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Navigating the healthcare reimbursement landscape — OMNI Surgery Center administrator John Paoni on out-of-network reimbursement and the future of healthcare

New York City-based OMNI Surgery Center Administrator John Paoni is passionate about ASC reimbursement.

Mr. Paoni recently renegotiated his center's contracts to ensure the carriers at his ASC are all in-network.

He spoke to Becker's ASC Review about reimbursement and its possible future.

Note: Edited lightly for style and clarity.

Question: How are surgery centers adopting in this decreasing out-of-network landscape?

John Paoni: Patients prefer the ASC setting versus the hospital setting. The carriers also prefer the ASC setting as it results in a lower cost of procedure.

In our area, we are out of network with [Blue Cross Blue Shield]. We have had a very challenging time trying to get our managed care plan in place, with little success.

As [more] patients prefer ASCs, that will result in more procedures scheduled at the ASC instead of the hospital. That will bring in more patient and case volumes to the ASC.

Q: If a center wanted to try to keep all its business out-of-network, is it possible in this landscape and how would they do it?

JP: An ASC can elect to not become in-network with any carrier by simply not filling out the credentialing application.

But you will need to look closely at each plan.

They all offer different policies.

The ASC needs to understand the out-of-network coinsurance for each carrier and policy. It will likely result in a large out of pocket expense to the patient. Many patients may not be able to carry that additional cost of a procedure. Combine that with a co-pay and meeting a deductible and the patient ends up with a large amount due to the surgery center.

Q: What do you think the landscape will look like five years down the road?

JP: I think that healthcare is at a pivot point.

I am eager to see what our current administration will do.

We have to develop a better, more affordable way to pay for healthcare, but our current system is extremely complex and it will definitely take a very long time to get it to a point of affordability.

I am optimistic that within five years from now deductibles will be lower but the cost of care will continue to rise. Premiums will continue to skyrocket and carriers will stop allowing coverage for many different procedures if we don’t get ourselves on track.

Learn more from Mr. Paoni at the 24th Annual Meeting: The Business and Operations of ASCs in October 2017. Click here for more information.

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