Reimbursement was on the minds of those attending the AAASC meeting...

I attended the American Association of Ambulatory Surgery Centers (AAASC) meeting this week.  I didn't get to attend all lectures but of those that I did attend, it was clear reimbursement issues are on the minds of most providers.   

Many ASCs are still struggling to negotiate fair contracts with third party payers and consequently, are continuing to provide services on an out-of-network basis.  This strategy is working for some, but most acknowledged that the payers are fighting back.  Many payers are limiting out-of-network benefits for outpatient surgery by implementing daily maximum benefits of $380, $500 and $600, or by separating the deductible pools so that patients have to satisfy a large out-of-network deductible before their plan benefits apply.  The limits can deter patients from using non-contracted providers.  One executive from a surgery center management company acknowledged that their non-contracted facilities loose about 5% of the cases scheduled.  To limit the number of lost cases, he as well as the other participants in the session acknowledged that as a non-contracted provider, they offer courtesy discounts so that patients are not financially penalized.  

However, it seems some payers including Aetna and the Blues are exercising a clause in their contracts with physicians that requires contracted providers to use contracted facilities whenever possible.  Some plans have actually threatened to cancel their contracts with physicians utilizing non-contracted facilities.  This strategy has been somewhat effective for health plans because most physicians can't afford to loose their contract with a health plan, especially prominent plans.  One of the attorneys in our discussion group was in the process of evaluating the legality of the action because it limits the members choice.  People choose Preferred Provider Plans (PPO plans) because they want access to the providers they choose.  Too few patients read the fine print of their policies prior to selecting a plan and therefore, only learn about these limitations when they try to access care. 

It is important for healthcare providers to fight back on these issues to ensure they are fairly paid for their services.  Educating patients about their benefits and involving them in the payment process can be very effective if done well and at the right time.  Educating patients the day before surgery is upsetting to most.  Money matters are generally sensitive issues and become more so when coupled with the anxiety most patients feel prior to surgery.

Insurance verification should start at least 5 days prior to surgery to ensure you receive the most accurate information about the patient's outstanding deductible and out-of-pocket maximum.  Patient Financial Counseling should be done within 2-3 days prior to surgery in writing and patients with balance of $500 or more due at the time of surgery should be called.

Our new online training and tools for business office staff will ensure your Financial Coordinator knows what to ask health plan representatives during the insurance verification process, how to calculate the expected payment and the patient's portion of the bill and tools for educating patients about their benefits and financial responsibilities.  According to HFMA, business office staff have as much impact on patient satisfaction as the clinical staff.  Those dealing with the money matters with out a doubt impact patient satisfaction.