Endoscopic balloon sinoplasty is a surgical procedure that treats blocked nasal sinuses using a small, flexible balloon catheter to enlarge sinus pathways and restore normal sinus drainage without damaging the sinus lining. A relatively new procedure for surgery centers, balloon sinoplasty can be successful and profitable for ENT-focused centers with the right planning. Neal Maerki, administrator of Bend (Ore.) Surgery Center, discusses several issues to consider when adding endoscopic balloon sinoplasty to your surgery center.
1. Determine whether you will be reimbursed for disposables. Since endoscopic balloon sinoplasty is a relatively new procedure in the outpatient setting, Mr. Maerki says it can be difficult to convince payors to reimburse for disposables in the ASC setting. If payors will not reimburse for disposables, you will need to work with vendors to lower the price of disposables or reconsider adding the procedure.
"If we're the facility that's performing the majority of those procedures [in the community], we really work with the vendor to say, 'We're almost the sole provider of services in this town,'" Mr. Maerki says. "You have a lot of leverage to have the physician chime in and try to negotiate the costs."
Mr. Maerki recommends negotiating pricing with the vendor before the physician gets to trial the disposable. He says once the physician can use the item and is happy with the product, you will find it more difficult to negotiate a lower price with the vendor.
2. Renegotiate contracts before you add the procedure. Mr. Maerki recommends renegotiating your insurance contracts before you start adding significant endoscopic balloon sinoplasty volume to your surgery center. If the payor notices that you are asking for an increase in reimbursement for the procedure but sees that you aren't performing many of the cases, you may receive the increase without much argument.
"Well before we ever did any cases, we were already trying to negotiate the reimbursement as if we were doing them," he says. "Those weren't throwaway codes for us when negotiating contracts — they were codes that had meaning for us, but they had less meaning for the payors because the payor wasn't seeing a utilization of the CPT codes."
3. Consider that you may pick up collateral cases. One positive aspect of adding endoscopic balloon sinoplasty to your ASC is the potential for picking up — or at least not losing — collateral cases. For example, if you do not offer your physicians the opportunity to perform endoscopic balloon sinoplasty, but the local hospital does, they make take other procedures to the hospital as well for convenience. "You don't want your physicians taking balloon sinoplasty to the hospital, because then the hospital might also get two tonsils and two tubes," he says.
You may also pick up additional volume from physicians who haven't previously focused on the procedure. Speak to all your surgeons and determine whether certain specialists might consider performing the procedure if you provided the equipment. "We didn't look for a guaranteed volume, but we knew we would pick up more volume from another ENT specialist who wasn't doing as much endoscopic sinus surgery but would down the road," Mr. Maerki says. "Physicians may think, 'I don't want [another physician] to be the only person in town providing this service for patients. I want to jump in and learn how to do balloon sinoplasty."
4. Make sure you clarify the procedure when scheduling. Mr. Maerki says your ASC schedulers must make sure to clarify whether the endoscopic sinus surgery involves a balloon before adding the case to the schedule. If the surgery involves a balloon, you will have to prepare your supplies accordingly. He says it may be easier to call the physician directly. "There's nothing worse than getting it incorrect and then having to cancel or delay a case," he says.
5. Ask physicians for a commitment to performing cases at the ASC. While you can't force physicians to bring cases to your surgery center, you should sit down and talk about the feasibility of their providing substantial long-term case volume prior to adding this procedure. Mr. Maerki says maintaining endoscopic balloon sinoplasty volume can be challenging for a surgery center because the procedure is reimbursed very well when performed in a physician office.
"You may lose some of your business down the road to being done in the physician office," he says. "Insurance companies are reimbursing physicians very well for some of the easier balloon sinoplasty procedures." He says while you can't control reimbursement or the decisions of your physicians if reimbursement changes, you can be honest about your concerns and ask them to give you feedback. If they realistically think the office will be a more profitable setting for the procedure, you may want to consider other options.
Learn about Bend Surgery Center.
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1. Determine whether you will be reimbursed for disposables. Since endoscopic balloon sinoplasty is a relatively new procedure in the outpatient setting, Mr. Maerki says it can be difficult to convince payors to reimburse for disposables in the ASC setting. If payors will not reimburse for disposables, you will need to work with vendors to lower the price of disposables or reconsider adding the procedure.
"If we're the facility that's performing the majority of those procedures [in the community], we really work with the vendor to say, 'We're almost the sole provider of services in this town,'" Mr. Maerki says. "You have a lot of leverage to have the physician chime in and try to negotiate the costs."
Mr. Maerki recommends negotiating pricing with the vendor before the physician gets to trial the disposable. He says once the physician can use the item and is happy with the product, you will find it more difficult to negotiate a lower price with the vendor.
2. Renegotiate contracts before you add the procedure. Mr. Maerki recommends renegotiating your insurance contracts before you start adding significant endoscopic balloon sinoplasty volume to your surgery center. If the payor notices that you are asking for an increase in reimbursement for the procedure but sees that you aren't performing many of the cases, you may receive the increase without much argument.
"Well before we ever did any cases, we were already trying to negotiate the reimbursement as if we were doing them," he says. "Those weren't throwaway codes for us when negotiating contracts — they were codes that had meaning for us, but they had less meaning for the payors because the payor wasn't seeing a utilization of the CPT codes."
3. Consider that you may pick up collateral cases. One positive aspect of adding endoscopic balloon sinoplasty to your ASC is the potential for picking up — or at least not losing — collateral cases. For example, if you do not offer your physicians the opportunity to perform endoscopic balloon sinoplasty, but the local hospital does, they make take other procedures to the hospital as well for convenience. "You don't want your physicians taking balloon sinoplasty to the hospital, because then the hospital might also get two tonsils and two tubes," he says.
You may also pick up additional volume from physicians who haven't previously focused on the procedure. Speak to all your surgeons and determine whether certain specialists might consider performing the procedure if you provided the equipment. "We didn't look for a guaranteed volume, but we knew we would pick up more volume from another ENT specialist who wasn't doing as much endoscopic sinus surgery but would down the road," Mr. Maerki says. "Physicians may think, 'I don't want [another physician] to be the only person in town providing this service for patients. I want to jump in and learn how to do balloon sinoplasty."
4. Make sure you clarify the procedure when scheduling. Mr. Maerki says your ASC schedulers must make sure to clarify whether the endoscopic sinus surgery involves a balloon before adding the case to the schedule. If the surgery involves a balloon, you will have to prepare your supplies accordingly. He says it may be easier to call the physician directly. "There's nothing worse than getting it incorrect and then having to cancel or delay a case," he says.
5. Ask physicians for a commitment to performing cases at the ASC. While you can't force physicians to bring cases to your surgery center, you should sit down and talk about the feasibility of their providing substantial long-term case volume prior to adding this procedure. Mr. Maerki says maintaining endoscopic balloon sinoplasty volume can be challenging for a surgery center because the procedure is reimbursed very well when performed in a physician office.
"You may lose some of your business down the road to being done in the physician office," he says. "Insurance companies are reimbursing physicians very well for some of the easier balloon sinoplasty procedures." He says while you can't control reimbursement or the decisions of your physicians if reimbursement changes, you can be honest about your concerns and ask them to give you feedback. If they realistically think the office will be a more profitable setting for the procedure, you may want to consider other options.
Learn about Bend Surgery Center.
Related Articles on ASC Procedures:
5 Recent Findings on Glaucoma
5 Changes for Outpatient Anesthesia in 2012
End of Year Busiest Time for Weight Loss Surgery