Ambulatory Surgical Centers Are On The Rise And So Are Their Unpaid Commercial Health Insurance Claims

Surgical centers are growing in number. These clinics, also known as ambulatory surgical centers, specialize in outpatient surgeries where the patient goes home after a short (usually a few hour long) recovery period. Since these surgeries require less aftercare and can be done in a specialized center as opposed to a full hospital, they are favored by both patients and healthcare workers. The billing process for these centers is similar to that of most hospitals. This means that they go through the same amount of state-level appeals before those unpaid and underpaid commercial health insurance claims cause a problem.

Surgical Centers Are Becoming Increasingly Popular

According to a report published by Becker’s ASC Review, the number of ambulatory surgical centers run by ophthalmologists exploded in the northeastern part of the United States last year. The four places that this report focuses on are in different states – Massachusetts, Pennsylvania, New York, and New Jersey – but they are representative of the rest of the United States. To put it simply, these surgical centers are opening up at an almost exponential rate. Their success hinges on two different factors: the number of patients going to them and the payment rates of commercial health insurance companies.

A 2016 report, also published by Becker’s sheds some light on the surgical centers. According to it, 56% of them saw more patients than they did the previous year. This is in stark contrast to those that had fewer patients – a mere 12% of them. The quality statistics listed are quite good, although what really matters here are the ones related to the revenue cycle. In 2016, the average payment time for claims was around 30 days, with 12% of them going past 90 days. Less than 5% of the claims were denied outright, and the net collection rate was an impressive 97%.

These lead you to believe that these surgical centers don’t need to worry about the unpaid or underpaid claims. However, the truth is that none of those statistics include an amount. We don’t know if that 97% includes the smaller claims, making the larger ones fall into the pile of unpaid ones. The results might be lopsided, meaning that those surgical centers could be in danger of running out of revenue.

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Billing Issues at Surgical Centers

Like with most billing departments, the ones at these surgical centers have a number of codes that they need to keep track of. Every commercial health insurance company has a contract with the surgical center. This information includes how much the surgical center can bill for certain procedures, as well as how those claims are sent in. Most are sent electronically to the insurance companies, making it easy to track them. The problem comes when mistakes are made in the billing process. Sometimes things end up getting miscoded, or the wrong amount is requested. When those claims are sent back to the surgical center, it’s up to the billing employees to double-check them and then resubmit them. This resubmission is the first of their state-level appeals. Only three are allowed.

In most cases (as you can see from the statistics included above) most claims are paid by the end of the three appeals. The problem comes when they aren’t. No matter the reason for the unpaid or underpaid commercial health insurance claims, these finished appeals can cause a number of problems.

State Level Appeals Lead To Unpaid Claims

Every surgical center has three state-level appeals that they go through when trying to collect on a commercial health insurance plan. The ways in which the appeals are done depends on the insurance company itself. Every one of them has a different form, another process, and sometimes a separate address that those claims need to be sent to. This just makes it more difficult for the surgical center’s billing employees. They need to know the specifics and have enough time to deal with each round of appeals. There’s usually a lot of paperwork involved. What makes this even trickier is the time frame.

According to the statistics in Becker’s most of these claims are sent out for payment within three days of the surgery. The time that it takes to wade through the codes and billing documents to find the correct forms is what generally leads to these delays. Without those specifics, the process would move much faster. It gets even worse when you consider what happens when those claims are sent back unpaid or underpaid. You only receive three state-level appeals on these claims before they end up being shelved for good. At that point, they end up in what we call a debt bucket, on the wrong side of the balance sheet. If those add up enough – and the rate of fully paid claims begins to fall precipitously – then your surgical center ends up in financial hot water.

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Unpaid Claims Can Lead To Unpaid Bills

Surgical centers have quite a few bills to pay, including the surgeons and supporting doctors and nurses, their utilities, any building maintenance and upkeep, and necessary supplies. Without a cash flow that consists of 100% paid claims, your surgical center could end up in financial trouble. There’s also the issue of the “boom period” that surgical centers are in. The need and market for them could end up shrinking, making these unpaid claims even more important.  

Federal ERISA Law Can Ensure That Those Claims Are Paid

Thankfully, there’s an option when it comes to those reject surgical center claims – the Federal ERISA appeals process. ERISA, also known as the Employee Retirement Income Security Act, is a method used by specialists to ensure that those commercial healthcare claims get paid. According to ERISA, which was created to govern employee retirement plans and then expanded to include self-paid health insurance, those unpaid commercial healthcare claims must be paid. However, this is a specialized and time-consuming process.

The main issue is that the surgical center billing employees don’t have the time to go through the Federal ERISA appeals process. These billing employees more than likely don’t know how even to begin such an appeal, nor do they have access to complete the paperwork and follow up on them. They’re too busy sending out bills for current claims, as well as dealing with those that are in still working through the state level process. All of that money – which these surgical centers really could use – is going uncollected. You need us, ERISA Recovery, to handle the Federal ERISA appeals for you. We don’t require any payment up front and even have a 12-month $1 million guarantee. To be specific, we guarantee that we’ll collect $1 million in claims for you over a 12-month period, as long as we have access to the information that we need.


It’s time for you to take control of your surgical center’s financial future. You need to ensure that your collection rate from commercial health insurance companies is 100%. This is why you need to contact ERISA Recovery today so that we can help put the Federal ERISA appeals process in motion. You can reach us at (972) 331-4140 or by filling out the contact form on our website.