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CMS, commercial payers pushing procedures to ASCs

CMS and commercial payers are adopting new policies that push providers and patients out of the hospital and into surgery centers, The National Law Review reported Feb. 24.

What you should know:

1. UnitedHealthcare and Anthem both adopted policies that restrict sites of care for some elective surgical procedures. UHC adopted its policy in November 2019. The payer only reimburses for surgical procedures performed in hospital outpatient departments if the setting was medically necessary. When adopting the policy, UHC said the restrictions would save beneficiaries $500 million in 2020.

2. Anthem adopted a similar policy in 15 states in August 2020. Anthem will only allow procedures in an HOPD if the procedure is too complex for an ASC or if the individual is too high-risk for an ASC.

3. While CMS hasn't adopted a policy like this, it has developed payment policies aimed at reducing cost of care and continues to add procedures to the ASC-payable list. The National Law Review pointed to CMS continuing migration of total joint replacements to the ASC setting as a way the government is looking to cut costs around healthcare delivery.

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