Snagging profitable payer contracts and high reimbursements has historically been an obstacle for ASCs, particularly when competing with hospitals’ big pockets.
However, many ASC leaders are seeing a shift in payer behavior – with insurers beginning to favor ASCs. And while some ASC owners are reporting efforts by insurers to increase prior authorization requirements and ramping up denials, others are seeing evidence of payers advocating for ASCs.
“With the continued rising cost of patient care in the hospital setting, ASCs have become many insurance companies’ preference for outpatient surgery,” said Dianna Reed, administrator of Sani Eye Surgery Center in Templeton, Calif. Becker’s.
Many payer policies in the past year have pointed to a growing interest in the migration of procedures from hospitals to the lower-cost ASC setting.
In April 2021, Empire BlueCross BlueShield in New York began requiring a medical necessity review to have certain procedures performed in the outpatient hospital setting instead of an ASC. In June, UnitedHealth Group made a commitment to push more surgeries to ASCs. According to a company report, the group aims to have more than 55 percent of its members’ outpatient surgeries and radiology services delivered at cost-efficient sites of care by 2030, which means directing many patients to ASCs.
Some leaders are seeing payers deny coverage for procedures at a hospital. Barbara Clancy-Sweeney, administrator of gastroenterology and hepatology at Thomas Jefferson University in Philadelphia, told Becker’s that insurance companies in her area are “no longer paying for a screening colonoscopy in the hospital.”
“Healthy patients wanting to have a colonoscopy at their local hospital will have high out-of-pocket costs,” she said. “[ASCs] … Usually only do healthy patients and do not have the regulatory requirements and overhead of a hospital unit. “
ASCs can offer serious savings for payers. The potential savings of moving total joint replacements to ASCs, for example, is significant – with the cost of treatment being about 40 percent less in an ASC compared to a hospital setting.
Surgery centers can also reduce the amount of time spent on-site by patients for a procedure, Ms. Reed said. In her market, wait times before and after procedures at a hospital surgery center can be up to two to three times greater than her ASC.
Insurers used to favor hospitals for internal workflow efficiencies, but in some markets, ASCs seem to be gaining the upper hand.
“The future is bright for ASCs with commercial payers seeing the cost savings for themselves and their customers by moving cases to the ASC setting,” said Chris Blackburn, BSN, administrator of South Kansas City SurgiCenter in Overland Park.