Where the relationship between ASCs and payers stands today

ASCs and payers continue to face obstacles as they work through the challenges and changes of today's healthcare environment. 

The push to low-cost settings

As payers push for physicians to perform procedures in low-cost settings, ASCs are becoming a go-to facility for physicians. 

"With the continued rising cost of patient care in the hospital setting, ASCs have become many insurance companies' preference for outpatient surgery," Dianna Reed, administrator of Sani Eye Surgery Center in Templeton, Calif., told Becker's

Reimbursement rates fail to budge 

Payers regularly pay more to hospital outpatient departments than to ASCs for the same procedures. Private insurer payments to hospital outpatient departments were 2.6 times larger than payments to ASCs from 2018 to 2020, and Medicare payments were 2.1 times larger, according to research published by the Rand Corp. 

"Most of my time is spent on payer negotiations and payer issues. I spend more time negotiating  with payers than I ever expected in this role," Jessica Rodriguez, administrator of OAM Surgery Center at MidTowne in Grand Rapids, Mich., told Becker's. "The payment landscape for ASCs is another big challenge that we face. Costs are going up exponentially, but we are not seeing a corresponding increase in reimbursement."

Prior authorizations remain a roadblock 

There have been several wins and losses for ASCs in the push for prior authorization reform in 2022. Still, 79 percent of medical groups said that payer prior authorization requirements increased in the last year.

"My biggest industry concern is the ever increasing barriers by payers to provide high-value care to our most vulnerable patients in a timely fashion," Kenneth Nwosu, MD, a spine surgeon at NeoSpine in Puyallup, Wash., told Becker's. "Over time, it appears that the default decision for procedures needing prior authorization is a denial, as indicated by a rising number of peer-to-peer reviews where the reviewing physician openly states that the ordered surgery should not have been denied. Alternatively, I am seeing more denials where a peer-to-peer review time is dictated by the payer, which is often in conflict with the treating physician's availability. In some instances, there is not an option to partake in a peer-to-peer review following a denial."

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