Wiki When an ASC starts as a non-contractor facility how do you handle this?


Pensacola , Florida
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:confused: -I have worked for asc's who are 98% in contract, but now a fairly new one who is not contracting with payers I suppose to help financially ( double edged sword ?? )

so how do I handle billing; coding and pricing for an ASC when they are not in contract with payers? Are they able to do whatever they want - will this make adjudication more difficult ? Or , well there is no adjudication you just "accept" whatever they pay ?? How do you keep them on track and fair ?
If there is no contract how do you know what they should have paid ? :confused:

Anyone involved in this now or in the past I could use your advice and help !! - this concerns me a lot!

go to the nearest Walmart and buy as many bottles of Ibuprofen as you can fit in your cart.

just kidding..well kinda.

The billing, coding, pricing isnt going to matter, thats all done the same.
The part that becomes an issue is going to be on the back end and the appeals etc. It will be extremely important to let each and every individual that comes through your doors know that you are non-par with their carrier. It would be quite beneficial for your ASC to collect the patient portion up front as otherwise you may have a difficult time getting it. You can not just accept what the carrier pays and write the rest off, the balance remaining will be the patient responsibility and they should be billed accordingly. Most carriers base their processing for non par under what they call "reasonable and necessary", but it really doesnt matter what they deam R/N because the patient is still responsible for the balance on the account.

Be cautious with BCBS patients, as they tend to send the payment dirrectly to the patient when you are not a contracted provider. We had a patient receive a check for 19K and never paid us...left the state..gone...history COLLECTIONS!!

I do not envy you.

Good Luck and hope this sheds some light on what you are up against.
OMGOSH !! I have to first of all THANK YOU for being so straight forward and to the point ! Honestly I really appreciate it ...however, now that I have gotten up off the floor can I ask you for any tips, advice on dealing with the payers such as BCBS can I prevent the payer paying the pt from the start ? So , since they pay R/N there is no knowing what they will pay or "should pay" ?...we just have to accept whatever the payer sends and bill the rest ? I didn't think this was going to be easy...but I do love a challenge !! So here goes!
Now...can I ask for anyone out there ...including you True Blue to be able to email you when I need some advice ? I could really use someone to bounce some things off of ... thanks!

Reasonable and customary amounts are determined by each individual payer. Wouldn't it be fair to say that your rates ARE reasonable and customary for your area? That said, non contracted payers that allow less than your billed charge should be considered underpaid. The benefit % may be less due to your NON Par status (i.e instead of 90/10 insurance may pay 70/30) and patient may have a higher out of network deductible. Aside from informing the patient's of NON Par status upfront, you should consider initiating appeal guidelines. We call these "courtesy appeals" (consider templates) on the patient's behalf. These courtesy appeals let the patient know that we feel their insurance has underpaid AND, if deductible/co-pay was not collected upfront, allows us to balance bill the patient at the same time. If the insurance makes additional payment, patient overpayment, if any, is then refunded to the patient.

Julie D, CPC
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There is no way to prevent BCBS from paying the patient since there is no contract between your ASC and the carrier.

you are welcome to e-mail me anytime and i'll try to help you :)