March 15, 2019

Industry Awareness

ASC Tailwinds Creating Opportunity in Even Resistant Markets

ASCs have not always enjoyed tailwinds in the US. The past few years have brought on several remarkable developments that have shifted headwinds to tailwinds for freestanding independent ASCs. One of those tailwinds is the increasing number of surgeries that ASCs routinely accept. The rapid evolution of total joint replacements from the hospital to the surgery center is proof positive. Another of those tailwinds is the desire to curtail surgical costs as patients become more healthcare aware consumers. Vermont has long been a hospital state, and as such, resistant to the freestanding ASC movement. In 2015, the first multispecialty ASC was proposed. It has been a long slog, but tailwinds, a changing marketplace, and devoted efforts look to be on the cusp of paying off. The Green Mountain Surgery Center has the approval to do business in a now favorable state regulatory climate that is creating opportunities for private practices.


Business Models and Decisions Matter

It is always big news when a large, well-known business comes grinding to a halt. In the case of Laser Spine Institute, from the outside looking in, that grind appeared to be abrupt. It clearly was abrupt for the 1,000 staff affected across all sites, who did not know the closure was coming. It was awkwardly abrupt for patients who showed up for surgery and were told, “Sorry, we’re closed.” The closure touched off a quick frenzy for patients from other spine institutes all over the country. The Tampa-based institute opened in 2005 and served over 100,000 patients while raising the national awareness of the benefits of minimally invasive spine procedures. In the days following the March 1 closing, additional problems have become known. Laser Spine Institute had weathered a couple of high profile lawsuits, the last of which was so damaging that the banks forced liquidation. Laser Spine Institute’s franchise model in which they leased medical equipment and buildings meant there were no assets to fall back on.



ASCs as Growth Industry

ASC outpatient procedure volume will grow an estimated 16 percent through 2026, with large growth opportunities in spine, orthopaedics, cardiology, and certain cancer procedures. The ASC market is expected to grow in the next couple of years from $36 billion in 2018 to $40 billion in 2020. Twenty-five ASCs opened or announced in February, so growth in surgery centers is not just future hope, but a present reality.


Supply Chain Reconsidered

Technological advances and the deepening presence of healthcare newcomers are causing ASCs in particular to reconsider how they tend to their supply chain. Amazon is well positioned to deliver to smaller-sized facilities that require an agile partner. Newer supply chain solutions have the capacity to upend some traditional vendor rep approaches while keeping ASCs well supplied.


Revenue Cycle

Revenue Cycle Strategies for Success

Providers and patients are adjusting to complex payment models where more money comes directly from the patient. Of necessity, healthcare consumerism and patient financial responsibility change providers’ calculus for revenue cycle success. Revenue cycle automation is a key component to reducing administrative burden, streamlining workflows, and decreasing labor costs. Frontend process improvements like prior authorization automation could clip days off the workload each week. Financial health for ASCs comes from an intact and healthy strategic revenue cycle, so problems on the frontend inevitably turn into backend challenges.



Turning the Tide: Recent Out-of-Network Provider Lawsuits

by Laura Raymond, Contego Paralegal, from the office Jon Sistare, JD, Contego Attorney

We are all familiar with the struggles that out-of-network providers face in obtaining proper reimbursements by their patients’ insurance carriers. Even when a patient’s plan clearly outlines out-of-network reimbursement levels, getting the plan to pay the correct amount to the provider can be a herculean task. For the past several years, providers have had relatively little success in the legal arena resolving these issues; in most cases, providers have been forced to settle before trials begin because of the severity of the claims or counterclaims leveled against them by insurance companies. However, two recent cases of providers going on the offensive show that the balance may be shifting in their favor.

The first is an ongoing suit in Texas. Nearly two years ago, Victory Medical, a chain of out-of-network hospitals, filed suit against nearly fifty Blue Cross Blue Shield affiliated insurers, alleging underpayment of thousands of claims that eventually led most of the hospitals to file for bankruptcy. The past 22 months have been spent arguing over jurisdiction, but the ERISA case is now set to move forward in the Eastern District of Texas. The fact that the case has survived several motions to dismiss and is now proceeding signals that the court believes there is some merit to the allegations.

The second involves a few individual out-of-network hospitals that sued Anthem for sending reimbursements directly to patients, a practice common among so-called ‘anti-assignment carriers.’ The Central District of California ruled in the hospitals’ favor, stating that Anthem knew that patients were profiting from this practice at the expense of out-of-network providers, and they were ordered to pay over $400,000.00 to the providers (which Anthem has appealed). However, these recent movements indicate that there may be more to come in provider-insurer litigation arena this year.


At a Glance