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New reasons insurers are denying payment

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Commercial insurers are changing their policies to deny hospitals and ASCs payment for services deemed unnecessary or lacking enough evidence to move forward.

In the last few years, such companies as Empire BlueCross BlueShield in New York; Anthem; and UnitedHealth Group have been directing outpatient procedures to ASCs.In some states insurers have stopped paying hospitals for outpatient procedures. UnitedHealthcare will begin denying emergency department claims for services that it doesn't consider emergencies when the pandemic ends. The company originally planned to implement the new policy July 1, but then delayed the change June 10, according to the StarTribune.

When Anthem has a similar policy, the payer denied 12,000 claims in three states during a six-month period in 2017.

American Hospital Association CEO Rick Pollack criticized UnitedHealthcare's policy in a June 8 letter to UnitedHealthcare CEO Brian Thompson and requested the company reverse the policy. The American College of Emergency Physicians also came down against the policy.

While ASCs don't typically provide emergency services, executives recently have noticed stricter policies for preauthorizations and service denials. Tammy Stanfield, BSN, RN,administrator and director of nursing at Conroe, Texas-based North Pines Surgery Center, said an increase in the number of pending authorizations from insurance companies or more frequent denials could break the center.

Taylor Cera, COO of Orthopaedic Surgery Center in Youngstown, Ohio, said he constantly reviews payer contracts and communicates with contract managers to avoid missing a policy change that could hurt his centers.

"We've already seen some new trends and new rules from insurance companies, specifically regarding preauthorizations in orthopedics," he said. "It has caused some issues in our flows and our processes, so I think continuously having those conversations and understanding things that are coming down the pipeline that are going to affect our internal processes is extremely important to know."

Andrew Bush, MD, an orthopedic surgeon at Central Carolina Orthopaedics Associates in Pittsboro, N.C., also noticed a trend of insurance companies more routinely denying diagnostic tests and requesting more peer reviews.

"We recently had a Blue Cross Blue Shield policy deny a surgical knee arthroscopy due to something like lack of sufficient evidence, but be willing to authorize the surgery if I agreed to make it a diagnostic arthroscopy, which would cut my reimbursement in half," he told Becker's. "I refused BCBS for obvious reasons. The patient ended up paying out of pocket for the case, and I ended up doing the surgery I initially indicated."

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