ASC

Insurers Help Themselves By Helping You Help Patients . . . At Your ASC

April 19, 2021

Need a marketing consultant to help grow your ASC? You might want to check with your carriers first. 

Background

As the latest step in a trend that began several years ago, effective for 2021, CMS added 267 new codes to Medicare’s ASC covered procedures list. 

These are the codes for procedures that Medicare recognizes for payment in the ASC setting. Put another way, no code, no payment. Put even another way, with a code, it’s not only Medicare that follows, that is, pays, commercial carriers look to Medicare in that regard.

And, put even another way, procedures that previously could be performed, meaning performed and reimbursed, only in a hospital setting, whether inpatient or outpatient, can now be performed in an ASC.

In addition, CMS has announced the phase out over 2021, 2022, and 2023 of the Inpatient Only List, the list of procedures, that to be reimbursable, must be performed in a hospital on an inpatient basis.

Those procedures that were once inpatient only will be going to HOPDs and to ASCs. Over time, when CMS reaches payment parity between HOPDs and ASCs, all will be ASC procedures.

Carriers Helping Push Procedures Out of HOPDs Today

Complain as you might about carriers raising premiums and cutting reimbursement, often on the same day, they know a good deal when they see one.

Take, for example, New York’s Empire BlueCross BlueShield, which announced a new coverage policy to push more procedures out of the HOPD setting to ASCs by making ASCs the default site of service for a host of outpatient procedures for commercial plan patients. 

Patients need a medical necessity review to have their procedure performed in an HOPD. No medical necessity review applies if the procedure is performed in an ASC.

According to a carrier spokesperson, “Empire BlueCross BlueShield is committed to being a valued healthcare partner in identifying ways to achieve better outcomes, lower costs and deliver access to a better healthcare experience for consumers.”

What This Means For You

How the story’s changed! 

Just two decades ago, carriers saw ASCs, predominately owned by physicians, as “conflicts of interest.” How could they, they claimed, trust a physician to admit his or her own patient to a facility he or she owns?

But now, it’s clear that ASCs provide better care at lower cost, in a setting that’s preferred by both patients and physicians. 

Some see the payment policy shift, governmental and commercial, as motivation for hospitals to acquire or build their own ASCs. 

As to 100% hospital-owned ASCs, physicians who’ve already given up control of their practice to the hospital through employment will have no choice but to go along, meaning without ownership. 

But as to all other physicians, as well as in connection with potential joint venture ASCs, why would physicians want to partner with a hospital at all? It can’t be for their ASC management skill; they have none. And, if the hospital proposes a three way JV to independent physicians, you’ve got two “partners” and a diluted physician ownership percentage. 

As I see it, we’re about to witness a huge increase in the already tidal shift in the site of surgical service to the ASC setting. Partnering with the right long-term, and, therefore, non-PE backed, management company makes sense, as they bring skills to the table that you’re lacking. 

However, be careful to avoid a manager that’s as bureaucratically impacted as a hospital (or an insurance carrier!) or you’ll risk losing both your competitive advantage and the fun, yes, fun, of doing your cases in an enjoyable environment. 

Comment or contact me if you’d like to discuss this post.

Mark F. Weiss

www.weisspc.com

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