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ASC payer landscape: 4 insights from administrators & leaders

Four ASC administrators and executives share their observations on the payer landscape and where they see the best opportunities in the future.

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Benita Tapia. Administrator of 90210 Surgery Medical Center (Beverly Hills, Calif.): There has been a tremendous change in the payer landscape and value-based care is definitely the trend. Payers are making it difficult for ASCs to sustain out-of-network, and we are seeing max per day rates on OON cases some as low as $350 with some paid at a percentage of Medicare, which means larger deductibles and a larger coinsurance that the patient has to pay. This makes it not cost effective for the patient or the ASC to do the case OON.

We are seeing more and more bundled payments and incentives for surgeons to bring eligible patients into the ASC environment, and payers are sometimes stating if the patient is eligible, to go to the ASC for some procedures. The procedure may only be reimbursed in the ASC and not the hospital environment. I would predict that in the future we will see more incentives for the patient to go to an in-network facility, especially if the bundled payment methodology is chosen. There would be less deductible and copayments for the facility and increased reimbursement for physicians using the in-network facility and participating in the bundled payment methodology.

Joy Taylor, JD. COO of Polaris Spine & Neurosurgery Center (Atlanta): While the out-of-network opportunity has narrowed, it hasn't altogether disappeared, depending on the geographic region. We are learning all we can about how to continue to maximize that, where it makes sense to, while we still can. CollectRX has been a valuable partner in that area. We have also worked to expand some of our more "niche" work in workers' compensation and personal injury. While these will never be the bulk of what we do, they are a nice complement to our other payers, often having appreciably higher reimbursements, in addition to expanding our market.

We also find ourselves in the complex intersection of having multiple physician owners opted out of Medicare, which has proven a great strategy from an opportunity cost standpoint, but also means we do no Medicare cases in the surgery center at all. As the government is increasingly enmeshed in healthcare, we vigilantly monitor these developments.

Catherine Ruppe, RN, CASC. Executive Director of Proliance Highlands Surgery Center (Issaquah, Wash.), Overlake Surgery Center (Bellevue, Wash.) and Redmond (Wash.) Surgery Center: You have to be much more cost-conscious today when you are scheduling cases than you did in the past. Some of the orthopedic procedures used to have multiple codes involved, such as ACL surgeries, and now they are bundled to just one code, which hurts the reimbursement rate.

We have also noticed that for some of the big payers, there is more preparation work to do and paperwork to fill out to show the conservative treatment has been done. Our mountain of paperwork grows every day and adds cost to the case because our staff is taking another 10 to 15 minutes than usual to schedule the case. That time all adds up.

Michael McClain. Executive Director of Proliance Orthopedic Associates (Renton, Wash.): Payer consolidation is a huge challenge for us. Payers are moving in as operators such as Kaiser or Optum; what does that mean for ASCS? Does that help drive reimbursement or make it more likely a small subset of centers will excel based on who they affiliate with in terms of operations? There is a potential for payer partnerships to go very well if the payers are involved directly, such as co-businesses that are involved with ASCs, because payers may finally understand the significant savings with surgery centers. But you do have to worry about whether payers are coming to the table with a value proposition for the center or just because it would further define the exclusivity of their narrow networks. This has the potential to give the payer a huge amount of direct information about what makes a successful ASC and practice, and what doesn't, as well as what value really is.

If a payer has access to all contracts in a particular market and knows what everyone is paid, it's difficult to successfully negotiate a new facility because the payer knows more than you do. Payer consolidation represents all sorts of potential risks. A successful administrator today is a lot more savvy, or needs to be more savvy about the greater healthcare environment considering payers, politics and the relationship between healthcare facilities in the community than they used to be. You have to be much more astute and educated about what is going on around you today. What used to be your competitor might be your partner in the next month, or an enemy might partner with another one of your enemies.

More articles on surgery centers:
CMS proposes 2% ASC pay increase in 2019: 5 key notes
10 big changes CMS proposes for ASC, outpatient payments
House passes ASC Payment Transparency Act: 6 things to know

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