Many healthcare providers worried about how insurance mega-the mergers will impact reimbursements. However, there are opportunities for ASCs as the payer environment changes.
Naya Kehayes, CEO and managing principal of Eveia Health Consulting & Management, addresses these opportunities and steps ASC should take when looking at their insurance contracts.
"If an ASC has a contract with both payers that are merging, they should review the merger and acquisition language to determine if one contract rate will prevail over the other," says Ms. Kehayes. "The ASC should contact the payers to seek more information to determine if there is an impact on either contract."
1. ASCs could see new in-network opportunities. A merger may prove beneficial to an ASC, especially if the facility previously was out-of-network with one payer.
"If the ASC has a contract with one payer and desires to be in contract with the other payer and they consolidate, the ASC can potentially get access to the other payer as a result of the transaction," explains Ms. Kehayes. "The merger presents opportunity for the ASC to access members who you may not have access to prior to the merger. For example, if the ASC is out of network with one of the two payers merging and the payer eventually sells all services under the products that are covered under the contract the ASC is in network with, then volume is expected to grow as a result of the volume growth coming through the surviving contract."
2. Insurance companies will take more interest in ASCs in unsaturated markets. Payers may opt to work with ASCs depending on the type of market an ASC is operating in. "If you're in a market that is dominated by hospitals, and there is a need for ASCs in the network, the payer consolidation may result in the payer having more interest in working with the ASC because it provides a more cost-effective option," says Naya Kehayes.
3. Reimbursement rates may change. The major concern voiced by many healthcare professionals is how the mergers may impact reimbursement rates. Many fear reimbursements will continue to fall, which is a real possibility for many healthcare facilities. However, individually contracted rates could go the other direction as well.
If your center has two separate contracted rates with the merging entities, the payers often want to roll all members on to one contract so it is not uncommon for the payer to consolidate contracts and/or restructure insurance product offerings to employer groups. Therefore, it is possible that the ASC could see the lower contracted rates boosted to the higher contracted rates post-merger if the surviving contract is the one with the stronger rates; of course, this could go the other way as well. Every situation is different, but with any change there is potentially opportunity.
"Contract change is not necessarily negative," says Ms. Kehayes. "It is dependent on the structure of the payment methodology relative to the case mix of the ASC."
4. ASCs gain access to procedures they weren't in previous contracts. An insurance merger could allow an ASC to perform new procedures that were not previously covered under the ASC's contract with the payer. If one payer did not previously authorize certain procedures in the ASC setting under contract, and they merge with a payer that does authorizes such procedures, the mega-merger brings can provide access to a new volume of cases
"Mergers may create an opportunity to provide more services," says Ms. Kehayes. "The payer merger may result in the expansion of the ASC list of approved CPT Codes that could include services such as total joint or spine surgery."
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