Becker's ASC Review

42 CODING & BILLING 6 ASC Payer Contracting Missteps to Avoid By Anuja Vaidya P ayer contract negotiations can be a thorny and challenging process, but ambulatory surgery center adminis- trators can mitigate the stress by preparing thoroughly and avoiding common missteps. "Payer contracting is never an easy or quick pro- cess," says Jessica Nantz, president of Outpatient Healthcare Strategies in Houston. "e key to effective contracting is understanding your busi- ness and the costs of providing your services. Unfortunately, many facilities are worried about losing access to patients, so rather than being prepared to walk away from a contract that could harm volume, they sign contracts that will not pay enough to cover the cost of the services and, ultimately, the center loses money." Here are six common mistakes ASC admin- istrators make when entering negotiations with payers: 1. Thinking the ASC can make up the difference between contracted pric- ing and actual cost. Administrators sometimes agree to a less-than-satisfactory contract, thinking the center can make up the difference through increased volume, says Ms. Nantz. While an increase in cases decreases fixed cost, it does not lower other costs, such as salary or supply costs, enough to be an ef- fective solution. It is important to have specific reimbursement rates and/or carve-outs for each procedure that cover all of your costs and provide a margin of profit per case. 2. Accepting vague language. e terms of any contract should be stated clearly so ad- ministrators fully understand what their ASC is agreeing to. Administrators can avoid pitfalls by obtaining a legal review of their contracts. "For example, be aware of terms like 'lesser of ' in the payment methodologies and their ef- fect on your reimbursement," says Ms. Nantz. "Also, avoid language that limits your ability to change your chargemaster, and make sure the contract includes a clear definition of a 'clean claim.' is is important information for your ASC in producing clean claims that will result in expedited payment. Include specific remedies for untimely payments, for example, interest or late fees. Finally, insist on language addressing timeframes for submission and payment of clean claims." 3. Allowing contracts to roll over. Be aware of evergreen contracts that can continue from one year to the next without renegotiation or a termination date, says Ms. Nantz. Medicare reimbursement may change from contract year to contract year, and you may not be receiv- ing the increases in your rates as compared to Medicare if the contract rolls over without re- negotiation. If a new procedure or technology is approved during the contract term, ensure your contract has language that will allow you to ne- gotiate or renegotiate pricing. 4. Not building a relationship with your payers. An ASC rarely gets every- thing it wants in negotiations. You need to establish a rapport with the payer, know your high-revenue groupers so you can give and take with the payer. Also, document your costs, prove your value, request parity with hospital outpatient departments, always have a counteroffer ready and, finally, be patient. 5. Not drilling down into the specif- ics. Go over every payer policy and clause to clarify the payer's payment policy on multiple surgical procedures, down-coding and bun- dling. "Be aware of the existence of different policies and procedures for different payers that may be included under one contract and request a list of payers attached to the con- tract," Ms. Nantz adds. 6. Not reviewing contracts before ne- gotiations. Review all documents and sup- porting information, and then develop a nego- tiation "road map," advises Ms. Nantz. Focus on the specialties that have the largest impact on your business to achieve the goals and objectives you set out to meet for your ASC. "While negotiations vary among payers, knowledge of your ASC's volume, costs and specialty needs will always be essential factors for a positive result. Critical to any success- ful contract negotiation is an administrator's preparation and a thorough knowledge of the ASC's operational and financial situation," says Ms. Nantz. n 10 Top-Paying Medicare Procedures for ASCs By Laura Dyrda T he 2016 VMG Health Intellimarker Multi-Specialty ASC Study com- piled a list of the top ASC proce- dures for Medicare spending. Here is a list of the top 10 procedures in 2015 including estimated payment information and the total percentage of Medicare ASC spend each proce- dure represents. 1. Cataract surgery with IOL, 1 stage • Estimated payment: $1,092 • Percentage of total Medicare spend: 28.1 percent 2. Colonoscopy and biopsy • Estimated payment: $181 • Percentage of total Medicare spend: 4.6 percent 3. Upper GI endoscopy, biopsy • Estimated payment: $177 • Percentage of total Medicare spend: 4.5 percent 4. Lesion removal colonoscopy • Estimated payment: $117 • Percentage of total Medicare spend: 3 percent 5. Cataract surgery, complex • Estimated payment: $95 • Percentage of total Medicare spend: 2.4 percent 6. Injection foramen epidural 1/s • Estimated payment: $94 • Percentage of total Medicare spend: 2.4 percent 7. Injection spine 1/s (cd) • Estimated payment: $75 • Percentage of total Medicare spend: 1.9 percent 8. Diagnostic colonoscopy • Estimated payment: $69 • Percentage of total Medicare spend: 1.8 percent 9. After cataract laser surgery • Estimated payment: $65 • Percentage of total Medicare spend: 1.7 percent 10. Colorectal screening: high risk 1/s lev • Estimated payment: $46 • Percentage of total Medicare spend: 1.2 percent n

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