Surgery centers say to payers: We are not going to take it any more!

Exclusion from contracts, low and late payments push centers to action

How would you like to go from receiving no payment increases from one of your payers to receiving rate increases of 3% to 11% four years in a row? Sound impossible? Not for ambulatory surgery centers (ASCs) in Ohio, which became proactive in educating their workers’ compensation board after receiving no payment increases for three years in a row.

ASCs across the country are reporting similar strategies as they go on the offensive after years of complaining that they are being blocked out of payer contracts, receiving delayed payments, and/or being given payments even lower than Medicare and Medicaid.

"We want to get rid of the ASC list, thereby putting the decision about where surgery is performed in the hands of physicians and patients," says Lisa Spoden, PhD, executive director of the Ohio Association of Ambulatory Surgery Centers in Columbus and the Kentucky Ambulatory Surgery Center Association in Frankfurt.

Surgery centers are focusing their lobbying efforts on Medicare because that system has the most antiquated list, she says.

"So many payers use Medicare as baseline for what they approve in procedures and what they pay," Spoden adds. "That has been a stumbling block for us, because Medicare is so behind in the procedure list they approve for ASCs."

And that’s not the only problem, say sources contacted by Same-Day Surgery. Some ASCs say they’re unable to obtain contracts with payers, says Rob Schwartz, executive director at the Colorado Ambulatory Surgery Center Association in Denver.

"We have members who have expressed concerns that they’re locked out — that the answers they’re getting from carriers is that they’re making business decisions," Schwartz says. "Some choose not to elaborate or explain beyond that."

Another concern is payers are developing pricing for ASC procedures that displaces them from serving individuals with that payer, even in situations in which they’re paid as "out-of-network" providers, says Craig Jeffries, executive director of the American Association of Ambulatory Surgery Centers in Johnson City, TN. Still other facilities are having difficulty getting payments from payers, Spoden says.

To successfully address problems with payers, take these steps:

• Educate payers.

Members of the Ohio Association of ASCs realized payers didn’t understand the difference between hospital outpatient surgery departments, freestanding ASCs, and physician offices that performed surgery, Spoden explains.

In response, the association provided information, advocacy, and education. For example, the Ohio association shared benchmarking data with payers to show high levels of patient satisfaction and low infection rates when compared with inpatient facilities, she says.

A computerized presentation with graphics provided basic information on what surgery centers are and what they do. The presentation, given to seven payers, discussed patient satisfaction rates and technological advances. The association representatives met with the state workers’ compensation board to discuss what procedures should receive reimbursement in surgery centers.

"We used some well-written, well-documented writings from physicians proving the efficiency of the cases," Spoden notes. That educational effort led to 35 new procedures being added to the list of procedures reimbursed under workers’ compensation, she says. "They continue to add each year a number of procedures," Spoden adds.

• Establish an ongoing dialogue with payers.

It’s important for ASCs and payers to understand how each works, she says. An ongoing dialogue can help ASCs understand where claims may be getting delayed and where the information pipeline is disconnected between the centers and the payer, Spoden says. "It also helped to identify who our ASC experts are, and when they have questions, they can come to the association and we’ll help them understand a particular procedure or answer their questions," she says. "We tried to have regular dialogue to benefit insurers, ASCs, and ultimately, our patients."

While the Ohio association initially established a working group with the workers’ compensation board, they are trying to do the same with other payers. The association wants to try to explain the centers’ position in different areas, including the benefit of performing multiple procedures at one time, why implants need to be paid above the established rate, and why some patients need longer than two to three hours to recover properly, Spoden says.

Another important piece of the dialogue with payers is having them tour your facility, Spoden emphasizes. "It gets payers out to see how things are done in an ASC, and they come away with a better understanding of why it’s a great site for patient care," she says.

• Ensure your state’s laws for payment are followed.

Some states have regulations that set a payment turnaround time for all medical providers, Spoden says. "If you’re having problems with a particular payer, advise the payer of the statutes," she suggests.

If you don’t receive a positive response, meet with them and discuss the problems, Spoden says. Examine where the delays are, and determine if there is anything the surgery center can do to speed payment, she suggests. Also share where you see payer problems that need to be addressed, Spoden advises.

"If you’re getting nowhere, go to your [state] department of insurance and talk about the problems you’re experiencing," she says. Her association has taken that step, and centers are reporting better payment turnaround, Spoden says.

If you have problems with payers saying they never received claims, consider filing electronically so you can set up your system to notify you when the information is delivered. If you send paper claims, have the insurance company sign when they receive the claims, Spoden suggests.

When you initially approach payers, emphasize that it’s a partnership and you want the same outcomes, Spoden suggests. "Our goal is to provide good quality outcomes and be cost-effective for them, save insurance and purchasers of insurance — the companies that have workers — money and yet have fair payment to ASCs," she says. "That’s the bottom line of ASCs."

Sources

For more information on payment policies for ambulatory surgery, contact:

  • Rob Schwartz, Executive Director, Colorado Ambulatory Surgery Center Association, 6825 E. Tennessee Ave., Denver, CO 80224. Phone: (303) 761-3596. E-mail: rob.schwartz@stratresources.com. Web: www.cascacolorado.com.
  • Lisa Spoden, PhD, Executive Director, Ohio Association of Ambulatory Surgery Centers, 17 S. High St., Suite 1000, Columbus, OH 43215. Phone: (614) 358-0177. Fax: (614) 228-7702. E-mail: lspoden@shcare.net.