For many ASCs, navigating payer behavior and declining reimbursements is the biggest challenge in maintaining profits.
Jim Freund, managing partner for Physician Transaction Advisors, told Becker's the biggest threat to ASCs is the reimbursement difference between ASCs and hospital outpatient departments.
"There's no reason that cases shouldn't be paid the same whether they're outpatient or inpatient," he said. "If you're doing a total joint, it should be reimbursed at one level, but hospitals are being reimbursed much higher than ASCs. I think that's a huge threat. It doesn't make sense, and it's all political. It's the same results, same outcome, same procedure, but you're being reimbursed at completely different rates if you're a surgery center versus a hospital."
The move increases the challenges for ASCs to handle the same cases that hospitals treat, particularly simple ones, he added. Procedures done in HOPDs can cost 58% more compared to a physician's office or ASC, according to a 2023 analysis by Blue Health Intelligence, the Blue Cross Blue Shield Association's data analytics company.
"The payers are controlling this," he said. "We've got to see it for all, not just Medicare and Medicaid, but across the board."
Payers are also challenging physicians to secure reimbursements with prior authorization policies. Nearly 97% of providers have seen delays or denials for necessary patient care due to PA requirements, according to the Medical Group Management Association's 2023 "Regulatory Burden Report." Additionally, PA denials for outpatient care claims jumped 16% in the last three years.
Some payers are even trying to clawback for procedures that have already been performed. Along with the clawbacks, ASCs in some markets have noticed insurance companies denying care or re-evaluating circumstances of the case to recover funds.
"All the insurance carriers are now hiring companies to look at a post-procedure type of PA or post-authorization," said Adam Bruggeman, MD, a spine surgeon at San Antonio-based Texas Spine Care Center and chief medical officer of MPOWERHealth, during a June 21 panel at the 21st Annual Spine, Orthopedic & Pain Management-Driven ASC + The Future of Spine Conference in Chicago. "Essentially you'd perform the procedure and then after the procedure, using all the same data they asked for going into surgery, they're now asking hospitals, surgery centers and doctors again to confirm that they really should have approved the surgery the first time and then they're clawing back the money, or not paying the money as a result."
Columbia (Mo.) Orthopaedic Group has seen similar tactics by local payers and built a department focused on preauthorizations and post-surgery payer requests, CEO Andrew Lovewell said. The group spends hundreds of thousands of dollars per year to maintain the department.
"Our physicians feel the pain in the clinic, but they haven't felt it in their wallets yet because our departments are really, really good at making sure we get the money that's theirs," Mr. Lovewell said. "We have a lot of robust processes ahead of time where the doctors know the day before surgery exactly what codes are approved. They have to email if they do anything differently in the case. They have to tell us immediately or they face a penalty inside of our own group. We take both sides of it, not only to educate our providers but then go directly after the payers."
For Hardy Sikand, CEO of Carmel-based Indiana Spine Group, payer relationships and reimbursement pressures are the biggest challenge his team is facing as a wholly independent spine practice.
"It's been extremely, extremely hard," Mr. Sikand said. "They were very favorable to us when we opened our facility, but it's become really challenging to deal [with large payers in our market]. But when you can offer members the cost savings that we get, they have to be able to offer us contracts."