ASC Industry Awareness
Procedures Expanding, Outlook Favorable
Most ASCs are end-of-year busy and are optimistic about the future as they catch up with the backlog created by state lockdowns. One of the big reasons for optimism is the expansion of procedures moving to surgery centers. In 2019, CMS issued the final rule for specific cardiac procedures to migrate to surgery centers and hybrid cardiovascular program models are enabling that to happen quickly. Due to the complexity of spinal procedures, they have been slower to move to the ASC setting, but the ten percent of spinal procedures completed in ASCs today will likely become thirty percent over the next couple of years. The same market and technology forces that are driving increased types and numbers of surgeries to ambulatory surgery centers are also at play for office-based surgery centers.
Almost 500 ASCs with Total Joint Replacement Procedures
CMS released its final payment rule for 2020 in November 2019, allowing total knee replacement procedures in ASCs for Medicare patients. Nearly 500 ASCs and outpatient surgical centers report that they are now serving total joint replacement patients, demonstrating the readiness of ASCs to carry out total joint replacements. Due to affordability, convenience, and the high quality of relationships between patients and physicians, ASCs, like this one in Texas, continue to add total joint surgeries to their offerings.
Healthcare Industry Trends
CMS Expands Telehealth
Temporary telehealth provisions put into play over the past few months by CMS made sure that providers would be paid the same for virtual visits as for in-person care. This policy has been a big driver for the increasing use of telemedicine. Basic telehealth solutions have been around for a couple of decades and have recently proven to be more expansive than most users previously believed. The big issue for providers is equitable payment for telehealth services. This has been a huge barrier to appropriate adoption. CMS is expanding access to telehealth services through Medicare Advantage and Medicare Part D. Seema Verma, CMS Administrator, recognizes the value of telehealth in improving access to care, even potentially across state lines. However, the question of equal payment for virtual visits and in-person care is still an open one. The level of private insurance carrier adoption will be an important development to follow in 2020 into 2021.
Resuming Hospital Care
Forty-eight percent of Americans delayed care during the pandemic. Just as ASCs are working hard to serve those patients, hospitals that emptied out due to lockdowns are pushing patients to return. In some cases, that push amounts to creating marketing campaigns to give patients a better sense of safety and comfort in returning. Of course, patients are not the only ones facing new issues. Health system clinician leaders are concerned about another outbreak and about how patient demand will affect supply chains, testing capabilities, and the availability of personal protective equipment.
Healthcare Digital Transformation Watch
Healthcare IT Evolves
While some health system IT projects are on hold temporarily to see how finances shake out, responses to the lockdowns have also created a lot of opportunity for healthcare IT. The most recent survey of hospitals and large physician practices has confirmed that many took the lockdown opportunity to audit where they were in their digital transformation efforts. Eighty-eight percent plan to continue with their current efforts without curtailing spending. Clearly, telehealth has been a significant area of growth over the past few months, but not the only one. Chatbots with transcribing and translating capabilities, EHR workflow efficiencies, and virtual classroom collaborating are all advancing to meet the need.
Out-of-Network Watch
Federal Government and Some States Still Addressing Surprise Medical Bills
In the last couple of years, states have addressed surprise medical bills with a variety of solutions from direct price controls (as in California) to baseball-style arbitration (as in New York). Ohio’s House Bill 388 is marked by years of negotiation between stakeholders. Ohio’s House Bill has adopted the style of addressing surprise bills that Congress has been pushing most recently. Ohio’s Senate is now viewing the bill, which would require insurers to pay out-of-network providers the area’s median for that specific procedure. If providers and insurers do not agree, they would have thirty days to negotiate. If they still cannot come to terms, they can go to arbitration as a last resort.
Legal
Viant Vexation
by Sean Laffey, Contego Legal Analyst, from the office Jon Sistare, JD, Contego Attorney
The term “third party vendor” triggers headaches for providers and practices, as demonstrated in four class action lawsuits filed against Cigna and United Healthcare. The suits allege that both companies used a pricing company, Viant, in order to “pay a fraction of what providers were owed” and caused “hundreds of millions of dollars” in balance bills to patients. The suits contend, “These are amounts that United unjustly retained and used to pay a kickback to Viant for its role in the underpayment enterprise.” United has publicly stated that they believe the allegations are without merit and they intend to defend themselves vigorously.
Contego has encountered this issue when pursuing reimbursement for facility charges; United Healthcare will incorrectly apply multiple procedure reductions on claims using the excuse that it is within their contractual rights with Viant to do so. Regardless, Contego has maintained that whatever contract or arrangement may be in place between the two companies, the obligation to process claims in accordance with member plan documents remains clear. Both United and Viant refuse to furnish this purported contract, leaving plan participants blindsided with unexpected costs. Healthcare providers are encouraged to monitor claims processed by United and Cigna to ensure that unnecessary reductions are not applied. Hopefully, the lawsuits will set a precedent that patients and plan documents will prevail over previous actions by UHC and Viant.
At a Glance
ASCs as Hospitals without Walls during Reopening?
Some Payment Scenarios Decent for ASCs, Some Not So Much
American Society of Anesthesiologists Urges Azar
to Place a Moratorium on Health Insurer Contract Cancellations
Contego Demonstrates Path to Optimal Reimbursements
Animated Video Points Way Forward for ASCs and OBSs
Healthcare Real Estate Remains Attractive to Investors
Healthcare Property Management Firms Upbeat about Future
Off the Beaten Path, UK (United Kingdom) Podiatrists Reveal
…Toe Curling DIY Treatments Carried Out by Their Patients
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