BACK TO BASICS
In recent years, Ambulatory Surgical Centers have become one of the
most regulated aspects of the medical industry. They are being held to
higher standards, tougher payments restrictions and increased scrutiny as
regulations pile up on both state and federal levels.
The definition of what constitutes an ambulatory surgical center varies from state to state, but is generally understood to be a facility that is not owned or operated by a hospital, and primarily provides surgical services to patients that do not require a length of stay over 23 hours or hospitalization. According to a 2011 study by the Centers for Medicare & Medicaid Services, the most common specialties in ASCs are:
Ophthalmology 30 percent, Orthopedics 15 percent, GI 14 percent,
Pain Management 10 percent, Plastic/Reconstructive 8 percent Urology 5 percent.
An ASC may include multiple specialties or focus on just one.
So, you want to bill for facility fees at your ambulatory surgical center. …
Step One: Get to know the regulatory body that oversees ASCs in your state. In most states, licensing and certification is overseen by a division within the department of public health. In many states, the guidelines follow closely or have been adopted from the Conditions of Coverage developed by the Centers for Medicare & Medicaid Services. Conditions of Coverage must be met for all patients, not just Medicare beneficiaries.
In order to operate, a facility must remain compliant with state licensure requirements, which may include participation in the Medicare program and/or accreditation from one of the following approved private companies:
• The Accreditation Association for Ambulatory Health Care
• The American Association for Accreditation of Ambulatory Surgery Facilities, Inc. • Joint Commission on Accreditation of Healthcare Organization
• Healthcare Facilities Accreditation Program
Due to the costs associated with the survey process, most states accept a Medicare certification or “deemed” accreditation instead of requiring a separate survey process. Not all accreditation companies are approved in each state. Check with your state regulatory guidelines for specific requirements and details. Never assume that your state will accept accreditation or Medicare certification in lieu of a state license. If your state has Certificate of Need requirements, it is highly recommended that you proceed with the assistance of legal counsel. A successful accreditation survey does not override the states right to review any violation or compliance complaints.
Survey Process
The CMS “deemed status” accreditation survey is an on-site inspection that extensively reviews the facility and its practices for compliance with the Medicare “Conditions for Coverage.” Additional information regarding the standards included in the Medicare CfCs can be accessed at the Centers for Medicare & Medicaid Services website,
http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/index. html?redirect=/CertificationandComplianc/02_ASCs.asp
The inspection will require 15 surgeries to be performed prior to the initial survey so that a full review of records and procedures are available. The 15 surgeries can be a combination of Medicare and non-Medicare procedures.
Prior to applying for certification, obtain a complete copy of Medicare’s standards for accreditation and conduct a self-survey. Completing your own review will allow you to evaluate any areas that may need correction ahead of time, saving you costly delays and corrective actions. The Medical Director of the facility should perform the same review at least annually. All accrediting bodies, state departments, and Medicare have the option to survey the facility for compliance at any time during the year without announcement. A facility may be denied or have its accreditation revoked if any surgeon who utilizes the facility has:
(1) Had his/her privileges restricted, limited or suspended by any hospital related in any way to lack of clinical competence, ethics, refusal to take an emergency call or other professional problems.
(2) Been found to be in violation of the Code of Ethics of any professional society or association. (3) Had his/her right to practice medicine and surgery limited, suspended, terminated or otherwise affected by any state, province or country, or if he/she has been disciplined by any licensing authority.
(4) Non-reporting of any of the aforementioned.
A facility’s accreditation request may also be denied if it is found to be deficient in any standards required by CMS or the accrediting agency.
Preparation for Inspection:
• Obtain a copy of the floor plan of the entire facility, including dimensions and purposes of each room.
