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Payer problems: 7 reimbursement issues at ASCs

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From COVID-19 setbacks to CMS' proposal to cut 258 procedures from the outpatient-approved list, ASC leaders are working through many challenges to secure reimbursements.  

Here are seven payer issues ASC leaders are watching:

1. Procedure approval

John Lavin, director of operations of OrthoConnecticut in Danbury, is having trouble securing procedure approval from payers. 

"Payers are making it harder and harder to allow patients to seamlessly get the care that the physician feels is appropriate," he told Becker's. "The process gets dramatically slowed down by the prior authorization process and the increased use of peer-to-peer reviews."

These reviews slow down the process, he said, as well as increase the administrative workload and force staff to alter schedules to allow the doctor time to complete them. 

2. Medication coverage 

Eric Shepard, MD, director of anesthesia Frederick (Md.) Surgical Center, is concerned about commercial payer coverage of nonopiate pain relief medications such as Exparel and Zynrelef. 

CMS covers the medications, but they are "hit or miss" with private payers, he told Becker's

"These medications are too expensive to use in the ASC environment, and I just hope to get paid," he said. "There is even inconsistency within providers. We may get paid by Blue Cross of Maryland but denied by Blue Cross of Illinois."

3. Delayed payer communication

Taylor Burnett, CEO of the Plastic Surgical Center of Mississippi in Flowood, is having trouble contacting payers — making it difficult to deal with claim issues. 

"COVID-19 is getting blamed for their staffing changes or lack of staff, and with that, payers have instituted more rigid 'online only' communication," she told Becker's. "Prior authorizations responses are taking much longer, and claim issues are increasingly difficult to work without additional contact measures."

4. Direct contracting & bundled payments

"We are and have been monitoring the direction of direct contracting and bundled payment programs for the past few years," Grant Foley, executive director, Midwest Center for Joint Replacement in Indianapolis, told Becker's. "With the high number of sales calls we receive from deal makers in the market, it's always tough to gauge the true volume or value an agreement will bring to an organization. Most of them are simply searching for the lowest cost procedure and are unable to deliver much in return."

Mr. Foley said he is approaching these conversations cautiously and ensuring that partners are a good culture fit. 

5. Evolution of the inpatient-only list

CMS on July 19 proposed to reinstate the inpatient-only list in its 2022 Hospital Outpatient Prospective Payment System and ASC Payment System proposed rule.

Andy Wilkinson, Boston-based Shields' director of financial planning and analysis, ambulatory surgery, is concerned with the evolution of the inpatient-only list. 

"A few of our commercial payers base our rates on a multiplier of Medicare and largely only reimburse procedures covered by Medicare," he told Becker's. "My short-term concern is that payers will remove procedures similar to how Medicare is reverting some cases back to a hospital-based setting."

Specifically, Mr. Wilkinson said he is concerned about CMS coverage of total joints in an ASC setting. In the longer term, however, he said he expects more commercial payers to cover these services in ASCs, rather than waiting on CMS. 

6. Lack of opt-out option for new products

"One of the bigger payer policy trends that I am keeping an eye on is the change in language that seems to be requiring in-network providers to essentially take any new products which the payer adds without providing for an opt-out of said product," Stephen Blake, CEO of Central Park ENT & Surgery Center in Arlington, Texas, told Becker's. "If this holds true, the payer will simply be able to design new plans and move covered lives to cheaper paying plans."

He said he expects this pattern, paired with physician consolidation, will further erode competition. 

7. No Surprises Act

CMS is taking on surprise billing with a proposed final rule released July 2 which would mandate that cost-sharing, such as coinsurance and deductibles, be based on in-network provider rates.

Additionally, surprise billing for ancillary services at in-network facilities would be prohibited, including anesthesia services.

Mark Schnitzer, MD, medical director of Baylor Scott & White Quality Alliance, is concerned with "the measures payers will use" after the implementation as well as "the countermeasures providers will use."

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