Becker's ASC Review

23 Thought Leadership Reimbursement challenges for ASCs: 3 leaders weigh in By Patsy Newitt H andling reimbursement issues is critical to ASC suc- cess. Here are three ASC leaders on their biggest reimbursement challenges: Ed Hellman, MD. President of OrthoIndy (Indianapo- lis): Right now one of the biggest challenges with insurance companies is sight-of-service determinations. We're all aware of the push to do more procedures in an outpatient setting — in many cases this has been led by physicians and has led to significant savings and improved patient satisfaction. Unfortunately, payers have taken it to an extreme, requiring procedures to be done in an outpatient or clinic setting. There still needs to be clinical judgment involved so that procedures can be done in the most appropriate location for the patient to have a successful outcome. Eugenio Hernandez, MD. Vice President of Clinical Affairs of Gastro Health (Miami): Rate pressures are ubiquitous whether a service is being delivered at the ASC or in an office setting. The challenge is demonstrating a value proposition to the payers. At the ASC, this includes associated anesthesia and pathol- ogy costs. As such, an organization that can provide a fully integrated experience is more likely to impact both cost and quality in a positive manner. This also allows more readily for value-based payment models and shared-savings programs. Nicholas Frisch, MD. Orthopaedic Surgeon and Presi- dent of Operations of Smithfield Surgical Partners (Birmingham, Mich.): Hands-down the biggest challenge for our center has been prior authorizations. Most would agree these have never been fun, but at least it used to be straightforward. Over the past several months, prior authori- zations have been getting significantly more onerous. We have had to expand our staff and have full-time em- ployees exclusively working on prior authorizations. It's not just about managing denials and peer-to-peer evaluations anymore, the entire process is taking significantly longer. This not only has a huge impact on our practice, but also our patients, as we are having to schedule out further than we have had to in the past. n ASCs get creative to thrive amid consolidation By Laura Dyrda A SC administrators are watching mar- ket consolidation trends closely and planning their next move. "As many organizations are reeling from the financial impact of the pandemic, there remains strong activity in practice acquisition or the creation of strategic partnerships," said Andy Poole, CEO of Monticello Commu- nity Surgery Center in Virginia's Albemarle County. "ASCs need to evaluate their position in their market and best position their center for ongoing success." e pandemic accelerated the volume and complexity of procedures performed in the outpatient setting, but that doesn't mean hospitals are eager to acquire centers. Many are either developing their own surgery center networks or partnering with physician groups on joint-venture ASCs. "e increasing healthcare costs, coupled with the ASCs efficiency and high patient satisfac- tion, as well as opportunities for physician ownership and innovative strategies and surgical improvements, will lead to more joint venture ASCs in 2021," John Stewart, CEO and founder of Physician Advisors and Total Spine & Wellness said. Raleigh (N.C.) Orthopaedic Clinic, a privately owned midsize group with two ASCs, devel- oped a collaborative relationship with the local hospital system to become part of its referral network. CEO Brian Bizub said the practice works closely with hospital administration to promote growth of both entities. "Raleigh Orthopaedic Clinic's position is greatly different than other highly competitive markets, so our 100-plus-year organization, physician reputation and willingness to work with a hospital system continues to allow for the organization to stay independent and profitable as a midsized physician-owned practice despite the challenges that every private practice is facing today," he said. Others haven't developed a close relationship with hospitals and may need an injection of capital before thinking about growth. Andrew Lovewell, administrator of the Surgical Center at Columbia (Mo.) Orthopaedic Group, sees private equity making a bigger splash this year aer pulling back during the pandemic. "Private equity or nonprovider-driven organi- zations are continuing to develop diverse in- vestment portfolios by taking an interest stake in healthcare organizations," he said. "As health- care costs continue to rise, and the opportunity for narrow network or high value networks with steerage develop, I think that private eq- uity will continue to take a larger stance in the healthcare markets across the country." He also sees mergers and acquisitions between physician groups accelerating to form "super- groups" of 100-plus physicians. "With large payers demanding a reduction in cost and site of service shi, many large ortho- pedic groups across the country have started to do this already," he said. "Hospitals have been combining forces to generate a larger catchment population or service area for quite some time. It's nothing new, but the formation of supergroups across the country could create some large market disruptions." n "ASCs need to evaluate their position in their market and best position their center for ongoing success." - Andy Poole, Monticello Community Surgery Center

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