As payer prior authorization requirements grow more complex, ASCs are increasingly caught in what one administrator describes as a “game of chicken” between patient care and financial survival.
Elisa Auguste, administrator at East Setauket, N.Y.-based Precision Care Surgery Center and vice president of the New York State Association of ASCs, joined Becker’s to discuss how the disconnect between payers, surgeons and ASCs is leading to delayed care, denied claims and mounting pressure on operations.
Editor’s note: Responses have been lightly edited for clarity and length.
Question: How have payer authorization and reimbursement practices changed over the last five years or so, and what has that meant for how your ASC operates day to day?
Elisa Auguste: The biggest change is that the ability to obtain authorization has gotten more difficult. I understand why part of it is a big push to avoid patients getting unnecessary treatments, but my concern is that with the authorization process, there are just more hoops to jump through.
They’re requiring patients to do all these noninvasive treatments. For example, if I see a patient as a surgeon and I know they have a certain kind of injury and I’m telling the payer they need surgery, the insurance company will often say something like: “No, we want them to do six weeks of [physical therapy]. We want to see an MRI.”
Now the insurance company is forcing unnecessary treatment. In their mind, they’re trying to force the patient to do all these conservative treatments to avoid the more expensive treatment, not realizing that if they still need surgery in the end, they will spend more money anyway and they’ve wasted both the patient and the surgeon’s time. I feel like they count on the fact that patients don’t want to jump through the hoops, and they’ll give up and say they can tolerate the pain. They count on that to save them money.
Every single year, there are new roadblocks to getting authorization, or the insurance companies are making changes in what they cover and what they don’t cover. I understand the reasoning, but I feel like there wasn’t enough input from actual medical providers on how to do this process in a way that’s not impeding patient care, while still protecting patients from that small minority of providers who may abuse the system.
Q: Can you dive a little deeper into this disconnect between payers and surgeons making real-time decisions?
EA: As an orthopedic facility, part of the problem is that the doctors are seeing the patients. Insurance companies are not. Cases get denied just to get denied, and then we’re doing peer-to-peers. I get complaints all the time that the person on the other side of the phone isn’t actually a surgeon like them, or isn’t in the same specialty. I’ve had a doctor tell me he’s fighting with an insurance company to get a rotator cuff surgery approved, and the person he’s talking to is a dentist. They hire retired physicians or surgeons, or people who have had issues with their licenses, to review cases. But it’s not actually peer-to-peer. Yes, the person’s a doctor, but if it’s not the same specialty, how are you going to be able to tell surgeons what to do with their patients? How is a dentist going to tell me whether I need rotator cuff surgery or not? Healthcare is way too expensive for that.
A patient comes in with a fracture and they need authorization. The person broke their wrist. You start getting to 10 to 14 days out, that person’s wrist is completely screwed. And you’re taking two weeks to decide about an authorization that I have to do a peer-to-peer for. It’s like a game of chicken — who’s going to bend first?
We have two options. The patient comes in with a fracture, we put in for authorization, and we can say, “You know what, we’re going to go ahead with the surgery anyway because obviously the patient needs it.” We don’t want to harm the patient, and we run the risk that we may not get authorization.
We’ve done it several times. We’ve done cases where we were waiting on authorization and we just went ahead so the patient wasn’t in pain and didn’t have issues, and then after the fact, it gets denied.
We chose that option, and now we’re doing it for free. And like I said, patient care is always the utmost priority. We will do cases for free where we don’t get paid. The problem is that it’s not a sustainable system.
It costs to provide healthcare. The average surgery case is about $2,000 to $2,500. Now to do that case for free, if I do three or four or five a month, that’s a lot of money. You have overhead, staffing, electricity, water. So it’s like we’re constantly giving and giving and giving, and when they just don’t want to pay, it’s not sustainable.
