Becker's ASC Review

21 ASC MANAGEMENT The payer trends impeding ASCs today By Laura Dyrda A SC owners and administrators are finding it more difficult to obtain payment from insurers as compa- nies change coverage policies. But the cur- rent strain could push insurers and ASCs to find common ground on caring for the entire episode of care more efficiently and cost-effectively. Three big challenges facing ASCs today include more prior authorizations, deni- als and emerging financial models for care delivery. More prior authorizations, more problems Insurers across the U.S. are changing their policies to require prior authorizations for more procedures than in the past, which means more paperwork for the physicians and ASCs. "One of the biggest issues we're seeing to- day with payers is added administrative work related to prior authorizations,," said Tina Piotrowski, CEO of Traverse City, Mich.-based Copper Ridge Surgery Cen- ter, who also sees a potential for a fluctu- ating payer mix attributed to "the Great Resignation," or more people across the country quitting their jobs and moving to health plans from the exchanges or Medic- aid, which have low reimbursement rates. Prior authorization requirements delay procedures since surgeons have to get ap- proval from the insurance company before moving forward. "These delays add cost to an already ex- pensive system and delay necessary care, eroding the physician-patient relation- ship," said Adam Bruggeman, MD, of San Antonio-based Texas Spine Care Center. "The administrative burden related to de- layed payment through increased requests for records does not currently have a solu- tion, and we continue to work with payers to collaborate and ensure that this process is only used in cases where it is necessary." Texas passed groundbreaking legislation this year related to prior authorizations af- ter studies showed the process was waste- ful and the authorizations were granted in 99 percent of the cases. The policies also hinder needed care and treatment. "Payers are trying to catch up with new cancer screening and surveillance guide- lines," said Rajat Chander, MD, a gastro- enterologist from Cary, N.C. "They some- times require precertification for upper endoscopies or anesthesia." Denials, denials, denials Payers are tightening their policies to ap- prove fewer patients for surgery and deny- ing patients who previously would have been clear-cut surgical candidates. Sur- geons worry denials delay needed proce- dures and worsen the patient's condition. "I see payers as opportunistic," said Joe O'Brien, MD, a spine surgeon with Or- thoBethesda in Maryland, and medical director of minimally invasive orthopedic spine surgery at Virginia Hospital Cen- ter in Arlington, Va. "They will deny care when they can, they will deny payment when they can, and they will provide poor contracts when they can. I'd love to see a future model where the payers were true partners with the patients and doctors." Anesthesiologists are also seeing increased roadblocks to receiving pay. Mark Jamie- son, MD, a partner at Los Gatos, Calif.- based G2 Anesthesia, said insurance companies his group contracts with have denied payments over easily fixable cleri- cal mistakes. In one case, his team didn't check a box delineating physician care from nurse anesthetist care, and in the other the payer cited 'nonlegible' names on the anesthesia records. "These are examples of nonpayment and delayed payment for contracted physi- cians," said Dr. Jamieson. "There are thou- sands more stories on noncontracted phy- sicians and payment denials." Emerging financial models Traditional payer contracts operate as fee-for-service, but those contracts have become unsustainable in some cases as in- surers are only willing to make small pay increases, if they increase rates at all. "A careful review of reimbursement shows that fee-for-service is a steady march to the bottom without a foreseeable end," said Dr. Bruggeman. Bundled payments aren't much better for ASCs. While some surgery centers have successfully crafted bundled payment contracts with payers, many lack the data management infrastructure to negotiate toe-to-toe with insurers. The standard- ization of best practices and outcomes is easy for some procedures, like total joint replacements, but harder for spine surgery since there are so many factors dictating favorable outcomes. "[Bundled payment model] paradigms, as they currently exist, are hampered by de- pendence on diagnoses-related groups that currently are not adjusted for procedure- specific and geographic variation or indi- vidual conditions," said Kern Singh, MD, a spine surgeon at Midwest Orthopaedics at Rush in Chicago. "The future of these pay- ment models will likely incorporate input from surgeon experts to stratify bundled reimbursements by patient comorbidity burden, complexity of care, geographical variation and elective vs. nonelective con- ditions." Dr. Singh sees a trend toward specializa- tion that will allow for greater standard- ization of outcomes and efficiency while also decreasing costs. Dr. Bruggeman has a similar perspective, taking bundled pay- ments to the next step of managing popu- lation health from nonoperative treatment through postoperative care. n

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