and minimize thresholds. When negotiating and renegotiating contracts, allocate time to discussing reimbursement for implants. Priorities should include receiving coverage that at least covers your facility’s cost—so your surgery center does not lose money on any implants you need to purchase for a procedure—and minimizes thresholds for reimbursement. Payers might try to set very high thresholds— thresholds as high as $2,000 are not unheard of. While you might be satisfied with receiving reimbursement for implants at cost plus 5 or 10 percent, an overlooked threshold could prevent you from ever collecting that reimbursement.

Perform ongoing cost analysis. Case costing is an essential process for any ASC, and it can take on even greater importance when high-cost implants are used. Regularly review the costs of your cases to identify the procedures that are causing your surgery center to lose money. Take this data with you to the renegotiating table to support your argument for increased reimbursement for procedures and implants or the reduction or elimination of thresholds.

Make Proper Billing and Collections for Implants a High Priority

Getting paid fairly for implants is often difficult. Even in the best of circumstances, it is not unusual to see payments missed or underpayments made. That is why ASCs must develop processes to effectively monitor implant payments and address when payments are missed or underpaid. Failure to do so could result in losses of thousands of dollars in earned income for an ASC.