Navigating reimbursements from CMS and commercial payers is a difficult task for ASCs. Here are six ASC leaders on their biggest problems with payers.
1. Cost of higher-acuity procedures
The pandemic drove more high-acuity cases to ASCs, including joint replacements and spine surgeries. But these procedures are costlier to ASCs, and centers could lose money if reimbursements fall through.
"The ASC is recognized as a high-quality, cost-effective site of service, but there is a risk of limited access if the reimbursement creates an unsustainable reality for these providers," Teresa Copeland, the director of managed care for Knoxville-based OrthoTennessee, told Becker's ASC Review.
Angela Laux, nurse administrator for Advance Spine Center of Wisconsin in Neenah, echoed these concerns, saying, "It is an ongoing process to show insurance companies the value of doing complex spine cases in an ASC compared to a hospital and reimburse ASCs fairly for these types of cases."
2. Appeal delays
COVID-19 has been an obstacle for appeals in many ASCs, which has made it difficult for some centers to treat patients in a timely manner.
"COVID-19 played a role in slowing the communication down between ASCs and the insurance companies as they shifted to having employees work from home," Ms. Laux said.
"The appeals process takes two to three months, which is a very long time for patients who have a decreased quality of life because of chronic pain," Angel Oliver, administrator for Austin, Texas-based The Pain Relief Surgicenter, told Becker's ASC Review.
3. CMS reimbursements
The difference in CMS payment between ASCs and hospitals does not necessarily reflect the difference in costs in performing procedures, which could leave ASCs falling short.
Because Medicare can bring volume to an ASC, commercial payers cannot expect the same pricing as Medicare with significantly less volume, unless CMS has overpriced the services offered, David Horace, vice president of site development and ministry at St. Louis-based Cardiovascular Centers of America and administrator/owner of Bel-Clair Surgical Center, told Becker's ASC Review. The CMS yearly review of overpriced services ensures that if this happens, it does not happen for long.
"ASCs have to compete in the same market for labor and pay competitive wages, and suppliers do not charge ASCs less than a hospital [group purchasing organization] for the same supplies," Mr. Horace said. "Yes, the overhead is lower at an ASC, but to remain viable, an ASC must have an adequate profit margin and cannot price services at the marginal cost to provide services."
4. Ensuring correct documentation
Ensuring that authorizations, documentation and reference codes are squared away is critical to ASC payer success.
"Managing your [accounts receivable] is the lifeblood of your business. Making sure you have the best billers and coders will help in this — do not try to save money on your billing or coding department," Brock Kreienbrink, MSN, RN, administrator and director of nursing for Wildwood-based Outpatient Surgery Center of Central Florida, told Becker's ASC Review.
5. Incorrect payment denial
Specific procedures are often denied despite the procedure's approval by CMS.
Jeff Baird, administrator for Salem, Ore.-based Willamette Ear, Nose, Throat & Facial Plastic Surgery, told Becker's ASC Review that his center has received incorrect denials based on "information not received even though a request for information was never received," and date of discharge denials, despite being an outpatient-only facility.
"Despite indirect spinal decompression being an approved surgery by Medicare, we continue to see denials from the replacement plans for this surgery," Ms. Oliver echoed.