The ASC market will likely see significant growth into the next several years, but many ASC leaders and physicians continue to feel tied down by arduous administrative burdens.
Prior authorization
According to Medscape's "'They're Awful and Impede Patient Care': Medscape Physicians and Prior Authorizations Report 2024," 86% of physicians feel that the time they spend processing prior authorization requests or appealing denials has led to delays in patient care. Another 61% said that patients frequently abandoned recommended treatments due to prior authorization delays.
"It's meant to be a financial tool to help offset costs of care for a person, but it's not," Rory Murphy, MD, a neurosurgeon with Barrow Brain and Spine group in Phoenix, told Becker's. "It seems to have swung the other way, essentially, [and is] now a system to ration care. They're actively trying to avoid paying."
Physicians feel that a lack of transparency surrounding the requirements for prior authorizations and the processes by which they are approved or denied leads to breakdowns in care and in patient-physician relationships, while also contributing to burnout among staff and eating away at valuable time resources.
"Prior authorization does absolutely nothing except try to save insurance companies money once we finally give up. It does nothing for the patient or the doctor. It costs physicians time and money and only delays appropriate treatment," Klaud Miller, MD, an orthopedic surgeon and medical director of Windy City Orthopedics and Sports Medicine in Chicago, told Becker's.
"It certainly takes away any profit. If I have a peer review, I am making no profit on that case," he added.
Claims denials
Denials of claims are also increasing, along with the administrative strain of managing them, according to Experian Health's "2024 State of Claims" survey.
The survey, which included responses from 210 healthcare professionals involved in administration, found that 73% of those professionals felt that claims denials are increasing. The most common reasons for claims denials were missing or inaccurate data, authorization issues and incomplete or inaccurate patient information — but physicians feel that the avenues for addressing these denials are dually inefficient and unclear.
"We as physicians have very little, if any, opportunity to speak with payers. If we are lucky, I get to speak to a 'claims specialist' to argue about why I am not being paid," Ravi Krishnan, MD, an ophthalmologist at The Eye Institute of Corpus Christi (Texas) told Becker's. There is some so-called negotiation of the payment schedule beforehand, but as an owner of a small solo practice, I have very little bargaining power."
Reimbursement challenges
CMS recently finalized a 2.83% cut to its 2025 physician payment rule, which has been met with criticism from physicians and advocacy groups.
"To put it bluntly, Medicare plans to pay us less while costs go up," AMA President Bruce Scott, MD, said in a Nov. 1 statement. "You don't have to be an economist to know that is an unsustainable trend, though one that has been going on for decades. For physician practices operating on small margins already, this means it is harder to acquire new equipment, harder to retain staff, harder to take on new Medicare patients, and harder to keep the doors open, particularly in rural and underserved areas."
Surgical specialties have also been hit hard by recent reimbursement cuts. On Nov. 1, Anthem Blue Cross Blue Shield Plans representing Connecticut, New York and Missouri announced changes to their evaluation process for claims for anesthesia services.
"This is just the latest in a long line of appalling behavior by commercial health insurers looking to drive their profits up at the expense of patients and physicians providing essential care," said Donald Arnold, MD, president of the American Society of Anesthesiologists. "It's a cynical money grab by Anthem, designed to take advantage of the commitment anesthesiologists make thousands of times each day to provide their patients with expert, complete and safe anesthesia care."
Gastroenterology is another area that has been heavily impacted by reimbursement cuts and payer behavior. Unadjusted and adjusted average reimbursement for GI procedures dropped by 7% and 33%, respectively from 2007 to 2022, according to a study published in The American Journal of Gastroenterology. Reimbursements for colonoscopies and biopsies decreased 38% during that period.
"I think we'd all agree that there's only so much juice you can squeeze out of the orange before quality and value are compromised," Omar Khokhar, MD, a gastroenterologist at OSF St. Joseph Medical Center in Bloomington, Ill., told Becker's. "Reducing reimbursement doesn't make the patient disappear. If we can't provide that care, those patients end up in the ER with serious conditions like anemia or a colon mass. It just kicks the can down the road."