Insurers are deploying a growing arsenal of strategies to delay, deny or reduce reimbursements, creating major operational and financial strain for ASCs.
Becker’s spoke with two ASC leaders about the most common payer strategies they’re seeing and how the resultant delays are impacting their bottom lines.
Editor’s note: These responses have been lightly edited for clarity and length.
Question: What strategies are insurers using to delay, deny or reduce payments, and how has that impacted your revenue cycle?
Liliana Lehmann. President of Axis HealthCare Partners (Fort Lauderdale, Fla.):
- No prior authorization denial: Most of the time, the information has already been provided or there is a lack of clear communication regarding preauthorization requirements. Although most initially denied claims are paid, the administrative time and cost involved are appalling and hurt the cash flow of the center.
- Request for additional information denial: The required documentation may be a medical record, which usually was already submitted by the provider who rendered the services.
- Lack of medical necessity denial: The interpretation of medical necessity varies among the countless payer policies. The insurer’s refusal to pay for a procedure performed, even if the provider deems it necessary, can become a very intricate situation. Meanwhile, the ASC is denied reimbursement while the payor and healthcare provider discuss the medical facts of the case in question.
- Bundling denial: Rather than paying fees for two separate billable procedures, those procedures are grouped into a single code.
Marjorie Reiter. Administrator of Surgery Center of Central NJ (North Brunswick): We have increased the number of projects focusing on incorrect or no reimbursement, especially with new devices or pharmaceuticals used in Pre-Op and the OR (e.g., Dextenza, Iheezo, iDOSE). Even though we bill with what should be the correct codes, these are treated as a carve-out when that’s not the case, an exception to the contract or a flat-out refusal to pay. We have to go toe-to-toe with these payers. We are getting ready to renegotiate our contracts, so looking to change some of the language to address some of these issues and make things much more inclusive and reduce or eliminate the carve-outs. As long as Medicare reimburses, other payers should as well. We are certainly concerned about the developing issues with Medicare Advantage plans, so we will continue to monitor them closely.
