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FEATURE


she says. “And then if the patient’s plan pays only 50 percent of that for OON centers, whatever the procedure is, we may only get $125.” It is next to impossible for her center


Confront Your Elephants


Overcome your ASC’s biggest financial and management challenges BY SAHELY MUKERJI


W


hile providing top quality care remains the first priority in


ASCs, putting patients first also means navigating numerous fiscal and man- agement concerns.


Reimbursement Industry experts agree that reim- bursement is one of the toughest chal- lenges that ASCs face today. “With the Affordable Care Act (ACA) and its influence on certain insurance carriers, reimbursements are not increasing and, in some cases, are decreasing while expenses are increasing,” says Gary A. Richberg, RN, CASC, administrator of Pacific Rim Outpatient Surgery Center in Bellingham, Washington. “So it is getting difficult for ASCs.” Certain insurance companies have


been very slow recognizing the unde- niable benefits of ASCs, he says. “I am continually stressing to both our con-


14 ASC FOCUS AUGUST 2015


tracted insurance payers and surgeons that ASCs are a more cost-effective alternative to the hospital outpatient department (HOPD) setting. During ASCA’s Capitol Fly-Ins, our teams focus on presenting this critical data to the legislators. We educate them and remind them that ASCs play a signifi- cant role in the reduction of both fed- eral and commercial health care spend- ing and that our reimbursements for those procedures needs to remain via- ble for us to continue providing patients with these procedures. These cost sav- ings are especially of major importance to our Medicare insured patients.” Benita Tapia, RN, CASC, director of nursing at 90210 Surgery Medical Center in Beverly Hills, California, runs an out-of-network (OON) ASC. “The commercial insurance companies are doing a flat rate or a Medicare rate, in some cases, as low as $350 a day,”


to take such cases without running a loss, she says. “Patients think they are paying for OON benefits but, in fact, they are forced into going to an in-network facility because of the out- of-pocket reimbursements,” she says. “This is a bigger problem now than before. We have seen an increase in this over the last year, and it is forcing us to negotiate a contract with the commercial carriers. To get a good rate, however, you have to know the system and how to negotiate. Many of us are RNs who run surgery centers; we are not trained to negotiate good in-network rates. It is becoming obvious that we will need to hire negotiators to do this for us as our livelihood depends on it.”


Cost Containment “Health care reimbursement for ASCs remains lower than HOPDs, even though ASCs provide the same level of care,” Richberg says. “The increas- ing gap in reimbursement for the same procedures in different settings has increased the criticism of the US health care system by taxpayers and those in the industry who are educated about the reimbursement disparity from the perspective of fairness.” Many patients are choosing to buy


lower cost health insurance plans, he says, and are surprised to find out that these plans often have much higher deductibles, he says. “I have not seen any ASCs embrace the ACA. Health care dollars are really being scruti- nized at this point, and ASCs are work- ing leaner to remain viable. This will continue in the future. I have spoken to many ASC administrators who have had to place some of their patients on payment plans due to their individual high-deductible plans under the ACA. The concern that many of them have


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