Here are three updates payer policies and decisions that ASCs need to know:
1. Anthem Blue Cross Blue Shield recently reduced QZ services performed by CRNAs to 85% of the physician fee schedule starting Nov. 1. This was met with backlash by the American Association of Nurse Anesthesiology, who pointed out that the rule could be in violation of federal law regarding provider nondiscrimination in commercial health plans. Moreover, the association also indicated the move could increase costs, particularly for rural communities who rely more heavily on CRNAs for anesthesia support. CRNAs overall are a critical component in combatting the ongoing anesthesia provider shortage.
2. On Sept. 1, UnitedHealthcare released a list of procedures that will be eligible for its new physician gold-card program. The program aims to save patients and providers more time by allowing providers who qualify to skip the prior authorization process for certain procedures.
Some providers feel the program is a welcome change, while others are more skeptical. "Ultimately, our concern is for our patients. UHC's gold card program risks disrupting their access to timely care. … With colorectal cancer rates rapidly rising among younger Americans, it is especially important for UHC to refrain from imposing barriers to the vital care that can catch concerning polyps at an early, more treatable stage," Maria Abreu, MD, AGA's president told Becker's.
3. CMS' finalized payment rate for ASCs was 3.1% in its 2024 final rule, a decrease from 2023's 3.8%. Declining CMS payments continue to be a major struggle for ASCs.
"The biggest threat is payer reimbursement for ASCs," Raghu Reddy, chief administrative officer at SurgCenter of Western Maryland in Cumberland, told Becker's. "This topic has been beaten to the pulp lately, but we are not seeing any quantifiable results. Most ASCs struggle to get rate increases from the payers; with rising costs across most cost buckets, the profit margins are decreasing rapidly."