Beware the Changing Reimbursement Landscape What ASCs need to know BY KYLIE KACZOR, RN, CASC

While guidance for licen- sure proceedings, facility accreditation and Medi- care certification is read- ily available to new ASCs,

what ASCs new and old often over- look are the current and pending state regulations and constant shifts in the healthcare marketplace. These include changes in self-funded and managed care plans. How do ASCs today man- age all of these factors while growing and protecting their bottom line?

State Laws

Does your state have a surprise bill- ing law? Many states have renewed their focus on balance billing or surprise billing legislation. These laws are the result of the increased use of high- deductible

health plans post-Afford-

able Care Act implementation, which creates conditions that allow patients to receive large and unexpected med- ical bills after treatment at an in-net- work facility by an out-of-network provider. States have long been mak- ing changes to legislation in an effort to protect consumers in these scenar- ios, which are often difficult to antici- pate. From 2016 to 2017, at least 89 bills had been introduced in 28 states on the issue, with nearly every state in the country addressing some form of consumer protection related to balance or surprise billing. Understanding how your state regulates balance billing will help your facility remain compli- ant as you manage your revenue cycle.

Local Employers and Self-Funded Plans As health care costs have contin- ued to rise so has the number of self-


Collect the reimbursements you deserve in 2019 and beyond. Join the popular Coding Update & Reimbursement Strategies track at ASCA’s 2019 Winter Seminar— January 17–19 in Austin, Texas— to review the coding updates that occurred this year, prepare for changes coming in 2019 and make sure you aren’t leaving money on the table. Sign up by October 15 to get the best rates. 2019winterseminar

funded plans in the marketplace. Companies, particularly large com- panies, are gravitating to this type of plan where the payment of employ- ees’ premiums and medical claims are the responsibility of the company itself. Self-funded plans make up, on average, 65 percent of the main insur- ance carrier’s business today. In June, the Trump administration expanded access to association health plans for small businesses. This ruling allows small businesses and self-employed workers to come together to buy health insurance. This will result in continued and expanded growth of the self-funded marketspace. In addition, these self-funded plans are governed by ERISA, the Employee Retirement Income Security Act of 1974, which means that your ASC may have dif- ferent managed care contracting con- siderations and appeals and denials management procedures than those associated with commercial plans. Regarding payment responsibility, we are seeing contract language that

states the managed care organization will pay on claims for fully-insured patients; however, they have no legal responsibility to pay on claims for self-funded patients. In this sce- nario, when a claim is not paid and your team submits appeals to the insurance carrier, you could be wast- ing time and resources because it is actually the employer who is respon- sible for payment. Unfortunately, in this scenario, regardless of how many times you appeal, you will not suc- ceed because you are appealing to the wrong group.

When preparing to open a new ASC, and even for existing cen- ters, it is imperative that you track the employer groups of your patient population to properly manage these self-funded plans. We also encourage you to obtain copies of the summary plan descriptions (SPDs) for these plans so that your team is knowledge- able about how these plans will pay for services.

Managed Care Contracting and Direction of Care

Pressure from the self-funded plan has forced managed care organizations to tighten up their contract language, and if you are not aware of these trends, you could see a direct impact on your reimbursement rates and revenue. Specialty product and payment responsibility language in managed care

contracts makes understand-

ing your patient population a neces- sity. Specialty product language gives the payer the right to exclude your participation in a specialty program, which could result in loss of patient volume to their plan’s preferred pro- viders. It also could result in unpaid

The advice and opinions expressed in this column are those of the author and do not represent official Ambulatory Surgery Center Association policy or opinion. 10 ASC FOCUS OCTOBER 2018 |

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