6 Tips to Overcome Payor Concerns With Spine Surgery in ASCs

Barbara Cataletto on spine coding in ASCsAmbulatory surgery centers are now able to bring spine procedures — including spinal fusions — into the outpatient setting. However, some ASCs are having a hard time finding payors who will reimburse for those procedures.

"I think there is a great opportunity for ASCs to incorporate spine, but it's not going to happen on demand," says Barbara Cataletto, founder and CEO of Business Dynamics. "ASCs must forecast costs, reduce rates and make it more appealing for the carrier to approve those procedures. They also have to enhance the patient experience, and outcomes will be extremely important — and should be seriously considered — when moving some of those procedures into the outpatient setting. When done right, all these things will drive spine procedures into the ASC."

Ms. Cataletto discusses six important tips to overcome the major concerns payors have about approving spine surgery in ASCs.

1. Provide evidence showing transfers are unlikely.
In some markets payors may be unwilling to consider reimbursement for spinal procedures in the ambulatory surgery center setting because they are concerned about transfer rates. They still consider spine surgery a big open procedure and are skeptical that it can be done in an outpatient setting.

"The transition of inpatient to outpatient spine surgery has been challenging for hospitals that have their own outpatient facilities," says Ms. Cataletto. "When you couple that with freestanding ASCs, payors wonder whether there will be a failure and transfer from the ASC. Carriers are reluctant to allow these types of procedures, especially fusions, in the ASC because of failure rates during postoperative treatment."

Even the occasional issue or transfer causes concern, and Medicare currently doesn't reimburse for any spine procedures in the ASC. Surgery centers need to break that barrier by showing these procedures can be performed safely in an outpatient setting.

2. Educate payors on new less invasive techniques.
New instrumentation and techniques have allowed spine surgeons to accomplish the traditional open surgeries through a less invasive approach, which means patients no longer need extended postoperative recoveries.

"The payors are looking for the lowest risk possible in the overall procedure," says Ms. Cataletto. "Stick with the same fusion procedure and build a track record of successful fusions to present to each different carrier in the market. You might have to do it carrier by carrier to get carve-outs allowing your ASC to perform those services if the carrier agrees it is an acceptable risk."

Surgery centers can work with certain carriers on the initial cases to show they are proficient with these procedures. "ASCs should have a track record of postoperative and intraoperative complications, even if it's not in spine, and track records on operational costs," says Ms. Cataletto. "Use past experiences to show you are worthy of performing these procedures. These standards of proof show the ASC's procedure standards are beyond those that would be expected at an inpatient facility."

3. Negotiate in-network contracts.
Some ambulatory surgery centers have problems performing spinal surgeries because they aren't contracted in-network. Staying out-of-network significantly increases the cost for insurance companies and they are unlikely to approve these expensive procedures in a surgery center when the savings aren't significant from the hospital.

"It would behoove the ASC to not only show that their facility can manage these cases, but also that they are willing to negotiate a case rate," says Ms. Cataletto. "They can ask for one without expecting to yield to the other case rate scenario."

4. Gain preoperative authorization for the ASC.
Same day surgery does not require an authorization in many cases, but for spine procedures payors may refuse to reimburse if it's not preauthorized for the ambulatory setting. Staff members need to mention an ASC as the surgical site to capture reimbursement.

"If the staff calls up and asks for authorization for a case and is told that it's not necessary, and then the surgeon performs the procedure, they may find themselves in a denial situation," says Ms. Cataletto. "ASCs are obligated to identify the procedure and find out if the carrier will cover it in the ASC setting."

5. Avoid using unlisted codes.
Whenever ASCs use an unlisted code they are challenged for reimbursement because the unlisted code signifies "experimental" to the payor. Payors often don't want to reimburse for "experimental" treatments in the outpatient or inpatient setting.

"When you are doing procedures with unlisted codes, you have to make sure the carrier covers them," says Ms. Cataletto. "Most carriers clearly identify non-covered items on their websites. Trying to sneak the procedure in the back door and then fighting for reimbursement afterwards isn't the way to go because then the patient is charged for the service."

6. Leave bundled codes bundled.
Ambulatory surgery centers must make sure they are coding spine procedures correctly, especially for bundled codes. There are some surgery centers that are inappropriately unbundling a series of codes which leads to higher charges than the insurance company will pay.

"The high charges submitted by the ASC is over billing," says Ms. Cataletto. "If the surgery center unbundles the codes for a discectomy, the payor will wonder why it costs $80,000 at the ASC when it could be done cheaper at another facility. Getting back to the acceptable norms for coding and charge levels has to happen if the ASC is to be taken seriously."

Make sure the coding and reimbursement levels are normal for the ASC's market. The bundling of codes means lower reimbursement, but it is necessary for the surgery centers to perform these procedures. "I believe the bundling trend will continue in the future, especially for new technology procedures," says Ms. Cataletto.

More Articles on Spine Surgery:

8 Important Spinal Technology Advances Heading Into 2013

5 Ways Independent Spine Surgeons Contribute to Spinal Research

12 Steps for Spine Surgeons to Take Now Before Bush Tax Cuts Expire

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