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Key trends in ASC payer policy, reimbursement and out-of-network today

Richa Singh is executive vice president of sales at Collect Rx.

Here, Ms. Singh outlines the big payer trends for ASCs today and what to expect for both in-network and out-of-network in the future.

Question: What are the most important trends you're seeing in the ASC field today?

Richa Singh: We see two major trends in the ASC field today as it relates to revenue and the financial outlook. The first is the overall reduction in payer reimbursements. This is achieved by what we call 'Payer Roadblocks,' defined as the barriers that payers put up to reduce and slow reimbursements. We're seeing across all payers significant increases in denials and underpayments, and significantly longer time to pay. This applies to both in- and out-of-network claims and includes both commercial and government payers. The good news is it is still possible to overturn these denials and underpayments, it just now takes more time, persistence, and expertise to do so.

The second trend is closely related. More and more ASCs are following the lead of larger healthcare institutions and outsourcing their revenue cycle management in an effort to combat the increasingly complex processes to obtaining fair and timely reimbursement from payers. There's more backlash than ever before against burdening patients with the negative effects of payer underpayments, and without experts on the providers' side leveling the playing field to get the appropriate payments, ASCs run the risk of incurring the same negative patient experience issues that hospitals have faced for some time. Outsourcing is a compelling answer to the problem, particularly for practices that have complex claims of all sorts.

Q: What are the key challenges keeping ASC administrators up at night?

RS: The most consistent challenge we hear from ASCs center around payer reimbursements and AR management, which means getting paid on time and accurately by the insurance companies. For physician leaders, we hear from most of our customers frustration about getting paid what they're due. For both contracted and out-of-network claims, payers are pretty dedicated to keeping their costs down, at the expense of providers. The roadblocks we referred to earlier are frustrating because they require so much additional time and expense to navigate for most practices and without the expertise in how to overcome the current set of barriers, efforts can be fairly unsuccessful. For administrators, finance and revenue cycle professionals, there’s a sense that they are leaving money on the table, and they never are 100 percent sure they are doing everything they can to get the reimbursements they're entitled to.

Q: What are the top one or two solutions to the big challenges you're seeing for ASCs today?

RS: We've identified two major solutions for our clients to resolve their revenue challenges: data and workflow technology supported by automated intelligence gathering. Leveraging these solutions allows providers to identify the claims that will yield the highest return for their efforts. By using AI, assisted information gathering technology, and historical data providers can identify the exceptions that haven't paid correctly or at the best rate, and prioritize them for follow up.

Workflow technology and data get the right claims to the front of the line to be worked most effectively and gain the highest rate of return. It also helps to identify denials before they happen so they can be fixed and get the initial payments faster. Without some form of automation, it's hit or miss which claims can be managed to gain the right reimbursements, and providers risk doing exactly what keeps them up at night, leaving money on the table.

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