'Can CMS be more confusing right now?' ASC administrators balk at outpatient final rule

CMS' outpatient payment final rule for 2022 contained positives for ASCs, including its plan to implement a transparent process to add procedures to the ASC-payable list. However, much of the provisions — particularly the decision to remove 255 procedures from the ASC-payable list — have caused confusion and frustration among ASC administrators.

Six administrators react to Medicare's Outpatient Prospective Payment System and ASC Payment System final rule for 2022:

Note: Responses are lightly edited for style and clarity.

Alfonso del Granado. Administrator of Covenant High Plains Surgery Center (Lubbock, Texas): The final rule contains a number of provisions that concern us.

For example, despite CMS' stated attempt to promote transparency, it has not provided clear, reasonable, clinical and financial justification for finalizing the elimination of 255 codes from the ASC covered-procedures list. We routinely perform more than a dozen of those procedures safely and cost-effectively, reducing patients' risk of exposure to COVID-19 and other healthcare-associated infections.

Also, some of the Ambulatory Surgical Center Quality Reporting measures are equally inexplicable, either because the effective 100 percent performance makes tracking meaningless or because they are inappropriate to our setting.

Finally, although the 2 percent effective inflation rate update is appreciated, it falls far short of two important realities: First, it falls short of the latest inflation projections, which began to manifest in the first quarter and developed fully in the second quarter — time enough for CMS to have taken them into consideration; second, the tight healthcare worker labor market, combined with COVID-related attrition and vaccine mandate-related early retirements are forcing us to make significant adjustments to our wage scales, a cost that we will have to absorb until industry pressure forces payers to make concomitant adjustments.

Although our centers are well-positioned for the coming year, I know of several that are struggling. Losing ASCs will not benefit the U.S. healthcare system and is not in the best interests of CMS and the population it covers. We have learned much during more than a year and a half of pandemic overloads and shutdowns, including just how valuable ASCs are as an integral component of the healthcare continuum. We continue to hold out hope that CMS will someday understand this lesson.

Christine Blackburn, BSN. Administrator at the South Kansas City SurgiCenter (Overland Park, Kansas): Can CMS be more confusing right now?

Bottom line from me:

  • ASCs are still being paid on the hospital market basket rate until 2023.
  • ASCs should be paid the same as HOPDs within the hospital market basket rate.
  • CMS should have to be transparent on why they are paying ASCs a different rate. Isn't pricing transparency the new buzzword?
  • When CMS moves a code back to the inpatient-only list, there should be data as to why this decision was made. Is there not enough data collected? Are the outcomes not what they are looking for?
  • There is so much uncertainty with the decision process of CMS that could lead to procedures that have been proven to be safely done in an ASC, to be moved back to the IPO. 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. This is costly and burdensome for the centers. The prior authorizations that are questioned after the procedure is completed. ASCs have to fight to get the money owed to them, and this is time consuming.
  • I think in the coming years the future is very bright for ASCs, even with the sometimes confusing statements from CMS:
    • We will see more commercial payers and CMS request their clients to have their procedure in the ASC and send letters to clients explaining this (this is already being done in some areas).
    • ASCs are more cost-efficient for the payer and the client.
    • The efficiency of check-in is enticing to the client.
    • The efficiency of preop/post-op is enticing to the client and their families.
    • The "boutique" feel to the client and family who are having a procedure at an ASC. Elective or not, this a stressful time to them and the "boutique" feel can be very calming.
    • Data collection is robust in the ASC.

Tracy Helmer, RN. Administrator of Seven Hills ASC (Henderson, Nev.): I see the final rule as a step backward in an effort to place patients in a healthier option for their healthcare needs. Patients have already voiced their concern with entering hospitals, and although I am sure there are plenty of protections for them, we must be concerned about the ones that quietly choose not to get healthcare due to perceived risks in the hospital. As an ASC that serves the cardiology arena, we see patients that arrive in worse condition, due to waiting to have coronary interventions. This is not good. 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 receive healthcare in a cost-effective way.

Catherine Retzbach, RN, BSN. Administrator of Memorial Ambulatory Surgery Center (Mount Holly, N.J.): CMS continues to be shortsighted regarding ASCs. It has been proven many times that ASCs save CMS financially and continue to provide good-quality, safe patient care. Taking away procedures that have been done safely in the centers does not make sense. The government continues to look for ways to save money, however, they continue to ignore a proven opportunity. 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, for fear this will happen again. There is truly a need for an ASC voice on the committees making these decisions. The Ambulatory Surgery Center Association can do only so much when there is no direct voice at the table. CMS is missing a golden opportunity to allow high-quality, low-cost, safely performed cases in an ASC.

Chhaya Patel, MD. Satellite Boulevard Surgery Center (Duluth, Ga.): I find these CMS changes for 2022 frustrating as the federal government is shifting cases that were safely performed in the ASC to the hospital. This is a step backward from 2019 policy, especially at a time when most of us are still recovering from the COVID-19 pandemic. However, our industry is resilient and will continue to evolve despite these setbacks because surgery centers are a lower-priced setting that provide patients access to high-quality care.

Andrew Lovewell. Administrator of Surgical Center at Columbia (Mo.) Orthopaedic Group: CMS' ASC final rule is quite simply a disaster. I see this as a nonprogressive move and it shows a lack of vision by CMS. Moving procedures back to the inpatient-only list shows a failure on CMS' part. With more patients asking for procedures to be performed at an ASC, payers steering to ASCs, and even employers looking to save money by preferentially using an ASC, CMS needs to catch on. ASCs represent a lower cost and more efficient option for patients, employers, and payers and CMS needs to embrace that. ASCs should be paid the same as HOPDs under the market basket, especially considering the services we provide are very similar and the costs are no different. CMS needs to pay more attention to ASCs and shoring up the reimbursement gap between HOPDs and ASCs in the future to assure that ASCs are fairly reimbursed.  

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