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6 payer updates affecting orthopedics, ASCs to know

The major payers across the country have entered into new partnerships and made updates affecting ASC and orthopedic payments this year.

Here are six updates to know:

1. CVS announced plans to launch a pilot program for Aetna knee replacement patients at the end of July. Few details were released about the program, but it aims to decrease readmissions and overall cost of care. The pilot will manage pre- and postoperative care for knee replacement patients through CVS pharmacy locations, an at-home clinical team and telehealth.

2. Aetna will change how it handles some ASC payment classification codes, starting Nov. 1. At that time, CPT/HCPCS codes generating ASC or APC error codes indicating Medicare doesn't cover a service also will not be covered for default Aetna payments.

3. Blue Cross Blue Shield of Minnesota changed its site-of-service policy in March to stop reimbursing hospitals for certain procedures. The company will only reimburse ASCs for seven forms of upper and lower gastrointestinal endoscopy, unless there isn't an ASC within 25 miles of the hospital.

4. Blue Cross Blue Shield also partnered with HFAP in March to include HFAP's Joint Replacement Certification With Distinction for ASCs in its BCBS Blue Distinction Specialty Care program. Both are designed to distinguish high-performing ASCs and hospitals, and ASCs with the distinction receive higher BCBS reimbursement for total joint replacements.

5. In March, Humana added more than 100 ASCs to its provider network through an agreement with SurgCenter Development. The company had 114 multispecialty, orthopedic-driven ASCs when the partnership occurred, and its physicians had performed more than 38,000 joint replacements.

6. Humana also expanded its spinal fusion and total joint replacement bundled payment program to add several new practices, most recently in July. The payer's bundled payment care model for Humana Medicare Advantage HMO and PPO health plan members now includes 75 medical practices in 21 states.

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