HCFA may release new ASC rates this spring

This spring, ambulatory surgery centers (ASCs) will enter a new payment era under Medicare. The Health Care Financing Administration (HCFA) in Baltimore expects to release details of a major restructuring of the Medicare ASC payment system, with which the agency will reimburse 1,500 freestanding same-day surgery centers nationwide. HCFA will explain the new system in a Federal Register filing. The Federal Register will contain descriptive information on the newly revamped system and the specific dollar amounts Medicare will reimburse ASCs. Also, HCFA is expected to publish a new list of ASC-approved procedures. It will hold a 30-day comment period before issuing a notice of final rule-making

A HCFA official, who cited department policy and asked not to be identified, refused to disclose early details of the new rates but said the plan is winding its way through an internal "clearance" process. It still could undergo significant alterations before it receives final approval.

The most surprising point raised by the dis-closure is that ASCs are likely to be paid under a new system unlike the present eight-tiered Medicare fee schedule. The new system will resemble a plan now being developed for hospital-based outpatient services using a methodology called ambulatory payment classifications (APCs).

Similar systems, different rates

APCs are derived from a classification system called ambulatory patient groups (APGs), which 3M's Health Information Systems division originally had developed under contract with HCFA to pay hospitals for outpatient services. Providers are being advised that the new name for both the hospital and ASC prospective payment system (PPS) could change again in coming weeks. Other terms reportedly being considered are ambulatory patient classification and Medicare outpatient groupings.

According to the HCFA official, the two plans will be similar in structure. However, the rates for the hospitals and those for the ASCs will differ. The hospital PPS is expected to become effective Jan. 1, 1999. HCFA is expected to issue a notice of proposed rule-making on it this summer and a final rule in November.

If the current ASC plan gets final approval, surgery centers would be paid according to APCs that would be assigned to particular surgical procedures. Each APC would be weighted and priced according to area wages and other economic factors. The procedures then could undergo further discounting and other refinements before getting paid. However, there is no certainty that HCFA will adopt such a plan, and "administrators should not assume anything," the official says.

Whatever plan ultimately is implemented, providers likely will receive extra time to adapt to it. HCFA officials have been reported as saying that administrators will be permitted an indeterminate time to submit claims to their Medicare carriers as usual.

ASCs have been waiting for months for news of the new payment rates, which were based partly on a sweeping ASC cost survey by HCFA beginning in 1994. The present fee schedule contains a listing of surgical procedures ranked by price in eight payment groupings. The groupings range in dollar amounts from $312 to $900.

HCFA will be looking for comparisons between known ASC payments and known hospital payments for the same procedures. Also, HCFA is accepting comments on what should be added to the list of approved procedures.

Same-day surgery providers are urged by leaders in the field to:

· Look for the notice to be published in the Federal Register.

· Compare their current payments with the proposed payments.

· Provide HCFA with comments that include reimbursement examples from their facilities.