Revenue in the ASC market is estimated to hit $43 billion in 2021, an increase of 54 percent from 2015, according to a report from Bain & Co. In contrast, the number of procedures performed in ASCs is estimated to hit 27 million in 2021, an increase of 35 percent from 2015. This highlights the movement of high-acuity, high-reimbursing specialties into outpatient settings as revenue growth is outpacing procedure growth.
This growth in revenue and high-acuity procedures, driven by advancements in medical technology, cost savings and convenience, presents a huge opportunity for ASCs to strengthen their margins and boost equity value, explained Nader Samii, JD, MBA, CEO of National Medical Billing Services in a Sept. 29 webinar.
Mr. Samii was joined by two other experts from National Medical Billing Services, Kylie Kaczor, MSN, RN, senior vice president clinical and regulatory affairs, and Scott Allen, vice president of managed care contracting, to discuss how ASCs can capitalize on the anticipated growth trends, strengthen their profitability and improve payer contracting.
The webinar was sponsored by NMBS and hosted by Becker's ASC Review.
Here are five key ways ASCs can capitalize on the growth:
1. ASCs can strengthen their margins and value by adding complex, high-reimbursing procedures. Mr. Samii described a scenario in which a 300-case per month surgery center could increase their high-acuity procedure volume by 30 cases per month to double their annualized EBITDA and see a revenue increase of 60 percent. For example, if a $7.2 million surgery center added a total joints program that saw 30 cases per month at $11,000 cash per case, the center would add $4 million in revenue per year and increase their annual EBITDA from $1.4 million to $3.4 million.
"There are very few things, very few opportunities in life where you can create that type of financial impact … than the opportunity presented right now in the surgery center market," Mr. Samii said.
2. ASCs should read up on state and federal regulations before adding complex care. Reviewing state laws for limitations on procedure types in ASC settings is key, Ms. Kaczor said. For example, in Pennsylvania, ASCs are required to notify the state in writing 60 days before starting to offer a new service. CMS is also working to transition 300 musculoskeletal services off of the inpatient only list, explained Ms. Kaczor. Staying on top of these regulations will help ASCs determine what procedures they want to add.
3. ASCs should prioritize accurate clinical documentation. Accurate clinical documentation is important to prevent denials and ensure proper reimbursement. However, it is especially important when adding a new procedure into the center, explained Ms. Kaczor. The reason is because Medicare consistently audits procedures recently added to a new site of service. "We expect Medicare to be reviewing these procedures for medical necessity, which means your documentation is critical to the success of your program," Ms. Kaczor said.
4. ASCs should prioritize getting managed care contracts right.Surgery centers will only see the reimbursement they desire if their managed care contracts are set up properly, explained Mr. Allen. This begins by gathering complete contracts, including crosswalks, fee schedules and amendments. After the full contract is on file, centers should analyze and ensure employees understand the contract language and what it dictates for every part of the revenue cycle process.
ASCs should also ensure the contracts are comprehensive in that they account for the full case, including how much is reimbursed with the primary code, implants and code combinations. Further, how payers will adjudicate multiple procedure codes in a single case, Mr. Allen explained.
5. ASCs should provide payers solid data when negotiating contracts for new procedures. Prior to heading to the table to negotiate with payers about adding a new procedure in orthopedics and spine, ASCs should detail outcomes and performance data, understand what is not making sense currently in terms of reimbursement, and research how many procedures of that type are being performed outside of the surgery center, Mr. Allen said. In addition, if a center wants to hire a surgeon to perform a new procedure, including that physician's information and case data into negotiations is helpful.
To learn more about setting up managed care contracts and steps ASCs can take to capitalize on the projected growth, listen to the full webinar here.
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