Situation
For nearly a decade, a multi-specialty ambulatory surgery center thrived in its community, providing patients with the highest standard of care and creating a successful local, physician-owned business. As recent clinical advances allowed more procedures to be performed in an outpatient setting, the Regent-managed ASC performed spine cases that historically were performed only in hospitals. Patients and physicians alike indicated frequently that they preferred outpatient spinal surgery because of the numerous, well-documented benefits offered by at-home recovery and no overnight hospital stays. Many payers, too, preferred reimbursing for spine cases at ASCs because of lower costs and better outcomes, as compared with an acute care setting. Still, one of the ASC’s contracted payers was not convinced. Nor were all of the facility’s prospective patients. And as a result, the ASC estimated it was losing at least 10 spine cases per month.
Regent’s Solution
The Regent-managed facility faced two major challenges in meeting this need in the local community: Educate reluctant patients on why ASCs offer the safest, most convenient and comfortable setting for spinal surgery, while developing and executing an effective approach for addressing payer concerns. Working with the ASC’s physicians, Regent developed a comprehensive two-pronged strategy that emphasized the center’s established track record of success in performing spinal cases. In its research, Regent discovered that prospective patients were primarily concerned about the level of care they would receive before and after — but not necessarily during – their spinal surgery. To address this issue, Regent developed a communications program for physicians and staff that helped allay these issues early on and better manage incorrect patient perceptions about outpatient spinal surgery. Addressing the payer’s misgivings, however, required a different approach. For years, the insurance company considered reimbursing for spine cases at the ASC, but was unable to make a final determination. Regent developed a new strategy to break the impasse, which involved leveraging the subject matter expertise of its clinical and business office staff. Specifically, a physician partner was tasked with making the clinical case, including why ASC spinal surgery improves outcomes, lowers costs and improves patient satisfaction. Meanwhile, through the entire process, Regent’s team of specialists worked closely with their payer counterparts to navigate myriad complex contractual issues with the payer and avoid the pitfalls that can typically derail reimbursement negotiations.
Results
Regent’s new approach finally convinced the payer – one of the largest in the local community — to reimburse for spine cases at the multi-specialty ASC. Throughout the process, Regent maintained a collegial relationship with the payer, which continued after the reimbursement deal was finalized. The new agreement also strengthened the financial performance of the ASC, improved patient satisfaction and filled an important need in the local community. Since reaching the deal with the payer, spinal cases at the ASC have increased by 300 percent and it now performs 15 total spine cases per month. Regent also streamlined the ASC’s financial and billing operations to increase operational efficiency and transparency with the payer. “We are very excited that we can now offer these spine procedures to our patients and serve a critical need in the community,” the ASC’s administrator said. “The payer also is one of the largest groups in our community and reaching this agreement was critical to the ongoing success of our facility.”