Becker's ASC Review

28 Coding & Billing P ayer relationships with amulatory surgery centers are making grad- ual changes as the healthcare system moves full steam ahead toward providing value-based care and reimbursement. Rate increases still low Payers continue to minimize rate increases, prolong the negotiating cycle and attempt to lock providers into multiyear contracts with no COLA, says Regent Surgical Health Director of Managed Care Andrea Woodell. How- ever, reasonable payments are achievable enabling centers to perform higher acuity cases in ASCs. Payers will offer too-low rates for procedures like total joint replacements or spine surgeries, so the facility must be prepared to sell their value proposition to each payer. Historically the payers have approved a short list of spine and joint cases for ASCs, and still label routine cases as investigational forcing the case to the hospital ORs where they do pay for it, says Ms. Woodell. However, as the healthcare system begins to incentivize lower cost care set- tings and studies show these higher acuity cases are safe in the outpatient setting, some payers are working with ASCs to move those cases; but it's still not easy for the center to make a profit. The payer's budget has only token increases for ASCs. While the outpatient center saves them thousands over hospital outpatient fees, most payers' systems are unable to credit the savings, offering insufficient dollars to the ASC to move the case to a lower acuity setting. Spine cases in ASCs Today, many surgery centers and payers are focused on bringing higher acu- ity cases to the outpatient setting, but they move slowly. Medicare is adding spine cases to the approved coverage list, but the codes introduced won't pay enough for fusion cases. There are typically four or five CPT codes for spine cases, and Medicare didn't add codes two through five. "The rates are inadequate and surgeons will hesitate to perform spinal fu- sions in the ASC for Medicare patients paying $7,842," says Ms. Woodell. "It is unlikely we will see many of these Medicare cases move, but the less acute cases such as the laminotomy or laminectomy will go to the outpa- tient setting." But the Medicare coverage is a victory. Most payers base coverage as a per- centage of Medicare, and Medicare's nod to spine surgeries — including spi- nal fusions — in the outpatient center signifies procedure safety and efficacy to other payers. Likely, the non-government insurers will develop appropri- ate rates for outpatient spine surgery including fusions. "Since Medicare allows these procedures, even the most conservative pay- ers will likely decide they are safe to perform in an ASC," says Ms. Woodell. "There is a liability issue that goes away. Contracts paying out Medicare grou- pers at a high percent are another opportunity to leapfrog reimbursement without touching the contracts." More progressive payers, like UHC, have been driving the appropriate pa- tients to outpatient surgery centers for a few years, and Ms. Woodell now sees more conservative payers including the Blues plans, Aetna, Cigna and Humana in some areas covering spine procedures in the ASC. "There is an increased confidence level with the payers that the ASCs are making smart, appropriate decisions with patient criteria and selection," she says. "There is increased security with neurologists to move spine into the ASC and among orthopods to do total joints outpatient, and that's all sup- ported by better clinical processes and payment control." But just being able to perform the surgeries in an ASC isn't enough for many centers; owners and operators are also developing 23-hour stay capabilities and postoperative services. State laws that prevent 23-hour stays in some places are loosening to allow longer stays and remove certificate-of-need roadblocks. "For states to make these changes in their coverage is a strong statement about how ASCs perform clinically," says Ms. Woodell. 5 Trends in ASC Relationships With Payers By Laura Dyrda "There is an increased confidence level with the payers that the ASCs are making smart, appropriate decisions with patient criteria and selection." — Andrea Woodell, Regent Surgical Health Director of Managed Care

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