'I have zero faith in our payers': Where ASCs are losing money with reimbursements

ASCs have long faced obstacles to reimbursements, and some leaders are finding increasing obstacles to securing necessary pay for procedures. 

Todd Neiss, business manager of Bismarck (N.D.) Surgical Associates, joined Becker's to discuss his organizations' obstacles with payers and claims. 

Editor's note: This interview was edited lightly for clarity and length.

Question: Where are ASCs losing money right now?

Todd Neiss: Where ASCs are losing money right now is with payers not processing claims correctly. They deny claims that should be paid or have a third party process claims that don't even follow the payers' policies and guidelines and they deny claims that should be paid. You fight for these claims to get paid, and they require you to appeal and you find out that the appeal is being sent to the same third party processor, and they automatically deny, citing the exact same reason the claim was denied in the first place. They didn't even look at the supporting documents included with the appeal outlining why the claim should be paid. Then finally, you are able to submit a second level appeal, which is then reviewed by the payer and you get someone who reviews the information and our claim gets paid.

There needs to be more regulation or standards that payers need to follow so providers can have some assurance that the claim they submit will get paid and paid timely.  Right now, I have zero faith in our payers. People want to know why the cost of healthcare is so high in America.  Look no further than the insurance Industry. If providers were paid what they should be paid for the work that is being done there would be opportunities to lower the cost of providing care  ASCs are already providing care at a lower cost and the government and payers are finally seeing the value ASCs provide.  

Q: What are ASCs biggest growth opportunities right now?

TN: If all payers required their patients to have their outpatient procedures performed in an ASC, where available, ASCs would automatically see growth in the cases they can perform and we would save the healthcare industry billions of dollars, which has already been proven by CMS and the studies they have performed. Instead, you have healthcare systems and payers colluding to make sure procedures are done in the hospital or the hospital outpatient departments, which winds up costing more money. These narrow networks that insurance companies offer because the health system is also selling insurance that requires the patient to be seen only by that health system is another thing wrong with the insurance industry. This is a conflict of interest and should not be allowed. 

Now, insurance companies are getting into the provider industry, and they will be doing the same exact thing by requiring their insured patients to only use providers owned by that insurance company. Patients need to fight to be seen by whichever provider they choose. This is the only true way we will be able to fix a healthcare industry that is broken. It is with competition and regulation to support fair competition. That will give ASCs a competitive advantage and will keep them as the low-cost alternative, which will provide them with opportunities for growth.

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