April 15, 2019

Industry Awareness

ASCs Taking Several Different Routes to Financial Success

The number of new ASCs is increasing at a 2.4% annual rate as of the last CMS reporting. Geographic distribution of ASCs is quite uneven due to a variety of factors, including state policy differences. Maryland enjoys the highest distribution of ASCs at 40 per Medicare Part B beneficiary, while Virginia only has half that many. Drive over to West Virginia, which neighbors both and the rate sinks to four ASCs per Medicare Part B beneficiary, among the lowest rate in the nation, which also reflects the variable growth rate due to population density. A wide variety of ASCs are opening in population centers. The first standalone reproductive ASC is making news in the state of New York as is the opening of a new orthopaedic ASC. Several orthopaedic ASCs have announced their openings in recent months in higher population density areas in the eastern third of the country.

Physician-Ownership Models Making News

One of the repercussions a virtual era creates is a yearning for the human, the analog, the personal. High tech plus high touch provides a powerful combination. This duo is where ASCs live and outshine the competition. Physician-ownership models are the most profound expression of the power of high tech/high touch healthcare. Patients benefit by the intense quality control that physician-owners have in their centers, through their direct relationships with physician-owners, and via the convenience of scheduling afforded by flexible, physician-owned centers. Two models of physician ownership have been highlighted so far in 2019. The “privademic” model of the Rothman institute that enables physicians to be shareholders in surgical practice with an academic hub is a unique arrangement in the ASC world. In addition, multispecialty physician ownership groups are making a comeback. 


ASCs Ready to Address Price and Quality Transparency

A recent total joint arthroplasty study performed at Midwest Orthopaedics at Rush gives some data to what we already expect. This controlled study of 314 patients demonstrated that patients opting to go home after same day total joint surgery were a little happier than patients who chose to stay overnight in the hospital. All-important patient education was not lost due to going home either. Other ASC trends will likely be adding to patient contentment. Many ASCs stand ready to address price and quality transparency ahead of most of the rest of the healthcare industry. Workplace safety is ongoing concern for freestanding ASCs. Leapfrog Group is shoring up social proof where data is skimpy regarding ASC quality ratings. Leapfrog has just launched their first annual ASC patient safety and quality survey. 

Revenue Cycle

Break Through the Top Reasons for Claims Denial

Getting a good handle on the most common reasons for claim denials will help providers break through to better, more satisfying revenue cycle management. Moving deductively from the general to the particular, the top 10 reasons for claims denials throughout healthcare include incorrect patient identifiers, prior authorization requirements, requests for medical records, and missing codes. These reasons for denial are not inconsequential to revenue and the winners in revenue cycle management are increasingly those who aim squarely on patient service. Contego serves to help ASCs break through claims denials barriers to healthier, more appropriate reimbursements based upon benefits for which patients have paid.


Authorized Representatives: The DOL Issues Clarification

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

Two years ago, Contego attorney Jonathan Sistare sent a letter to the US Department of Labor (DOL) requesting guidance on the ability of ERISA-governed plan members to appoint authorized representatives in various circumstances and the procedures surrounding that process. On February 27 of this year, they issued an information letter in response. The DOL clarified several key points regarding the appointment of authorized representatives and the ways in which plans must uphold those appointments. The letter can be found here: https://www.dol.gov/sites/default/files/ebsa/employers-and-advisers/guidance/information-letters/02-27-2019.pdf.

First and foremost, the DOL emphasized that, while a plan may establish “reasonable procedures” for determining whether an individual has appointed an authorized representative, it cannot prevent or preclude them from choosing one. This is significant because plans and insurance carriers will often attempt to invalidate a patient’s appointment of an authorized representative, forcing the patient to sign multiple different forms at different times in the process, give verbal confirmation every time the authorized representative tries to act on the patient’s behalf, and require wet signatures on forms mailed in by the patient themselves, etc. These hurdles are cumbersome and constitute a significant burden on both the patient and the authorized representative. In clarifying the limits that plans can place on the appointment of authorized representatives, we are hopeful that patients will encounter less difficulty in exercising this federal right.

Secondly, the DOL clarified that benefit plans must specifically include in their SPDs any procedures for designating authorized representatives. This will help standardize the process of appointing an authorized representative and simplify that process for patients. The letter also highlights that carriers and benefit plans should be sending any material they are sending to the patient to their authorized representative as well. Overall, the DOL’s stance in this letter falls squarely on the side of the patient, which should prove beneficial as patients’ authorized representatives work to ensure their claims are paid correctly. 

At a Glance

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