Handling reimbursement issues is critical to ASC success. Here are three ASC leaders on their biggest reimbursement challenges:
Ed Hellman, MD. President of OrthoIndy (Indianapolis): Right now one of the biggest challenges with insurance companies is sight-of-service determinations. We're all aware of the push to do more procedures in an outpatient setting — in many cases this has been led by physicians and has led to significant savings and improved patient satisfaction.
Unfortunately, payers have taken it to an extreme, requiring procedures to be done in an outpatient or clinic setting. There still needs to be clinical judgment involved so that procedures can be done in the most appropriate location for the patient to have a successful outcome.
Eugenio Hernandez, MD. Vice President of Clinical Affairs of Gastro Health (Miami): Rate pressures are ubiquitous whether a service is being delivered at the ASC or in an office setting. The challenge is demonstrating a value proposition to the payers.
At the ASC, this includes associated anesthesia and pathology costs. As such, an organization that can provide a fully integrated experience is more likely to impact both cost and quality in a positive manner. This also allows more readily for value-based payment models and shared-savings programs.
Nicholas Frisch, MD. Orthopaedic Surgeon and President of Operations of Smithfield Surgical Partners (Birmingham, Mich.): Hands-down the biggest challenge for our center has been prior authorizations. Most would agree these have never been fun, but at least it used to be straightforward. Over the past several months, prior authorizations have been getting significantly more onerous.
We have had to expand our staff and have full-time employees exclusively working on prior authorizations. It's not just about managing denials and peer-to-peer evaluations anymore, the entire process is taking significantly longer. This not only has a huge impact on our practice, but also our patients, as we are having to schedule out further than we have had to in the past.