ASCs leaders across the country are frustrated with the disparity in reimbursements between ASCs and hospital outpatient departments for the same procedures.
This disparity is the biggest issue for securing reimbursements because much of it is out of ASCs' control, Bill Rhoades, COO of Harrisburg (Pa.) Endoscopy & Surgery, told Becker's. Insurance companies base their fees off Medicare rates, and ASCs are paid substantially less than HOPDs, despite the cost savings.
According to a 2023 analysis by Blue Health Intelligence, the Blue Cross Blue Shield Association's data analytics company, procedures done in HOPDs can cost 58% more than a physician's office or ASC. Facility fees for colonoscopy procedures covered by private health insurance are 55% more at hospitals compared with those at ASCs as of May 2023, according to a study published in JAMA Health Forum.
So ASCs are fighting a losing battle, Mr. Rhoades said, despite following the same guidelines that HOPDs have to follow, adding that HOPDs' "conditions of participation" are virtually the same as ASCs' "conditions of coverage."
"The wording might be different, but we have to follow the same guidelines for environmental care, staffing, documentation and all that," he said. "Everything needed is exactly the same."
The difference, he said, is in the reimbursements, which for HOPDs are adjusted based on hospital market basket — a fixed-weight index of costs and services – while ASCs are stuck with a consumer price index – based on the rising costs of goods rather than medical supplies and pharmaceuticals.
The difference in pay is drastic. Medicare hospital pay increased 70% from 2001 to 2023, by contrast, Medicare physician payment has only increased by 9%, according to a report by the American Medical Association.
"Costs have skyrocketed, especially during COVID-19, and prices didn’t come down much once COVID-19 was over," he said. "Staffing and supplies didn't adjust back, so we're always behind the eight ball as long as Medicare views it this way. Private insurers tend to follow Medicare’s lead."
Mr. Rhoades, attributes much of this disparity to "lobbying by large health networks" who "have the resources to spend on lobbyists." And while state ASC networks have membership fees that go to lobbying efforts, there's just enough "financial clout" to fight the larger hospitals that have the bigger budget.