Ambulatory Surgical Center Insurance Verifications and Authorizations

Hello this is Natalie Tornese, Director of RCM at Outsource Strategies International. Wanted to talk a little bit about insurance verifications and authorizations for ambulatory surgery centers. I will be referring to ambulatory surgery centers as ASCs throughout this podcast.

• 00:21 Streamline ASC Medical Billing with Insurance Verification and Authorization

ASCs render same-day surgical care, including diagnostic and preventive procedures, which can include services rendered by anesthesiologists, radiologists, or pathologists. Outpatient procedures commonly performed in these centers include dialysis, gynecological procedures, gall bladder removal, kidney/bladder procedures, endoscopies/colonoscopies, and a lot more. Insurance verifications are really important to ensure that the provider gets paid for the services provided. You should check patient’s coverage before the surgery date. Collect the patient’s demographic, primary and secondary insurance information and verify benefits within 1-2 days of the procedure date. You don’t want to verify them too much in advance, because benefits can change frequently.

• 01:11 Perform insurance verification – You want to get the most accurate information, so you can allow collecting the patient portion due upfront. Collecting the patient balance before the date of service is the best way to ensure that you receive the payment. As personal insurance information can change at any time, returning patient’s insurance information should be verified in each and every visit. Details verified can include co-pays, co-insurances, deductibles, insurance policy status, affected date, payable benefits, plan exclusions and insurance caps. 

You should also verify plan type and coverage, lifetime maximum, if a referral is needed, if a pre authorization is needed, if the patient has out of network benefits, primary and secondary insurance, DME reimbursement, code/procedures, specific coverages, you know you want to get the information for every procedure that you perform, all patient out of pocket costs and of course the prior authorization is most important because without that you’ll not get paid.

Eligibility checks are critical to ensure that the patients’ insurance is active, but checking what exactly is covered is necessary. You want to verify the patient’s financial obligation and make sure to notify patient about it ahead of time, so that there is no surprise billing. Realize that if you don’t check the patient’s insurance plan in advance, you can actually receive the denial and not get paid at all.

• 02:42 Focus on prior authorization – You want to focus on obtaining a prior authorization, as up to 81 percent of medical groups have seen an increase in prior authorization requirements since 2020. Many plans require prior authorization to reimburse a facility fee for procedures when performed in an ASC.

Facilities must contact the patient’s health plan or to get prior authorizations for the procedure codes. 

• • Have patient information ready, including demographic details, the surgeon’s name, the diagnosis, the type of procedure and the date of services.
  • You want to have a list of all the CPT codes that require prior authorization.
  • You also want to have a thorough understanding of payer contracts and authorization requirements. 

Some teams and some authorization specialists also are trained in getting retroactive authorizations. CPT codes for planned and documented procedures need pre authorizations, but changes can occur during an approved surgery for different approaches used, findings lead to additional procedures being performed and/or implants are necessary to complete the procedure. In these cases, the surgeon should communicate the change immediately so that a retroactive authorization can be obtained. Some insurers require a retroactive authorization to be submitted within 72 hours, while for others this time period could be up to two weeks from the date of service. Some payers require code changes to be submitted during the appeals process. Obtaining the appropriate procedures/codes from the physician and authorizing them in advance can help if a change in approach is required. It’s also important to know the payer requirements on how the required information should be sent – either by email, phone or using an online form.

• 04:30 Include the authorization number – You want to ensure that your claim once billed, has the authorization number when an authorization is obtained you get a unique prior authorization number. It’s really important to put that on the claim itself. 

• 04:43 Check out-of-network billing – You also want to maintain a list that identifies which payers are in network with you as a provider, because a patient does not have out of network benefits and you are not in network, you can risk not getting paid. 

So I hope this helps but always remember that documentation and a thorough knowledge of payer regulations and guidelines is critical to ensure accurate reimbursement for the procedures performed. 

Thank you.