ASC Surgery in action

Effective Out-of-Network Strategy helps ASCs Rise to Reimbursement Challenges

Changing payor reimbursement policies were a big topic of discussion at Becker’s 15th Annual Spine, Orthopedic and Pain Management-Driven ASC Conference + The Future of Spine, held recently in Chicago. But as the healthcare landscape evolves, developing a profitable out-of-network strategy is one way ambulatory surgery centers (ASCs) can rise to the challenge.

But profitable is the key word. To make out-of-network reimbursement strategies pay, the experts at Regent Revenue Cycle Management suggest ASCs take a measured approach to embracing out-of-network, testing first, and taking on risk as they have resources to support it with persistence and know-how. Following are three key steps to embrace in the process:

  1. Test and Learn

Some ASC contracts have more potential in terms of out-of-network reimbursement than others. Analysis of payer mix and market share will help ASCs understand which contracts may offer out-of-network opportunity. From there, shifting a few procedures over a short period of time to out-of-network status with a payer can be a good test. If assessment of the results is positive, more services can be moved out-of-network with that payer. This approach helps manage risk, while enhancing understanding through trial and analysis.

  1. Work the Appeals Process

Dogged pursuit of the appeals process is another key to making an out-of-network strategy successful – capturing out-of-network reimbursement funds is not for the faint of heart. Staying organized through what can be a drawn-out process, renegotiating, following up, reviewing the explanation and assignment of benefits – to succeed, ASCs must play the appeals game to win.

  1. Be Smart About Payers

Employers and payers use a variety of tactics to control out-of-network cost on their end, by minimizing providers’ reimbursement. For example, narrow network plans force ACSs into an out-of-network environment in some markets, while payers’ use of third-party vendors to manage obligations to providers often can confuse and slow negotiations.

“You really have to do your homework and dig deep to develop a profitable out-of-network strategy,” says Erin Petrie, Director of Revenue Cycle Management at RegentRCM, “but if you do the work, the opportunity is there.”

For information about how RegentRCM can help you develop and implement a profitable out-of-network strategy click here, or call (708) 492-0531.