Nine ASC leaders spoke with Becker's ASC Review about the biggest obstacles they face with private payers, from implant costs to declining reimbursements.
Editor's note: These answers were edited lightly for clarity and brevity.
Question: What are your biggest obstacles with private payers?
Matthew Ewasko. Administrator of Physicians Alliance Surgery Center (Cape Girardeau, Mo.): Our biggest obstacles continue to be ensuring that we are being reimbursed properly according to our contracts. Payers are increasingly attempting to not pay for procedures at the correct rates. This is adding additional workloads on our billing department since they are chasing down payments or gathering additional documents so that we can dispute any claim denials. In the future, I see our facility needing to include additional carve-outs in our contracts so that the more complex cases can be reimbursed properly so that they can be done in our facility. These cases should be done in the ASC setting, but we must ensure that we get the necessary reimbursement.
Susan Cheek. Administrator of Dallas Endoscopy Center: We have worked very hard over the years with private payers to be in network for our patients. ASCs save all payers by being a low-cost, high-quality point of care. Payers seem to be recognizing this about ASCs and wanting us to join their networks. The largest obstacle that we face is negotiating increases year over year. ASCs compete in the same marketplace for clinical and clerical staff as other healthcare facilities, and oftentimes we do not receive volume pricing on medical supplies. So, while our costs continue to rise each year, our reimbursement does not always increase at the same pace. It is our job and mission to educate payers to this point. If they cannot give reasonable increases to our ASC, we may not be around in the future to be a lower-cost, high-quality alternative for their insured population.
Tammy Smittle. Owner of Smittle Consulting (Austin, Texas): The biggest hurdle with private payers is covering costs when implants are involved, specifically in orthopedics. Insurance companies have made it difficult on multiple fronts. There are contracts where implants are not covered at all, and we end up negative for a case when the patient has a complex injury. Next are the contracts where implants are covered, but a certain threshold must first be met, which, in turn, does not incentivize facilities to negotiate for the cheapest pricing, increasing the out-of-pocket costs for our patients. The final obstacle is the vague, payer-specific implant language that is very difficult for billers to understand, and then mistakes occur. Every commercial payer must be handled differently which drastically increases staffing costs and, in turn, decreases net revenue per case.
Tracy Helmer. Administrator of Seven Hills ASC (Henderson, Nev.): Contracting with private payers has been challenging due to convoluted pricing structures — not accommodating our requests for carve-outs when needed and a lack of willingness to come to the bargaining table. We are often given one shot to take a contract, and we cannot always accept it because some reimbursements are suitable and other codes in the contract are intentionally low.
Patti Thompson. Director of revenue cycle management for Medical Billing Solutions (Murrieta, Calif.): The biggest obstacles would be preauthorization requirements both for in- and out-of-network providers. The process is not standard across the board; it's time-consuming and delays necessary treatments. In the meantime, patients wait for their treatment, and in some cases opt to not have the services at all or pay for them themselves, which defeats the purpose of having insurance. The other obstacle is lack of transparency in how out-of-network claims will be paid and processed. So much discrepancy from policy to policy. Both the providers and patients suffer the consequences. Healthcare should be accessible for all, not make it more difficult to receive the medical care that is needed in a timely fashion.
Mark Spina. Director of operations at Endoscopy Center of Connecticut (Hamden): Our biggest obstacle with private payers is negotiating new contracts. In particular, it's proving to be very difficult to get private payers to recognize the increase in labor and supply costs brought about by the labor shortage and supply chain disruptions in the economy.
Milica Dobricic. Billing team leader of American Surgical Centers (West Bloomfield, Mich.): Authorizations are required for almost everything now, which is time-consuming, and each payer has a different process.If things were more uniform, I think it would help. Also, in this current environment trying to get a timely response is near impossible if you get a response at all (email or returned voice message). We are trying to contract with some payers for a new facility, and there is no assigned representative, rather a generic email you respond to. Everything takes forever to accomplish nowadays.
Sean Barnard. Administrator of Idaho SurgiCenter (Pocatello): The hardest thing for us is getting authorization for any implants. As an ASC, we have to eat that cost, otherwise it will often be "included" with the primary billing code. Blue Cross and Medicaid will allow us to bill L8699, for example, and reimburse us the entire amount of the implant, but we have to initiate that authorization process a month in advance, which is often impossible.
Kristen Owens. ASC manager for Carolina Digestive Care UNC Health Blue Ridge (Morganton, N.C.): Contract negotiations. Some private payers want to pay less for more to the extent that we cannot accept the conditions, making our facility out of network for some patients.