September 15, 2022

ASC Industry Awareness

Make Some Noise for Small!

Market forces, payment strategies, and advances in technology in the United States are continuing to position ASCs/OBSs/OBLs/OBSSs for growth across all ownership models – whether hospital, corporate, physician, or a combination of owner types. This is clearly something to celebrate for patients and for ASCs of all stripes! As much noise as we all hear about consolidation in healthcare, according to 2022 data, 60% of ASCs are physician-only-owned. Eighty-four percent of our US ASCs are equipped with 1-4 operating rooms. Navigable size, heightened convenience, and personalized patient care are all significant aspects of the ASC competitive advantage. Efficiency, specialization, higher quality control, and the ability to obtain a greater percentage of profits are all reasons physicians continue to open and own ASCs.

ASC Stats for $1,000, Please

If you have ever wondered about the relative Medicare data on costs of procedures between ASCs and HOPDs, here are nine orthopaedic samples. Are you curious about which are the most common specialties for Medicare-certified ASCs? Click here to see if your state is one of the ten states with the most new ASCs since 2020. Perhaps you work in a state with few ASCs. Have you ever wondered which states have the fewest ASCs? Population density and state certificate of need status are huge factors in the number of ASCs per state and region. See how close you come to guessing the ten states with the most ASCs in 2022.


Healthcare Industry/Trends

ACA Exchange Premiums Rising, Cigna Expanding ACA Footprint

Relatively stable Affordable Care Act health plan premiums are set to rise more than normal headed into 2023. Insurers are projecting a 10% rise in premiums that will likely effect small businesses more than it does subscribers due to subsidy eligibilities. The 13 million subsidized enrollees could have had their premiums rise by 53% by the end of the year without the extension of subsidies recently signed into law by President Biden. Cigna sees that extension as a market opportunity, expanding their ACA footprint into three new states and fifty new regions in their existing markets. Inflation, utilization trends, COVID-19, and the eventual expiration of American Rescue Plan Act subsidies are all factors driving costs.

Price Transparency Moves Forward, Haltingly

As of July 1, 2022, insurers and employers are required to reveal health care prices in machine-readable files on their websites. However, it may be awhile before this information becomes easy to compare and truly useful for patients. Some hospitals are still failing to comply with price transparency, adding to the challenges for businesses and patients, though there is significant debate about how extensive the hospital transparency compliance outage is. A former CMS chief data analyst has gone on record, saying the transparency attempt is ““laudable, but flawed” since compliance requirements are still confusing.


Healthcare Digital Transformation Watch

Blockchain and Telehealth Showing Gains

Healthcare has been adopting a variety of technologies to further its innovations – robotics, artificial intelligence, and the internet of things among others, but it still has several digital transformation challenges due to security difficulties, regulatory concerns, and legacy systems. Recent advances are encouraging. In a clinical trial, Mayo Clinic is using blockchain, whose distributed ledger technology supports patient monitoring, thereby enabling patients to participate in its hypertension clinical trial from home while stakeholders access data from any interface. Telehealth is remaining popular despite the post-pandemic reopening of clinic offices. Strategic plans for utilizing telehealth are now more widely ranging, encompassing both inpatient and outpatient care.


Healthcare M&A, Valuation, Revenue Cycle

Pharmacies, Retailers, and PE Make Splashes

The drive to control swaths of the healthcare market is on display in recent deals. Walgreens Boots Alliance acquired a majority stake in home health organization, CareCentrix, in a partnership that advances Walgreens ability to provide care immediately following hospital discharge. CVS bested Amazon to buy home care company, Signify Health, for $8 billion. Last week, Walmart and Optum announced a 10-year collaboration to deliver value-based care to Medicare Advantage beneficiaries starting with 15 locations in Florida and Georgia. Interestingly, practices see more patients and bill more while their costs grow 20% following PE acquisitions. Collect Rx is joining RCM company Wakefield & Associates and is among the eight widely recognized RCM deals this summer.


Out-of-Network Watch

No Surprise Act (NSA) Final Rule Published

On August 19, HHS and The Department of Labor (DOL) released the NSA Final Rule , which is set to take effect on October 25, 2022. The final rule allows for better reporting of a downcoded service code , the advent of a fuller independent dispute resolution (IDR) process (which providers had requested), and a written explanation of IDR payment determinations with rationales to all concerned parties. The end goal of the final rule is to help providers more meaningfully inform the offers they submit to certified independent entities to resolve claim disputes.



Update on the No Surprise Act

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

On August 19, 2022, the Biden administration issued a finalized rule stipulating that median contract rates must be the starting point for resolving payment disputes over emergency health care and for when patients do not have an opportunity to select medical providers in the insurance networks.

Under the new rule, arbitrators, also called independent dispute resolution (IDR) entities, must consider the so-called qualifying payment amount, which is based on the median contract rate, “and then must consider all additional permissible information submitted by each party to determine which offer best reflects the appropriate out-of-network rate,” a fact sheet on the rule stated.

Hospitals and doctors wanted other factors listed in the No Surprises Act – such as the severity of the patient’s condition, the training and experience of the providers, and the market share held by providers and health insurers – to be considered equally with the median contract rate. Employer groups and insurers argued for relying primarily on the qualifying payment amount, which is likely to lead to lower reimbursements.

The rule also includes a provision requiring arbitrators to explain their payment determinations and underlying rationale in a written decision submitted to the parties and to the departments.

The rule implements provisions of the No Surprises Act passed in 2020 as part of budget legislation. That law, which took effect January 1, 2022, bars healthcare providers from billing patients for more than they would owe based on in-network rates. Such bills can run in the thousands or even tens of thousands of dollars. An interim final rule issued in September 2021 directed arbitrators to choose the offer that is closest to the health plan’s median in-network rate, barring overriding reasons. Healthcare providers challenged that interpretation and in February, a federal district court in Texas invalidated the previous arbitration process.


At a Glance

Cash Pharmacies Offering Cheaper Options Are Booming
Still, 91% of Pharmaceuticals Are Paid through Insurance

COVID-19 Travel Nurse Gold Rush Is Nearing an End
What’s Happening with Travel Nurses Now?

Comedian’s Creative Insurance Denial Video Goes Viral
Gastroparesis Treatment Denied as Not Medically Necessary

Investors Bet Ketamine Will Revolutionize Mental Health Care
Will It Prove to be a Fad or a Trend?

Cancer Is Now Leading Employer Healthcare Costs
Employer Healthcare Costs Increasing Rapidly in 2022

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