CMS misses 'golden opportunity' to reduce costs in 2022, ASC administrators say

CMS' 2022 outpatient final payment rule was largely disappointing for ASC administrators, many of whom were baffled by the agency's swift change in policy regarding payment for certain procedures in the outpatient setting.

Among the changes that caused most confusion were the decisions to halt the elimination of the inpatient-only list and remove 255 procedures from the ASC-payable list in 2022.

"We are disappointed that the agency finalized a decision to reduce beneficiary access to ASCs for a number of important procedures that were added just a year ago, despite CMS having little to no clinical data to use as a basis for removing them from our payable list," said Ambulatory Surgery Center Association CEO Bill Prentice.

But CMS argues the "change in policy promotes transparency and ensures that any service removed from the IPO list has been reviewed against Medicare's long-standing IPO criteria to determine if it is appropriate for Medicare to pay for the provision of the service in the outpatient setting."

Many procedures have been migrating to the outpatient setting for years, but the pandemic has particularly accelerated this trend. CMS and commercial payers have also been drivers of this migration, as well as patients who voiced concerns about having procedures done at hospitals because of the risk of COVID-19 transmission.

Arguably, the bigger concern is for patients who "quietly choose not to get care due to perceived risks in the hospital," Tracy Helmer, administrator at Seven Hills ASC in Las Vegas, told Becker's.

"As an ASC that serves the cardiology arena, we see patients that arrive in worse condition, due to waiting to have coronary interventions,'' Mr. Helmer said. "As a representative of ASCs and their ability to provide great care to patients, we want to see progress in helping to offload appropriate cases from the hospital environment. Reducing the number of cases that are only allowed in the hospital, helps Americans with viable and safe alternatives to receive care in a cost-effective way."

CMS walking back its elimination of the inpatient-only list is seen as shortsighted by many in the ASC industry, which has been shown to provide high-quality care at a significantly lower cost than hospitals, contributing to sizeable healthcare savings for the federal government.

The government continues to look for ways to save money but is hesitant on pulling the trigger on one proven opportunity to do so.

"The next time CMS allows new codes to be performed in an ASC some centers will be reluctant to invest in the procedures that they need new equipment for fear this will happen again," according to Catherine Retzbach, RN, BSN, administrator at Memorial Ambulatory Surgery Center in Mt. Holly, N.J. "CMS is missing a golden opportunity to allow high-quality, low-cost, safely performed cases in an ASC."

The lack of transparency and conviction will ultimately hurt ASCs, especially those that recently migrated procedures that CMS now says it will not pay for in the outpatient setting in 2022, despite having little to no clinical data to use as a basis for removing them from the ASC-payable list.

"I think this move makes the payers ask for more documentation from the ASC, which puts more burden on the [business owner] to collect money owed by submitting more documentation," Christine Blackburn, RN, BSN, administrator at South Kansas City Surgicenter in Overland Park, Kan., told Becker's. "This is costly and burdensome for the centers. The prior authorizations are questioned after the procedure is completed. ASCs have to fight to get the money owed to them, and this is time consuming."

While CMS has been criticized for a lack of transparency in some areas, ASCA CEO Bill Prentice said he was "particularly pleased" with the agency's plan to implement a transparent process to add procedures to the ASC-payable list, something surgery centers have recommended for years.

Beginning in March 2022, a process will be adopted to allow an external party — particularly specialty societies that are familiar with procedures in their specialty — to nominate procedures to be added to the ASC-payable list. If CMS determines that a procedure meets the requirements to be added to the list, it would propose to add the procedure to the list for Jan. 1, 2023.

Mr. Prentice commented, "We hope that we can work with the Biden administration in 2022 to make significant, constructive changes to the program so that more Medicare beneficiaries can get care in the ASC setting for the many additional procedures that can be safely performed in ASCs. Doing so will generate savings for both patients and the program."

ASCA said it will provide further analysis on the 1,394-page rule soon, which will include a rate calculator to determine what ASCs will be paid locally in 2022.

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