Becker's ASC Review

66 12th Annual Spine, Orthopedic and Pain Management-Driven ASC Conference + The Future of Spine - call (800) 417-2035 60 O rthopedic Surgery Center of Orange County began to adopt bun- dled payments in late 2008. Here is how they did it, according to Gabrielle White, RN, CASC, is executive director of ambulatory services and network development at Hoag Orthopedic Institute and the founder of an independent consulting company. Defining the bundled payment The first step in preparing to launch bundled payments is determining what falls beneath the umbrella of that bundle. At Orthopedic Surgery Center of Orange County, bundled payments are defined as a global payment. In this case, the bundle includes all facility and professional fees for a single episode, from admission to discharge, at the surgery center. A step beyond global payment is a warranty episode. In this case, the bundle will include all fees from admission to a certain number of days past the pro- cedure itself. "This is more work and detail, as you need to determine what is included and excluded in the warranty," says Ms. White. Global payment is a good place for ASCs to start. Easing into the process al- lows ASC leaders to build reliable processes that can serve as a foundation for future bundled payment program growth. Gauge payer interest Before diving into the details, reach out to payer coordinators. "You have to test the market," says Ms. White. "Don't put in too much effort for a payer only to find out they aren't interested." Level of payer interest and coopera- tion varies from market to market. Find procedures that fit Elective procedures without costly implants most naturally arise as bundled payment candidates. Select cases with predictable outcomes, OR time and supply usage. "Though all cases have a level of uncertainty, high volume pro- cedures are fairly predictable for any surgery center leader," says Ms. White. In orthopedics and spine predictable procedures may include: • Meniscectomy • Rotator cuff repair • Carpal tunnel release • Discectomy • Laminectomy Gather data Data is the lynch pin of any successful bundled payment program. Payers are interested in data and it will help ASC leaders understand how bundled pay- ments will work at their center. "You need to know the fee for the surgeon, as- sistant, anesthesia, pathologist and facility in one lump sum," says Ms. White. Important questions for calculating the bundle include: • What is each procedure's primary CPT code? • What are average costs for each type of procedure? • Are all of the ASC's physicians going to participate? • What are the average costs of pro- cedures by individual physicians? • How does this average play into the center's overall price average? • How will these numbers stack up when applied to the center's profit margin? "If you have good data on your physi- cians and their trends, you can easily come up with pricing, even including implants," says Ms. White. Once all of the data is in hand, ASC leaders can de- termine price limits for each procedure's global fee. Align providers All providers will need to be on the same page if a bundled payment program is to be successful. "It is really a matter of putting the concept together and presenting it in a simple, understandable way," says Ms. White. At Ortho- pedic Surgery Center of Orange County, Ms. White organized the data and presented a plan to the center's board. The ASC's surgeons and anesthesia team worked together to create a global price, which was imbedded in the facility's price limit. It's important to find equilibrium when working with providers. "If you are getting paid one check from the payer to cover all services and you have a surgeon with cases that cost a thousand dollars more than everyone else that is a problem," says Ms. White. Providers using more expensive implants or spending above average amounts of time in the OR will most likely not fit into a bundled payment model. Prepare coding and billing changes Coders will still need to code the operative report as with any other proce- dure. One issue to be aware of: if a surgeon does anything in addition to what is included in the bundle, it will not be covered. Ms. White has addressed this problem in a case such as complex arthroscopy by including all of the codes and average pricing that may be needed within that bundle. The largest changes come during the billing process. "You go from four dif- ferent providers sending claims to the payer, to one provider sending one claim," says Ms. White. "There is a lot of trust involved." A uniform process in place amongst all providers will allow for a smooth process of sending one claim and receiving one check. Ms. White's center has an in-house billing department, which was intimately involved in the bundled payment process since its inception. However, if you outsource billing, it's helpful to know the staff members in charge of a cen- ter's account. Do these staff members rotate? Do they all know and under- stand what is required for billing in the case of a bundled payment? Remain attentive to the process Putting in place a successful bundled payment process does not entirely elim- inate the possibility of mistakes. One provider may accidentally send a bill directly to the payer, resulting in double billing. Always identify a procedure as a part of the bundled payment system before it is performed and ensure all parties involved are aware. n How to Successfully Bring Bundled Payments to ASCs By Carrie Pallardy Gabrielle White

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