ASC/OBS Industry Awareness
Trends Driving Patients to ASCs
The COVID-19 pandemic has clearly been a huge challenge for healthcare systems the world over. However, in the US, it is also pressing trends toward office-based labs, office-based surgery, and ASCs. As patients avoided hospitals, they became familiar with the convenience, safety, and personalized care available in these specialized venues. Private payers are now increasingly incentivizing patients to utilize these specialty environments while physicians enjoy the benefits of autonomy not available in the hospital setting. ASCs and OBSs expect a steep rise in patient volume within the next several years as they take on ever more complex procedures and develop concomitant care management to support it.
Strategies for Private, Independent ASC/OBS Growth in 2022
Growth trends for ASCs and OBSs does not mean no market difficulties exist. Some of the deepest growth comes by pressing through challenges. Surgery centers are familiar with the opposition that often comes from existing healthcare institutions protecting their perceived turf. Hurdles for independent center growth include reimbursement issues, funding, and the growth of hospital-based employment. Orthopaedic groups and centers are planning to develop and expand their outpatient strategies as key differentiators to position themselves for growth. Developing strategic partnerships and reducing overhead are among the ways spinal groups are maintaining their independence. Contego Solutions exists to help independent ASCs and OBSs grow and stay independent by providing expertise in reimbursements.
Healthcare Industry/Trends
COVID-19 Response Presses Review of State Certificate of Need (CoN) Laws
Our national COVID-19 healthcare response has been amazing, particularly in the light of staffing and mandate issues. An area that many are now spotlighting for change are state CoN laws that slow or nix needed healthcare flexibility and development in 35 US states. Full or near-full CoN repeal bills were introduced in ten states in 2021 that have sufficient momentum to move toward at least partial repeal within the next calendar year or two. This movement toward cost-reduction by increasing market competition and forwarding healthcare availability and opportunity is worth watching in the coming years. It has been decades since US healthcare has experienced this amount of push for competitive change.
Increasing Medicare Payments for ASCs
On November 2, 2021, Representatives John Larson (D-CT) and Devin Nunes (R-CA), and Senators Richard Blumenthal (D-CT) and Bill Cassidy, MD (R-LA) introduced bicameral, bipartisan legislation to support quality, affordable outpatient surgical care in ASCs for Medicare patients at fair rates for providers. Their stated goal is to stem the gap between traditional hospital and surgery center Medicare payments. The net desired effect is to increase access to the high quality services ASCs provide while enabling ASCs to receive higher levels of Medicare reimbursement than traditionally has been allotted. Click here to read the text of the Outpatient Surgery Quality and Access Act of 2021.
Healthcare Digital Transformation Watch
HiT Trends, Predictions, and Legal Issues to Watch in 2022
Healthcare IT is expecting to play an increasing role in 2022 maximizing workflows that enable better supply chain efficiencies, democratizing access to healthcare, and personalizing the healthcare experience. Though it may appear self-serving, Zoom healthcare lead predicts that healthcare will become digital first in 2022. Among the HiT trends to watch in 2022 are transition to the cloud, further embracing of virtual care, and more acceptance of remote patient monitoring. HiT leaders will be focusing more energy on developing deeper platforms that do more for their organizations and on anywhere, anytime virtual care. 2022 will be full of legal considerations for HiT leaders including telehealth, FDA approaches to regulating digital health, privacy and cybersecurity, fraud and abuse, and antitrust issues that are at the center for increasingly targeted healthcare and technology industries.
Legal
More on the New Federal Requirements Effective January 1, 2022
From the office of Jon Sistare, JD, Attorney at Law
As you know, the federal No Surprise Act (NSA) took effect on January 1, 2022. However, a portion of it, known as the transparency requirements for individual medical providers, has been delayed due to the complexity of the notice requirements and communications necessary between the provider, the health insurance carrier, and the individual patient. You will see below the specific time frame requirements that will ultimately be in effect when the logistics for these requirements are ironed out.
What was intended by the NSA to take effect on January 1, 2022 requires providers (individual practitioners and facilities) to send the health plan a “good faith estimated amount” of scheduled services, including any expected ancillary services and the expected billing and diagnostic codes for all items and services to be provided. This notice then triggers the health plan’s obligation to send enrollees an “Advanced Explanation of Benefits” (“AEOB”) prior to scheduled care (or upon patient request). If the patient is uninsured, the provider must send the notice directly to the patient.
The health plan must provide the AEOB by mail or electronically (based on patient preference) either within three business days of receiving a request or a notice that a service has been scheduled if the service is scheduled at least 10 business days later, or within one business day of receiving the notice if the service is scheduled within 10 business days of receipt.
The AEOB provided by the health plan to the enrollee must contain:
- The network status of the provider. If the provider is in-network, the health plan will need to include the contracted rate for the item or service, based on the billing and diagnostic codes sent by the provider. If the provider is out-of-network, the health plan must include a description of how the patient can obtain information on in-network providers delivering that item or service.
- The “good faith estimate” of expected charges, including likely billing and diagnostic codes sent by the provider.
- A “good faith estimate” of the plan’s payment responsibility.
- A “good faith estimate” of the patient’s expected cost-sharing amount.
- A “good faith estimate” of the amount the patient has incurred toward meeting their financial responsibility limits, such as their deductible and out-of-pocket maximums.
- If applicable, a disclaimer that coverage for the item or service is subject to a certain medical management technique (e.g. prior authorization).
- A disclaimer that all information included in the notice is an estimate based on the information known at the time of scheduling (or requesting) and is subject to change.
- Any other information or disclaimers the health plans determine is appropriate for this notice.
While not all of this is in place as of yet, and there is no date certain as to when DHHS and CMS will require this to be fully in place and functional, the best course of action for any provider is to begin to plan now for these future requirements. It is believed that by the end of 2022 all of the requirements noted above will begin to be enforced by the respective federal government agencies.
At a Glance
Single Payer Healthcare Bill Stalls in California State Assembly
Single Payer Does Not Even Reach a Vote
First Hospital in Louisiana to Create a Medicare Advantage Plan
Ochsner Health Now Has Own Health Insurance Arm
NJ Gov. Murphy Approves Healthcare Cost Program
NJ Health Care Cost Growth Benchmark Program
Nero’s Law Passes the House in Massachusetts
Would Allow K-9 Partners to Receive Emergency Care
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