Step 1: Patient Registration and Insurance Verification

This is the first and the most critical step in ASC billing. Herein, patient’s insurance details, demographic information, and other relevant details are collected and verified to ensure they are eligible for reimbursement.

Step 2: Procedure Documentation

Herein, the surgical procedures performed, including any additional services provided during the same visit (e.g., anesthesia, pathology) are accurately documented.

Step 3: Medical Coding

In this step of ASC billing, specific codes are assigned to the procedures performed using standardized coding systems like CPT (Current Procedural Terminology) codes. Accurate coding is vital for claim submission and reimbursement.

Step 4: Claim Creation

Herein, important information, including coded procedures, patient demographics, costs associated with the procedure, and other relevant information, is compiled to create a claim for the patient with details of the services provided.

Step 5: Claim Submission

Herein, claims are submitted to the related insurance companies or third-party payers electronically or manually. Timely submission of claims helps prevent delays in processing of the same.

Step 6: Claim Adjudication

In this step of the ASC billing process, the insurance companies review the submitted claims, evaluating the coding accuracy, medical necessity, and other factors. It helps in determining the reimbursement amount based on the patient’s insurance plan.

Step 7: Payment Posting

In this step, the ASC receives the appropriate payment once the claims are approved by the insurance companies. The billing team then posts these payments, reconciling them with the claims submitted to ensure proper reimbursement.

Step 8: Denial Management

If a claim is denied, the billing team investigates the reason for the denial. They take appropriate actions to appeal or rectify the issue, which may involve re-submitting the claim with additional documentation.

Step 9: Patient Billing and Collections

Herein, the billing team generates patient bills in case there are deductibles or copayments apart from the insurance coverage. They then communicate with patients to facilitate the payment. This step in ASC billing ensures that the ASC receives the revenue owed.

Step 10: Reporting and Analysis

Next, the data regarding claim denials, reimbursement rates, billing performance, and overall revenue cycle metrics are thoroughly analyzed to identify opportunities for process improvement, optimized revenue capture, and enhanced operational efficiency. After proper analysis, a report is generated to present all findings and suggest ways to improve the process efficiency.

Step 11: Compliance and Auditing

This step ensures that ASC billing practices comply with healthcare regulations, coding guidelines and payer policies. It is performed by conducting periodic audits to verify accuracy and adherence to industry standards, promoting ethical billing practices.