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Tip: Review EOBs

Ambulatory Surgery Reimbursement Update, September 30, 2008

Do you ever take a close look at your facility’s payer explanation of benefits (EOB) when they come in? It is well worth an ASC manager’s time to perform regular reviews of payer EOBs for denial reasons. Look for trends—this will give you a wealth of information on operational issues in your ASC that you can use to bring in your money more efficiently.

 Review payment documentation closely to see if the carrier or payer:

• Paid on all of the charges billed at the contract rate
• Denied any line items billed
• Included an explanation for any unpaid or unprocessed charges
• Changed anything (e.g., codes, charges, etc.) from your original billing (down-coded)
  

Correct any missing or incomplete information you can and resubmit the claim for reconsideration. If the payer denied the claim, proceed with the payer’s appeals process. Be aware of your payers’ requirements for submitting corrected claims.

For claim denials on EOBs, review denial reasons for internal operational issues that your facility can improve. Watch for the following:

• No coverage on the date of service. Verify and confirm this information during your insurance verification procedures on the front end, before performing the case.
• No precertification authorization obtained. This denial is preventable by assuring all procedures were precertified before performing the case and that you have reported any changes to procedures to the precertification company within 24 hours of the surgery.
• Bundled procedures. Sometimes a procedure is unbundled in the National Correct Coding Initiative material but is performed in a separate area, making it billable using modifier -59.
• Claim sent to the wrong payer. This denial is preventable by performing thorough insurance verification procedures on the front end. 
  

This tip is brought to you by Ellis Medical Consulting, Inc.

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