• Review compliance with fire safety and National Fire Protection Association standards. • Compile a complete equipment list (Make, Model and Quantity)
• Gas Sterilizers
• Blood Pressure monitors • Defibrillators • Suction Equipment • Anesthesia Machines • Pulse Oximeters • X-ray/Fluoroscopy Equipment
Provider Credentials
This list may include documents that do not pertain to all provider types but should be included in your re-cords if applicable, may not be all-inclusive:
Facility
• Accreditation Certificate and Accompanying Approval Letter • Articles of Incorporation
• Contracts/Fee Schedules • Current Insurance Certificate • Current State License
• Doing Business As and/or Fictitious Name Permit
• Confirmation of all applicable NPI numbers from the National Plan and Provider Enumeration System
• IRS form showing legal business name form CP575, SS4, or other approved document • Signed and Dated W-9, including Tax Identification number and Legal Business Name • Voided Check or Bank Confirmation on Letterhead
Physician(s)
• Full name, date of birth, location of birth (city/state/country) and social security number • Current State Medical License
• Curriculum Vitae, including all degree & certifications • Board Certifications
• Medicare Numbers • Medicaid Numbers
• Current Drug Enforcement Administration Certificate • Current Professional Liability Insurance Certificate • Controlled and Dangerous Substances Certificate • Hospital Admitting Privileges
Medicare Enrollment
The Medicare enrollment process can be arduous and requires attention to detail, timely follow ups and lots of patience. All providers must obtain a National Provider Identifier (NPI) before they can even apply for enrollment. NPI assignment was mandated in 1996 with passage of the Health Insurance Portability and Accountability. An NPI can be obtained through the National Plan & Provider Enumeration System at their website:
https://nppes.cms.hhs.gov/NPPES/Welcome.do
To submit an application for enrollment, providers have the option to file a paper CMS-855B form or electronically through the paperless internet-based Provider Enrollment, Chain and Ownership System (PECOS). Medicare now also requires payment of a $523 (2013) application-processing fee.
Advantages of PECOS:
• Expedited Processing Time: According to the http://www.cms.gov website, average PECOS processing time is 45 to 90 days compared to 60 to120 for paper applications.
• Increased Access: Providers have more access and control of their information. They can even update their file including reassignments.
Your application and supporting documents will be reviewed and entered into PECOS. If any information cannot be properly validated the application will be returned for development. Typically
developmental returns require a response within 30 days, but always review the specific instructions in the letter from the enrollment analyst.
After the Medicare Administrative Contractor that serves your state has approved the application and supporting documents they will submit a request to your state to confirm licensure compliance and accreditation survey results.
Tips to ensure prompt processing of your application:
• Read the instructions.
• Confirm that you are submitting to the correct Medicare contractor for your region.
• Download the most current application directly from the website. CMS regularly updates the forms and any outdated forms will be rejected immediately.
• Check on page one of the application form to confirm you are completing the correct type of application.
• Complete the entire application (See Section 1B for instructions regarding which sections are required to be completed).
• Type your application: Even the smallest typo or stray mark can lead to costly delays.
• Sign in BLUE ink: All submissions must be original; CMS may return the application for a copy of your driver’s license or other evidence that your signature is valid if they cannot tell if the signature is an original.
• Submit accurate and current supporting documentation. Check all effective dates.
• Confirm that all “facility name” entries and supporting documents match the legal business name as it appears on an approved IRS Form (e.g. CP575).
• Use a method of delivery that tracks the package and confirms receipt Retain a copy of the confirmation as well as a complete copy of the entire submission.
After CMS has approved your facility’s application, they will issue a letter welcoming your facility to the Medicare program. The approval letter will include your Medicare Identification Letter, also known as a Legacy Number or Provider Transaction Access Number and an effective date. Once you have your approval, you are permitted to begin billing and collecting reimbursements for your facility.
Medicare Payment System
Billing for facility reimbursement under the Medicare program is limited to a specific list of approved pr0cedures. A current schedule of the approved cpts and a list of Correct Coding Initiative (CCI) edits can be found on the Medicare website. The CCI list is updated once a quarter by Medicare and contains critical coding information. Medicare also maintains a schedule of reimbursement allowed for each covered service performed in a facility. In 2008, CMS revised the ASC payment system based on Medicare’s hospital outpatient department payment system. The rates are reviewed for prosepctive changes and updated annually.
