Mike Madewell, administrator of Panama City (Fla.) Surgery Center, a Nueterra facility, identifies three situations when ASCs might send surgery to the hospital.
1. Money-losing cases. Because of significant payment differences, there are many cases that are money-losing for ASCs but money-making for HOPDs. Pay close attention to orthopedic add-ons, because they can turn an otherwise break-even case into a money-losing one. For example, shoulder surgery with multiple anchors can push the ASC's costs above the Medicare reimbursement rate, while an HOPD could still make money on it. For both the ASC and the HOPD, "it’s a win-situation," Mr. Madewell says.
2. Some out-of-network patients. Since patients often have to pay higher charges when they are out-of-network than in-network, a physician working in out-of-network ASC may choose to do the surgery at the hospital, which is more likely to be in-network. This is helpful to patients who cannot afford the extra charges that are becoming more difficult to waive. And it helps the ASC, which might have difficulty getting the full payment from the patient.
3. Patients in poor health. Patients with in very poor health should be sent to the hospital in case hospital care is needed. In the ASA physical status classification, the cutoff tends to be the fourth category, "patient with severe systemic disease that is a constant threat to life." Sometimes the surgeon schedules such patients for the ASC, only to be overruled by the anesthesiologist evaluating the patient on the day of surgery. Apart from repercussions for the patient, this late decision is disruptive to the ASC schedule.
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