One of the top issues for ASC’s for pain management billing is insurance verification, so it is important to do due diligence up front with patients.  Many employers are going self-funded, including medium and small groups, so it is important to know who is paying you and how it pays.


Self-funded        26% of medium employers (100 to 499 employees)

82% of large employers (500+ employees)

Source: US Dept of HHS


We are seeing this self-insuring increase at a very rapid pace.  Many payers are targeting companies that have 25 employees or more for marketing in order to get them to self-insure as a means to save cost.  In addition to the standard financial classes, your ambulatory surgery center (ASC) should add and track self-funded as a class of payer.  There are a number of changes that happen to the summary plan description and they have nothing to do with the actual insurance carrier administering the plan, these are just a way the employer decides a claim will pay.  Understanding those rules and requirements is critical to getting paid, just like for any other payer.


You can go to to check benefits.  You may need to go straight to the benefits page of the website of a self-insured employer plan, e.g. Disney, American Airlines, etc.  Can find specific details like American Airlines out of network claims allowed amount will be limited effective June 1, 2015, to 140% of the Medicare rate.  Disney and other payers also often publish their maximum allowable rate.


Make sure to research and document their rules and requirements, and then put them into payer rules in your billing system in order to ensure that claims do not get denied and get paid correctly.


Just as with insurance verification, a lot of ambulatory surgery centers rely on the pain management billing professional authorization in order to get reimbursed and today that will not suffice to ensure you get paid.  ASC’s need to call themselves and get their own auth.  For example, if the pain management physician is participating (in network) with that insurance plan and the ASC is out of network, when the professional’s office calls to get an auth, they are calling from an in network professional group and there is often a distinction.  So when they get a notice that an auth is not required, the surgery center may often still need an auth for that particular procedure.  When getting that auth, make sure to get specific CPT codes or a range of CPT codes for that pre-authorization.  It is getting harder and harder to get retro auths approved, and that includes adding or changing CPTs.  Remember that payers are looking for an excuse to deny your claim, so don’t give them one.


About Apache Health

Apache Health is a revenue cycle management (RCM) analytics, benchmarking, and auditing company. The founders of Apache formerly ran a large RCM company that was acquired by a private equity group in a rollup. Apache’s predictive analytics will benchmark billing performance and project exactly how much more revenue you should earn from your existing volume of patients.  Using many factors and a blend of artificial intelligence and specialty specific benchmarks, the model projects whether changing the billing process would improve collections for your particular mix of procedures and payers. Apache Health can help you evaluate whether to outsource the billing, determine which billing company to select to maximize performance, or track in-house billing performance improvement over time. For more information contact:


Sean McSweeney

Apache Health