ASCs' payer issues aren't new, but many are now increasingly challenged by complex and restrictive payment policies set by insurers.
As healthcare costs rise, insurers are adopting new reimbursement and authorization requirements that further limit ASC claims and pose difficulties for many leaders.
Several leaders joined Becker's on Nov. 1 panel at the 30th annual Business and Operations of ASCs Meeting in Chicago to discuss these issues.
New payment policies complicate implant reimbursements.
Velia Suarez, business office manager at Pasteur Plaza Surgery Center in San Antonio, has witnessed these obstacles firsthand, particularly with the reimbursement process for implants.
"We all have heard of the clinical policies," Ms. Suarez said, "but now you have payment policies that are impacting your claims, and a lot of times you don't have someone full time looking at these policies. So you find out at the time you get that denial."
These new policies mean payers are often denying coverage, citing that certain procedures don’t meet required coding standards, especially for device-intensive surgeries.
Pre-authorizations add another barrier
Adding to the complexity, ASCs are dealing with a significant increase in insurer-mandated pre-authorization requirements.
Niazy Selim, MD, a surgeon at Lake Charles, Louisiana-based Selim Surgery Center, shared his frustration with this trend, adding that it hampers patient access and delays care.
"Pre-authorization is actually an invention from the insurance company basically to cripple us," he said. "I mean they talk about patient's care and all this, and when you look at it, really there is nothing to do with the patient's care."
Dr. Selim emphasized that a key issue with pre-authorizations is the lack of supporting data and transparency. Without sufficient data or resources from insurers, ASCs are often left guessing about approval criteria, leading to wasted time and resources.
CMS pay continues to decline
For ASCs serving a large Medicare and Medicaid population, the decline in CMS reimbursements is particularly troubling.
According to Dr. Selim, his ASC is feeling the squeeze as CMS rates continue to decrease, challenging their financial stability.
"We don't make a lot of money, but we are just treading the water for now and we know it'll get hopefully better when we dip deep in the cash, but it's been a struggle," he said. "...Once Medicare gets payments down, everybody follows suit."
Tougher insurance contracts
Compounding these issues are increasingly restrictive payer contracts, which some ASC leaders feel favor insurers excessively.
"The insurance contracts are getting worse," Dr. Selim said. "We review our contracts every year, but we really feel like we can't win that war. We just can't… It is just very hard to negotiate these contracts with them. Honestly, that's what I found."
Karen Davidson, RN, nursing director at the Advanced Ambulatory Surgery Center of New Mexico, agreed, noting that despite their position as an alternative to large hospitals, they struggle to negotiate favorable terms with insurers.
"Payer contracts are a huge deal," she said. "We were under the impression that the payers would be thrilled to deal with us, the second choice in town besides the big hospital system, but not so much. We're a small fish for them and they're not that interested in dealing with us."