6 Points on Medicare Reimbursement Trends in Surgery Centers
1. Medicare is adding more procedures, particularly for orthopedics and spine. Medicare is adding more procedures that are typically inpatient level, and surgery centers — particularly those specializing in orthopedics — are gaining case volume as those procedures are approved, says Ms. Weaver. "Medicare continues to add CPT each year, and the spine procedures especially come into play," she says. "There are also discussions going on with the Ambulatory Surgery Center Association about the possibility of doing joints, and those are very positive."
2. Medicare is examining ASC procedures that are successful with commercial payors. ASCs across the country are doing total joint and partial joint replacements on non-Medicare patients — a promising step toward seeing Medicare add the procedures as well, says Ms. Weaver. "We are seeing this in ASCs in pockets across the country, including in Indiana, Wisconsin and Nevada — it's really coast to coast, but they're definitely popping up," she says. The success of these procedures with commercial payors is "setting the trend to have that discussion with Medicare."
3. Medicare's fee schedule increase has been fairly flat. ASCs will not see revenue increases based on increases on the fee schedule alone, says Ms. Weaver. "One cannot typically survive on Medicare alone in a center," she says. However, facilities can enhance Medicare reimbursement by ensuring that they are submitting clean claims. "Centers should conduct reviews to assure they are capturing all appropriate procedures on the claim, as a start," she says.
4. Medicare has added codes that accommodate high-cost supplies. According to Ms. Weaver, some of the medical surgical supplies being reimbursed by Medicare include J codes (drugs and pharmaceuticals), Q codes (including grafts) and P codes (including Albumin). "This is a positive trend over the past four to five years, and they continue to add to the list of items that can be reimbursed given the appropriate billing criteria," she says. "Medicare has become more flexible in terms of taking into account what we can do at surgery centers, how we need to bill and how we need to be reimbursed."
5. Medicare is reimbursing more device-intensive procedures. Ms. Weaver says that cardio simulator and pacemaker procedures, urology procedures, neurostimulator-related spine and pain management procedures and some ophthalmic and ENT device-intensive procedures are seeing greater reimbursement from Medicare in the ASC setting. This type of reimbursement began when we transitioned to the APC model, and continues to be enhanced to account for the high cost of performing these surgeries, she says.
6. ASCs should negotiate more aggressively with commercial payors. If a surgery center is struggling with Medicare reimbursement, another option is to take a second look at commercial payor contracts. "Be smarter and more aggressive with payor contracts if [the ASC] is in-network — I think that's where the opportunity is," says Ms. Weaver. "I've found that most payors, if you ask them in the appropriate way, will work with you on negotiating something within the reimbursement. People tend to sign their contracts and then they tend to forget about them — there has to be more of an active management of the payor contracts throughout the years."
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