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facility, or a full- or part-time staffer) specifically to conduct pre-
admission calls and verify patients' insurance. Since you're not get-
ting paid for claims rejected due to a lack of eligibility verification,
the added expense may be worth it.
Denial management
Having an unclear or unsuccessful denial management strate-
gy is the fourth biggest reason facilities lose out on revenue. While
denial management can encompass several of the factors that we've
already mentioned, including coding inaccuracies or following up
on AR, one of the biggest aspects of your strategy is how you han-
dle unpaid claims and how you appeal rejections.
Since the appeal process varies, depending on your state and the
type of insurer you're dealing with, make sure your billing team is
educated on the process for each of your insurers. Make sure your
team has a good grasp of the payer's deadlines and how to weed
out which rejections are worth the time and effort of an appeal
(things like missing eligibility verification often aren't winnable).
One overlooked part of denial management is the monitoring of
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C O D I N G & B I L L I N G
2016 Outpatient Payment Rates
ASC payment rates will increase 0.3% in 2016, based on a projected inflation rate of
0.8% minus a 0.5% adjustment required by the Affordable Care Act. Hospital outpatient
departments, on the other hand, face a 0.3% decrease, based on a 2.4% market basket
rate minus a 0.5% adjustment for economy-wide productivity, a 0.2% adjustment
required by statute and a 2.0% reduction to correct previous overpayments. CMS is also
adding 17 new procedures to the ASC-payable list, including spinal stenosis and vagi-
nal hysterectomy. — Kendal Gapinski
