Is the payer outlook bright or dark for ASCs?

While some ASC administrators have seen payers become more accepting of outpatient surgeries and drive cases to the ASC, others report continued challenges in contract negotiations.

"The payer landscape for our ASC is very poor," Lynn Winter, RN, BSN, administrator of Advanced Surgical Care of St. Louis, told Becker's. "The payers continue to provide low allowable [charges] along with high deductibles. Often the entire allowable goes to the patients' deductible, and since the patients often are not in a position to pay the day of surgery, the number of patient responsibility aging claims continues to grow. Patients must pay their premiums to the payer, and in turn the payer applies the allowed charges to the patients' responsibility. For the payer it is, more times than not, a win-win. For the insured it is costly, and for the ASC it means low to zero reimbursement."

Taylor Cera, COO of Orthopaedic Surgery Center in Youngstown, Ohio, said payer contracts and insurance company practices keep him up at night. He is constantly reviewing payer contracts and maintains communication with local contract managers.

"We've already seen some new trends and new rules from insurance companies, specifically regarding preauthorizations in orthopedics," he said. "It has caused some issues in our flows and our processes, so I think continuously having those conversations and understanding things that are coming down the pipeline that are going to affect our internal processes is extremely important to know."

His center has made updates in the revenue cycle process based on significant changes from insurance companies and sees maintaining a clean and efficient revenue cycle process this year as a top priority.

Marie Yarborough, CASC, administrator of Skyway Surgery Center in Chico, Calif., is more optimistic.

"I feel that the payer landscape is improving for ASCs," she told Becker's. "We have big insurance companies finally realizing the ASC's cost effectiveness, lower infection rate and better quality outcomes, thus passing new policies to cover procedures in surgery centers. We have CMS working toward creating policies that will improve our reimbursements and are advocating cases away from the hospitals. We have hospitals succumbing to our presence in the market. I feel the more this is being driven, the more valuable our services will become."

Meredith Warf, administrator of Mississippi Sports Medicine & Orthopedic Center in Jackson, Miss., believes the future is bright for ASC contracting.

"As the ASC migration has only accelerated post-pandemic, payers seem ready to discuss strategies to make the ASC an excellent option for procedures such as lumbar fusions and cardiology," she said. "CMS publishing the goal of eliminating the inpatient-only list in a few short years has opened the door for many payers to consider the significant savings afforded in the ASC with better outcomes. Moreover, advancements in technology and data insight will help to redefine quality of care. We believe the risk-sharing with bundled care will expand to include arthroscopy among other subspecialties, incentivizing multidisciplinary plans of care and patient communication throughout recovery."

The trend toward price transparency and physician reimbursement models may also boost the payer landscape for ASCs. Hospitals are now required to post payer-specific negotiated rates online for 300 services and that could be a boon for surgery centers. Patients typically rely on physicians to determine their location of care and employed physicians often are unable to perform surgery outside of their network, Julie Nelson, RN, BSN, executive director of Elmhurst (Ill.) Outpatient Surgery Center told Becker's. As a result, employed physicians may perform cases at the hospital inpatient or outpatient departments, where overall reimbursement is often higher.

"I believe that private payers are starting to address this by providing reimbursement incentives to physicians to move their care to an ASC," said Ms. Nelson. "Physicians have recently communicated that BCBS is implementing a 30 percent variance in reimbursement for specific procedures based on hospital versus ASC locations. Because patients are so reliant on their physician to determine location of care, I believe that physician reimbursement models will have more of an impact on location of care than price transparency."

Copyright © 2024 Becker's Healthcare. All Rights Reserved. Privacy Policy. Cookie Policy. Linking and Reprinting Policy.


Featured Webinars

Featured Whitepapers

Featured Podcast