February 15, 2021

ASC Industry Awareness

ASCs Are Trendy in 2021

Yes, ASCs are increasingly trendy. For those who have been involved in ASCs for any length of time, that shift is truly incredible. Surgery center development is coming in many shapes and sizes, but as the pandemic put increasing pressure on hospitals, the development of ASCs became trendy. ASC growth is uneven across the country and unfortunately, surgery centers in some areas are still hard pressed. States like Texas and Florida have been net beneficiaries. Some independent clinics and surgery centers, like this one in Minnesota, are expanding their footprint through additional regional locations. Others are growing by adding service lines, like this physician-owned hospital in Idaho.

ASCs Continue Adapting to Opportunities

This past year demonstrated the importance of adaptation for ASCs. Due to their very nature and size, ASCs are often well poised to adapt to shifting conditions. The migration of cases from hospitals and hospital outpatient departments to surgery centers is a huge driver of opportunity for ASCs. ASCs have a competitive advantage in quality and pricing to continue to build upon. On the pricing side, the Medicare Procedure Price Lookup tool enables comparison of CMS rates for hospitals and ASCs. Check out a sample comparison of ten orthopaedic procedures here. An independent ASC COO describes how adaptation is enabling their center to take on new opportunities for growth in this 15-minute podcast.


Healthcare Industry/Trends

Challenges for US Hospitals

Patient migration to ASCs, revenue declines, and even the move to hospital price transparency have all reshaped and challenged  shallowed-pocketed US hospitals over the past year. Over the past several years, we have become accustomed to rural hospitals being at risk of closure (see the state-by-state list). However, during the pandemic even our large cities, like Los Angeles and Chicago, are seeing hospitals close. The cash crunch of lower patient volumes, canceled elective procedures, higher expenses, and reimbursement reductions is causing hospitals in some areas of the country to lay off staff in early 2021. In just the first month of the year, healthcare shed 30,000 jobs while ambulatory services saw a job increase of 3,500.

Health Insurers Expect Volatility in 2021

Major commercial health insurers reported massive profits through the first three quarters of 2020. The usual types of claims they would be paying on dried up in the heat of the pandemic. Now that those non-emergent services are coming due in 2021, financial volatility is in the offing. This past fall, BCBS of Michigan hinted at the challenges ahead when they offered buyouts to 8,500 employees due to headwinds on the horizon. Anthem cut its outlook as profits fell 41% on care resurgence in Q4 from procedures coming due that were delayed earlier in 2020. UHC reported a similar Q4 dip in profit of 38% year over year, mostly owing to the return of more regular health care visits that had been postponed earlier in the year.


Healthcare Digital Transformation Watch

Patient Behavior Changes Create Digital Opportunities

An Accenture study has confirmed what most already believed, that over the past year people have experienced a long-term behavioral change in their expectations and habits surrounding virtual medical care. Sixty percent of respondents want to continue their virtual care beyond the pandemic. Digital healthcare offerings are becoming more predictive and cybersecurity is now paramount as telehealth continues to grow. Patient experiences are set to modernize in healthcare as HiT groups build the patient experiences that our population now expects and uses. The virtual care boom has remote monitoring wearables companies salivating over the increased opportunities for their products and subscription services.



A Win for Out-of-Network Providers in the 9th Circuit

   From the office of Jon Sistare, JD, Attorney at Law

A recent case out of the 9th Circuit Court (which compromises much of the western US) is a win for out-of-network providers as those providers fight for proper reimbursements with the large insurance carriers. The case is Beverly Oaks Physicians Surgical Ctr, LLC vs. Blue Cross Blue Shield of Illinois, 983 F. 3d 435, 442 (9th Cir. 2020).

In this case, the out-of-network surgery center filed claims with BCBS of Illinois on behalf of 14 patients. Prior to the services, Beverly Oaks had the patients sign an Assignment of Benefit form and verified the patients’ benefits with BCBS through phone calls. The claims were submitted after the services with a billed amount totaling $1.4 million. BCBS paid only $130,000 for these services.

Beverly Oaks sued BCBS through its assignment of benefit. At the federal district court level, BCBS claimed Beverly Oaks was actually not entitled to any payment due to the plan’s anti-assignment of benefit policy. The district court agreed, and dismissed the case.

Beverly Oaks then appealed to the 9th Circuit, which found in favor of Beverly Oaks by stating that BCBS waived its anti-assignment policy, as it had not raised that as an argument for non-payment prior to the lawsuit filed by Beverly Oaks.  Furthermore, since BCBS had told representatives of Beverly Oaks during the pre-procedure phone calls that BCBS would cover the services, the 9th Circuit court held that those statements were binding upon BCBS and they must pay the claims as so stated.

While this case is precedence in the 9th Circuit, its lesson is valuable for all OON providers throughout the country — which is to have solid pre-procedure protocols in place to verify a patient’s benefits, which include verifying with the patient’s health plan/insurance carrier exactly what they will pay for the respective procedures. Having that on record from the health plan/insurance carrier will pay dividends when it comes time for the health plan to make payment … and if it does not, it is solid evidence to use if a court battle ensues.


At a Glance

Stakeholders Create Affordable Coverage Coalition
Write Letter to Advance Expansion of ACA, CHIP, Medicaid

100 Healthcare Groups Work on Disaster Preparedness
Develop Report to Guide Healthcare Disaster Prep

Billionaire, Mark Cuban, Enters the Pharma Space
New Cost Plus Drugs Company Seeks to Offer Cheaper Generics

Port Huron, MI Neurology and Spine Center Moves
Converts Historic Olde Town Church into Medical Facility 

Hospitals Now Required to Make Prices Public Before Treatment
How Does Price Transparency Play in Myrtle Beach?


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