Urfan Dar, MD, manager and medical director of Theda Oaks Surgery Center in San Antonio, offers seven tips for pain centers.
1. Steer away from money-losing pain implants. Some pain implants cost too much to use in an ambulatory surgery center without losing money. For example, a percutaneous discectomy implant with a probe costs between $900 and $1,500, but the reimbursement for the procedure is around $1,000. "Every time we use this implant, we lose money," Dr. Dar says. "In some cases I have had to pay $300-$400 out of my own pocket." Try to persuade the insurer to pay more and if that doesn't work out, perform this procedure in the hospital from now on.
2. Beware of evergreen clauses. "Don't accept an evergreen clause," Dr. Dar advises. This kind of contractual clause provides for an automatic extension of the contract without approval each time by the provider. Through such clauses, the payor can lock in the same rate as the year before, precluding any possibility of an increase.
3. Make sure all allowables are included. The contract should include allowable charges for every code that ASCs will charge for. Some allowables are sometimes left off the contract. This can be remedied by contacting the insurer and asking for the missing allowables.
4. Keep track of procedures with no facility fee. A whole set of pain blocks and injections are only reimbursed a professional fee and not a facility fee. Therefore, these procedures have to be done in an office rather than an ASC. But the codes on Medicare's list with no facility fee change each year. Two or three years ago, for example, ASCs were not paid for hip injections but now they are, Dr. Dar says. Examine the Medicare fee schedule every year to identify changes.
5. Calculate true costs for procedures. Calculating the true cost of a procedure will help determine the necessary reimbursement. Add up everything used, including medications, needles and fluoroscopy, and add the time of nurses and other personnel for that procedure. Compare the total to the reimbursement. "If the reimbursement is only $10 more than your cost, you may have to start doing that procedure in the office setting," Dr. Dar says. Since calculating the true cost is time-consuming, billing staff can probably only do so once or twice a year. "If you regularly bill 30-50 payors, like many ASCs do, it is hard to do it more often," Dr. Dar says.
6. Start reviewing contracts immediately. Proposed contracts up for renewal are often sent to providers 1-2 months before taking effect. It is often a thick packet. Start reviewing the packet as soon as possible, because that leaves time to negotiate changes. For example, if the contract preserves the same reimbursement rate, ask for a cost-of-living adjustment of perhaps 3 percent. If the contract actually drops the price and you can't get that changed, you may have to stop performing those procedures in the ASC.
7. Don't overbuild. Building a surgery center that is too big is a common error. For example, two pain physicians, one orthopedic surgeon and two GI physicians want to invest in an ASC. The pain and GI physicians want two procedure rooms and the orthopedic surgeon needs a full-fledged OR. This group cannot possibly fill the center with cases, so it will lose money. "You walk into that ASC in the afternoon and everyone is gone," Dr. Dar says. If the ASC is already built, the physician-owners will need to scramble to recruit more physician-partners who can use the OR.
Learn more about Theda Oaks Surgery Center.