At the 10th Annual Orthopedic, Spine and Pain Management-Driven ASC Conference in Chicago on June 15, 2012, Steven Arnold, MD, CMO of Access MediQuip, discussed the importance of implants in ambulatory surgery centers and how they are susceptible to large amounts of fraud.
1. Impact of implants. Surgeries that involve implants has skyrocketed over the years. Currently, more than 40 percent of all surgeries involve implants, which account for up to 70 percent of the surgery cost. All in all, $45 billion every year goes toward surgeries involving implants from payors, Dr. Arnold said.
2. The past. Dr. Arnold put implants and surgeries in context, noting that payors never used to ask what kind of implant surgeons were putting in patients. Payors reserved the right to issue a denial if the implant didn’t meet the payor’s medical payment policy, but the issue of implants in surgeries used to be a lot more lax previously.
3. The present. Currently, Medicare Recovery Auditors, or RACs, reviewing inpatient claims and durable medical equipment, and implants could be next because they represent such a high cost of a surgery, Dr. Arnold said. RACs are here and now, and ASCs have to be aware of them and the possibility they will check implant claims. Spine implants, in particular, are susceptible to a critical eye from government and commercial payors.
In addition, Dr. Arnold said ASCs have to align their physicians on an implant strategy. A flawed strategy and unengaged physicians could lead to unwanted audits and a loss in profitability. “If you don’t know how to align surgeons, surgeons will continue to use the most expensive implants,” Dr. Arnold said. “Your margin at an ASC is going to dwindle down to nothing.”
Dr. Arnold also suggested that ASCs look at their implant costs and realize they very well may be losing money on them. For example, ASCs that stock implants with expiration dates lose money the instant they go unused and go past the expiration date.
4. The future. Dr. Arnold believes there will be “more steerage” of cases from hospitals to ASCs because ASCs are less expensive. However, implants will continue to be a growing caveat because of their potential for fraud. “How will payors shift burden of prior authorization?” Dr. Arnold asked. “Who will pay for implants? There will be an increase in administrative costs and an increase of implantable device costs, but data and analytics are essential to [help] with the process.”
1. Impact of implants. Surgeries that involve implants has skyrocketed over the years. Currently, more than 40 percent of all surgeries involve implants, which account for up to 70 percent of the surgery cost. All in all, $45 billion every year goes toward surgeries involving implants from payors, Dr. Arnold said.
2. The past. Dr. Arnold put implants and surgeries in context, noting that payors never used to ask what kind of implant surgeons were putting in patients. Payors reserved the right to issue a denial if the implant didn’t meet the payor’s medical payment policy, but the issue of implants in surgeries used to be a lot more lax previously.
3. The present. Currently, Medicare Recovery Auditors, or RACs, reviewing inpatient claims and durable medical equipment, and implants could be next because they represent such a high cost of a surgery, Dr. Arnold said. RACs are here and now, and ASCs have to be aware of them and the possibility they will check implant claims. Spine implants, in particular, are susceptible to a critical eye from government and commercial payors.
In addition, Dr. Arnold said ASCs have to align their physicians on an implant strategy. A flawed strategy and unengaged physicians could lead to unwanted audits and a loss in profitability. “If you don’t know how to align surgeons, surgeons will continue to use the most expensive implants,” Dr. Arnold said. “Your margin at an ASC is going to dwindle down to nothing.”
Dr. Arnold also suggested that ASCs look at their implant costs and realize they very well may be losing money on them. For example, ASCs that stock implants with expiration dates lose money the instant they go unused and go past the expiration date.
4. The future. Dr. Arnold believes there will be “more steerage” of cases from hospitals to ASCs because ASCs are less expensive. However, implants will continue to be a growing caveat because of their potential for fraud. “How will payors shift burden of prior authorization?” Dr. Arnold asked. “Who will pay for implants? There will be an increase in administrative costs and an increase of implantable device costs, but data and analytics are essential to [help] with the process.”
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