In a healthcare landscape rife with dwindling commercial and government payer reimbursement, one of the last remaining opportunities for ASCs to improve their bottom line is developing a successful out-of-network strategy.
As patient financial responsibility grows and a larger onus is placed on out-of-network billing, ASCs must be equipped with effective strategies to leverage out-of-network reimbursement. However, before ASCs draft an out-of-network game plan, it's crucial the center ensures appropriate resources and expertise are at its disposal.
John Bartos, JD, CEO of Collect Rx, an ASC billing and consulting company, and Richa Singh, executive vice president of sales for Collect Rx, highlighted how out-of-network remains a profitable strategy for ASCs at Becker's 15th Annual Spine, Orthopedic and Pain Management-Driven ASC Conference + The Future of Spine June 23 in Chicago.
Here are three things ASCs need to know about creating an out-of-network strategy.
1. Start small
To excel at out-of-network, ASCs must take a hybrid approach, Mr. Bartos said. This requires ASCs to analyze their payer mix and market share to pinpoint which contracts reap the most out-of-network reimbursement.
Once ASCs determine where their greatest out-of-network opportunity lies, Mr. Bartos suggests ASCs test the water by shifting approximately 10 procedures to out-of-network status with a payer. The key, Mr. Bartos said, is to go out-of-network with smaller payers for a short period of time — possibly four to six months —and asses the results prior to moving more services out of network.
"You're putting little at risk by doing that, and in the end you gain the understanding" of what expertise are required to implement a successful out-of-network strategy, Mr. Bartos said.
2. Be persistent in appeals
ASCs must establish a great appeal process to renegotiate out-of-network reimbursement, including a review of explanation of benefits and assignment of benefits, Ms. Singh said.
"If ASCs aren't checking their EOBs, they're definitely losing money," she added. Typically weeks pass before a decision is made on out-of-network appeals. Successful ASCs follow up and ensure the resulting reimbursement is correct. This may prove difficult as payers and vendors deploy different obstacles to increase ASCs chances of walking away from the appeal.
However, in the current reimbursement environment, ASCs can't afford to do that. Instead, they must construct an out-of-network strategy aimed at capturing these funds.
"I hear talk about what is happening in respect to out-of-network payments, and how they aren't as easy as they were 10 years ago," Mr. Bartos said. "There's still a lot of opportunity in regard to out-of-network — you just have to be good at it," or outsource to a company that is.
3. Know how to navigate payers' cost-containment tactics
Employers and payers are constantly looking for ways to control out-of-network cost by minimizing providers' reimbursement. A rise in narrow network plans has locked some ASCs out of certain markets and forced them to fully operate in an out-of-network environment.
One strategy payers also use to reduce ASCs' out-of-network payments is tapping third-party vendors to manage their out-of-network business. Mr. Bartos said more than 800 third-party vendors are helping payers reduce their out-of-network obligations to providers. As a result, ASCs' major insurer contracts could include agreements with third-party companies that are lower than rates agreed upon with the payer.
These contracts effectively cap the reimbursement ASCs can receive from payers, Mr. Bartos said.
"We're constantly seeing that these third-party vendors are referencing contracts and when you contact a provider, they have no idea about it because it's not well-documented," Ms. Singh said during the panel. "We'll get a copy of the contract and show them, and it's going to take a couple months to cancel it," time ASCs can't afford to waste.
Therefore, it's crucial ASCs analyze contract terms prior to entering a contract with a third-party vendor or terminating one. If an ASC lacks the appropriate resources to do so, outsourcing to a billing and consulting company may be the best option.