Facility Fee includes payment for the use of the ASC and its associated costs including but not limited to: • Nursing
• Technician (and related services)
• Diagnostic or therapeutic services or other items directly related to the provision of a surgical procedure
• Administrative, record maintenance and housekeeping
• The operating surgeon’s supervision of the services provided by an anesthesiologist • Drugs and biologicals
• Surgical dressings • Supplies
• Splints and casts
• Appliances and equipment that are directly related to the provision of a surgical procedure • Anesthesia materials and implants including intraocular lenses
Separate payment may be available for (Ancillary Services)
*When provided in conjunction with a Medicare-covered procedure • Some anesthetic agents
• Biologics
Private Pay and Commercial Plans
Reimbursement for services is determined by the plan benefits elected by the member during enrollment. Providers that have not entered into a written agreement are considered out of network or non-participating. Where as in-network providers are limited to a strict fee schedule, non-participating providers’ reimburse-ment may be based on any of the following or other conditions listed in the patients’ evidence of coverage:
• Percentage of billed charges
• Internal Fee Schedule developed by the plan • Maximum Non-Network Reimbursement Price
A rate based on a percentage of the published rates allowed by Medicare • Usual, Customary and Reasonable
The definition varies by plan but should be based on the following (based on current AMA guidelines):
1. Provider’s training, qualifications and length of time in practice. 2. Nature of the services provided.
3. Fees usually charged by the provider.
4. Prevailing provider rates charged in the general geographic area in which the services are rendered.
5. Other aspects of the economic of the medical provider’s practice that are relevant. (?) 6. Medicare reimbursement rates are based on a federal government reimbursement methodology and shall not be solely used as a basis for payment.
7. Contracted rates normally reflect a discount, and therefore, shall not be solely used as a basis for payment.
8. Any unusual circumstances in the case.
• Shared Savings Programs/Fee Negotiations
Fees are typically negotiated through third party vendors that have contracted with the payer to offer additional reimbursements, expedited payments and reduction of the patient
liability. Not all employers have elected a plan option that includes a “shared savings” option. A signed negotiation limits the rights that the provider and patient have to appeal or dispute a claims payment (processing). Providers should exercise caution and seek legal advice if they choose to negotiate independently.
• Benefit Maximum/Limitations
Recent legislation will abolish lifetime and annual maximums over the next few years, but the frequency of limitations placed on benefit “per diem” will continue to increase. In the past, this was limited to local area plans that targeted outpatient surgical centers by limiting the amount that could be paid to the center regardless of allowance. Current trends show that other provider types may also be affected in upcoming quarters, and providers need to be
Consider the level of service you will be providing and the amounts necessary to remain profitable and still provide the same excellent care. Your negotiations should consider the geographic location of your facility and its proximity to other hospitals and surgical facilities providing the same service, as well as the average rates reimbursed for similar services in the same setting.
Typically, in-network providers agree to set a “fee schedule” when entering into a contract with an insurance carrier. Reimbursement is based on the member’s specific benefit level, which may vary by service type. Compare in- and out-of-network rates to determine if a contract is financially beneficial. Should your facility choose to contract, consider the following conditions:
• Limit the contract to one year with a clause to renew • Carve-outs for higher cost procedure
• Clause to allow fee review and negotiation at least annually • Removal of overriding clauses, especially regarding fees
• Coding methodologies should adhere to Medicare guidelines or other guidelines available to the provider. Many plans have began applying “guidelines that the plan deems appropriate” but are not accessible and therefore cannot be reviewed for accuracy or enforced
• Clause to allow termination with or without cause, specify the time frame for termination. Example: 30 days with cause, 90 days without cause
Follow the plans process for filing the contract for review and consideration of changes, but request escalations to higher levels when necessary. If the payer will not accommodate the changes, then request that the clause be ammended to allow termination with cause if the provider does not agree with the chang-es made (Repetitive). Contracted providers should review their payments retrospectively to ensure that the plan is adhering to the executed agreement.
MediGain is a global full service revenue cycle management and healthcare analytics company devoted to improving billing, collections, and outcomes for healthcare providers and the patients they serve. With over 400 employees, MediGain provides solutions for physician groups, provider networks, ambulatory surgery centers and hospitals enabling them to reach their maximum potential through improved operational, financial, and clinical outcomes. For more information on how
MediGain can maximize revenue, reduce expenses and allow you to spend more time on providing your patients with quality healthcare, visit www.MediGain.com, call us at 888-244-4754 or email [email protected].
