Payer behavior ASC execs see more of these days

Payer policies and strategies are evolving as more surgeries become approved in the outpatient setting.

Some centers are seeing more willingness to pay for high-acuity cases, such as total joint replacement and spine surgery, while others are witnessing more intense scrutiny of their claims. Matthew Ewasko, administrator of Physicians Alliance Surgery Center and surgical services business analyst at St. Francis Healthcare System in Cape Girardeau, Mo., said he is seeing an uptick in commercial payer audit requests, especially for the center's orthopedic procedures.

"We're doing more and more with our commercial payers wanting to fulfill audits to make sure that they reimbursed us correctly," he said. "Even though they reimbursed claims correctly, according to our contract, they want to make sure we have all our ducks in a line. That means we get a lot of medical record requests. Historically at our facility, we didn't have many requests at all, but recently we have started to see an increase from all of our payers."

CMS and commercial payers are also calling for more prior authorizations, which makes it more challenging for surgeons to gain approval and payment for procedures in ASCs. CMS moved forward with its plan to require preauthorization for cervical fusions in hospital outpatient departments July 1, and surgeons have been critical of the change. Commercial insurers also have varying prior authorization policies that can leave patients without necessary surgery.

"It is interesting to see the variability in medical guidelines among the insurance companies," said Alok Sharan, MD, of NJ Spine and Wellness in East Brunswick, N.J. "I've had instances where a patient was denied spine surgery by one insurance company. They enrolled in another insurance plan and were subsequently approved for surgery. This contradiction clearly is not good for delivering high-value patient care."

Ophthalmologists are also noting "excessive" prior authorization requirements by payers and a downward trend in overall reimbursement.

Howard Katzman, MD, an ophthalmologist at St. Mark's Outpatient Surgery Center in Salt Lake City, told Becker's he's seeing reimbursement decline from private payers as well. UnitedHealthcare, in particular, has been most aggressively pursuing prior authorizations, he said.

"Their reimbursement for cataract procedures for freestanding ASCs has dropped so low that it's insane. If it wasn't for elective procedures — such as premium lenses, multifocals, astigmatism-correcting lenses and toric lenses — I don't think ophthalmologists could make a meal out of it," Dr. Katzman said. "It's crazy to go back and compare their reimbursement from 10 years ago to today. It's disheartening."

ASC owners and operators are also concerned about payer consolidations and monopolies. If one insurer dominates the market, the company may demand lower rates or kick the surgery center out of its network. The Springfield Clinic was recently unable to strike an agreement for a new contract with BlueCross BlueShield of Illinois ,and many of its ASC patients were booted out of network Aug. 19.

But there are good signs as well. In some cases, payers recognize the value of independently owned physician groups and are helping to make sure they thrive. Julie Nelson, RN, BSN, executive director of Elmhurst (Ill.) Outpatient Surgery Center, told Becker's commercial payers are motivating physicians to move cases to the ASC.

"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."

Blue Cross Blue Shield of Michigan bought a physician management services business to help physician practices stay independent and transition to value-based care models Aug. 11. The company aims to provide data and analytics support to physician practices, which can be expensive.

In June, Blue Cross and Blue Shield of North Carolina launched a similar joint venture with Deerfield Management Co., a healthcare investment firm, to provide administrative infrastructure and support services to independent practices.

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