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Insurers send mixed signals to ASCs, physicians

Insurers are sending mixed messages to ASCs and independent physicians. On one hand, they want surgery centers and physicians to stay independent to keep costs low; on the other, they are increasing prior authorizations and denial policies that make it harder to get surgeries approved.

"The biggest challenge to providers in providing exceptional and timely patient care today is largely the commercial insurers whose policies and protocols often lead to unnecessary delays and denials," said Judith Gorelick, MD, a neurosurgeon with Neurosurgery, Orthopaedics & Spine Specialists in Waterbury, Conn. "This is frustrating both to the patients, who don’t understand the issues and simply want treatment and to feel better, as well as to providers who have their hands tied in providing appropriate and efficient treatment."

Many ASC physicians and administrators report insurers are keeping their rates low despite rising inflation for overall costs of running a business. Still, cumbersome prior authorization restrictions have some surgery centers and physicians considering direct contracting with employers, cash pay, or other alternatives to the traditional insurance company model. Others are selling their practices to hospitals or taking on private equity investment to build the infrastructure to support more complex revenue cycle processes.

Consolidation is helpful for ASCs and physician groups aiming to get deeper into value-based care arrangements, which require sophisticated data-gathering and analyzing infrastructure.

But consolidation isn't good news for insurers because costs for medical care go up and patient satisfaction often goes down, according to studies published in Health Affairs. That's why insurers are stepping in to help independent physician groups stay that way.

This week Blue Cross Blue Shield of Michigan created a joint venture with Honest Medical Group, based in Nashville, Tenn., to help physician organizations make the transition to full financial accountability for Medicare and Medicare Advantage beneficiaries. The venture will help upgrade EHRs, billing systems, virtual care capabilities and more to improve care and reduce costs.

Blue Cross Blue Shield of Michigan is just the latest example of an insurer aiming to support private practice. Last year, Blue Cross Blue Shield of North Carolina created a similar joint venture with healthcare investment firm Deerfield Management Co., to provide a management structure for independent groups.

Gail Boudreaux, president and CEO of Anthem, has also said the insurer's goal is to keep practices independent.


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