How ASCs can build a business case for optimal payer contracts — 7 strategies

ASCs have a better shot at achieving reimbursement for high-cost supplies, implants or pharmaceuticals if they develop a strong business case tailored to each payer, according to ECG Management Consultants Principal Naya Kehayes.

EXPAREL® (bupivacaine liposome injectable suspension), a nonopioid postsurgical pain management local analgesic, became eligible for separate reimbursement for Medicare patients in Medicare-certified ASCs as of Jan. 1.

During a May 22 webinar sponsored by Pacira BioSciences, Inc., Ms. Kehayes explained how to make a strong case for covering EXPAREL® and other products in ASCs. Boston Out-Patient Surgical Suites Administrator Gregory P. DeConciliis and Nashville, Tenn.-based Envision Healthcare Regional Director of Managed Care Kevin Dowdy weighed in with tips based on their own experiences.

Here are seven strategies shared by the presenters:

1. Emphasize outcomes. A strong business case should include detailed information on the product's clinical results and how it can benefit patients. Mr. DeConciliis recommended customizing patient satisfaction surveys to collect negotiation-relevant information, such as the extent to which EXPAREL® improves pain scores.

"You can even tie in things like opioid use," Mr. DeConciliis said. "I've found that payers are really looking at opioid use and strategies to reduce opioids. So, if you capture that data and report it back to them, it'd be really key."

2. Communicate cost savings. It's essential to explain the benefits of shifting cases from the high-cost hospital setting to low-cost ASCs, Mr. Dowdy said. ASC administrators shouldn't shy away from estimating the potential savings opportunities they can deliver health plans.

"Framing quality in terms of cost mitigation may sound odd to us, but the expectation from the health plan side is the quality of care will be the same [as] — if not better than — what's provided in the hospital," he said.

3. Come to the table prepared. Ahead of negotiations, determine where reimbursement changes would have the biggest impact. If a certain payer comprises a large percentage of cases utilizing EXPAREL®, for instance, that may be the right payer to target for coverage.

The next step is reviewing each payer's specific methodology — such as the outpatient grouper method or fixed fee for service — because no two payers follow the exact same methodology. Ms. Kehayes explained this concept in depth during a prior webinar.

"Understanding the methodology, its limitations and/or opportunities will impact the approach [to] developing an effective business case," she said.

4. Collect useful data. ASCs should collect data over a time period long enough to identify trends, according to Ms. Kehayes. It could be beneficial to shed light on any change in case volume before and after adopting EXPAREL®. ASCs may also make their argument by using payers that already give adequate reimbursement as examples; if that coverage has facilitated the migration of cases to low-cost settings, be sure to point it out using blinded data.

5. Lay the groundwork for success. Negotiations can take up to a year to complete, so from the get-go, set timeline expectations for final contracted rates. To prevent delays, create an outline of key arguments supporting reimbursement for EXPAREL®, and develop a strategy for communicating those to the payer.

6. Get in front of the right person. Boston Out-Patient Surgical Suites has developed good working relationships with certain payer representatives, according to Mr. DeConciliis. These contacts can help get information in front of decision-makers at the insurance company.

"Utilize your contacts. Present the case to them, but ask them to take it up the ladder in the correct fashion," he said, explaining the importance of talking to the payer's medical director about procedures involving EXPAREL®. "When you have an MD on your side, it makes a world of difference."

7. Understand the payers' goals. Even with different payment methodologies, payers have one thing in common: a desire to minimize costs. It's essential to help payers understand how covering an item or implant supports the pursuit of that goal.

"Be prepared to educate. Part of this process is to help the health plan understand what you're asking for," Mr. Dowdy said. "Also, think about trying to anticipate questions they will ask; try not to have too many 'I'll get back to you' situations. Ultimately, all this information goes to the payer and helps them build their internal buyoff for your request, so do as much homework for them as you can."

To view the webinar, click here. To access the webinar slides, click here.

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