Here are 10 things to know about the burden of implant costs for ASCs:
1. According to a July 2024 report by Advantien, an ASC supply purchasing company, implants regularly represent one of the highest expense items for ASCs, sometimes exceeding the total reimbursement for a procedure.
2. Payers utilize a variety of reimbursement models for, specifically for orthopedic implants, according to the report. These might include:
- No separate reimbursement for implants
- 100% reimbursement of implant cost plus markup
- Reimbursement only after a certain dollar threshold is met
- Carve-outs for specific implants
This means ASC administrators and revenue cycle managers must be highly attuned to the specifics of implant reimbursements with the payers they work with.
“Let’s say, for example, you have a payer contract with a $1,000 threshold on a particular implant before they will reimburse you. If your RCM bills the implant at $995, the payer won’t reimburse your ASC for the implant,” said the report. ASCs may be able to maneuver around this issue by utilizing kitting in their billing to increase the total cost of an implant to include a disposable.
3. According to the report, the most common issues in implant reimbursement for ASCs include:
- Using incorrect CPT codes
- No “watchdog” to ensure payer contracts are honored
- Not getting pre-authorization
- Post-authorization clawback
4. Advantien also recommends calculating in-depth case costs on all surgery cases to confirm that the reimbursement will be enough to justify doing the surgery at the ASC. If not, ASC administrators may want to look into seeking a better reimbursement arrangement from the payer.
5. Manufacturers may offer rebates or volume-based discounts to incentivize loyalty from centers and increase market share, according to the report. Leveraging these relationships can be key to ASC profitability.
6. For negotiations with payers and vendors, ASC leaders should have in-depth data that details precise costs and utilization. It can also be helpful to have the support of a surgeon as one builds a case for higher reimbursement or lower costs.
7. ASCs should also be vigilant in minimizing erroneous denials of implant claims. Detailed documentation, efficient record-retrieval systems and emphasizing proper coding practices with specific healthcare common procedure coding system codes are best practices for avoiding claims errors.
8. Advantien also recommends developing a payer-reference tool and tracking implant reimbursement, as this can help staff navigate complex payer requirements.
9. Regular internal and external audits, timely claim submission and regular staff training on payer-specific guidelines are also effective ways to manage implant reimbursement and costs.
10. Third-party implant billing services are a recent development that offer possible solutions for ASCs navigating complex implant reimbursement requirements. These specialized companies offer implant price negotiations, supply chain optimization and financial analysis. Some purchase implants directly and reimburse ASCs for costs.
