Cardiology-specific ASCs are faced with new challenges as payers update policies amid these high-acuity procedures' migration to the outpatient setting.
Tracy Helmer, administrator of Mesa, Ariz.-based Tri-City Surgical Centers, told Becker's the biggest payer issue his ASC is facing is "denials that do not fall in line with the Medicare payable procedures."
Many private payers aren't matching Medicare codes for cardiology procedures, Mr. Helmer said, "for example, loop recorder implants are commonly denied for no prior authorization from private payers, yet, in the Medicare fee schedule, they require no authorization and there's usually not a problem."
"It feels incongruent for sure," he said. "It's also frustrating to think that you've got all of your I's dotted and T's crossed, and then get hit with a denial after the fact when you felt like you were doing everything required to be compensated for the case."
To combat the clawbacks, his team has begun trying to secure a pre-authorization for any case with denial potential.
"Usually, when we're looking at a secondary payer that may not have the same payment strategies as Medicare, we try to get authorization if they'll let us," he said. "Sometimes they'll give us a new authorization requirement, and then we end up with a denial. Then we have to go back and appeal it, and it just becomes a process to get paid for it. But we always try to get authorization ahead of time on either secondary payers or private payers."
Other ASCs throughout the country are facing this issue, along with insurance companies scrutinizing previously approved claims post-procedure.
Andrew Lovewell, CEO of Columbia Orthopaedic Group, told Becker's he's seen payers trying to deny implants from procedures that were performed six months ago.
"They're doing a huge sweep," Mr. Lovewell said. "They've hired a third party and then we're spending money and time sending all these records back to them and they approve every single one of them. It's just a nuisance."