Michigan ASC Association
2013
Ambulatory Surgery
Scheduling Strategies
with Case Cost Analysis
Dawn Q. McLane-Onofrio RN, MSA, CASC, CNOR
Director Integration Management
SCA
The Scheduler
Who is She?










Knowledge of surgical setting
Computer literate
Mature
Organized and able to prioritize
Multi-task (and stay sane!)
Attention to detail – accuracy
Critical thinking skills
Ability to produce reports
Marketing skills – interpersonal skills
Dedicated and cheerful
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2
The Scheduler
What She Does
Demographics
 Schedules procedure(s)
 Coding (in some organizations)
 Verifies surgeon’s privileges
 Verifies equipment availability
 Assures conflicts are resolved
 Verifies / communicates special requests of
the surgeon

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3
Scheduling Flowsheet
ANY SURGERY CENTER
SCHEDULING PROCESS FLOWSHEET
Receive Call from Surgeon Office
Scheduler
Receive Fax from Surgeon Office
Scheduler
Verify Information on Fax and Schedule into
Block or Open Time/ Conflict Checking
Scheduler
Notify Materials Manager if Resource Needed
(equipment or implant)
Scheduler/Materials Manager
DQM
4
Scheduling Flowsheet
Complete Patient Demographics in
Scheduling Program
Scheduler
Pre-op Worksheet to Registration and AR
Scheduler
Insurance Verification/ Patient Call if
Necessary regarding Co-Pay
AR Specialist
Pre-op Phone Call for Patient History and
Demographic Record Completed
Pre-op RN /Admitting Clerk
Patient Chart Completed
Pre-op RN
DQM
5
Scheduling Roles

Patient Registration



pre-op input demographics
review for previous visit(s)
Pre-op Nurse





chart complete 24-72 hours pre-op
pre-op test review and notification
pre-op nurse interview – patient history
anesthesia “alerts”
ID special needs (interpreter)
DQM
6
Scheduling Roles

Surgery RN , Anesthesia, Surgeon




live by the schedule
availability of equipment, implants, etc
room turn-over and on-time schedule
PACU & Phase II RN


staffing affected by schedule
Post-op Call – assess patient satisfaction
DQM
7
Scheduling Roles

Medical Staff


assure credentialing and privileging
Materials staff
review schedule for availability of supplies and
implants
 assures materials are available
 control overnight shipping costs
 schedule vendor reps

DQM
8
Scheduling Roles

Patient Accounts




verification of benefits – insurance card
billing case & implants
documentation of medical necessity
Payables Clerk

match documents and pay invoices for supplies
DQM
9
Information Systems


Experior “SurgeOn” (formerly Camberly)
Source Medical





Vision (Scott Palmer)
Advantix
SIS (SurgiCenter Information Systems
HST - Healthcare Systems & Technologies, LLC. (Tom
Hui)
Amkai – Medical Record, releasing ASC Program
DQM
10
Scheduling Formats

Open Schedule


first come first serve
Block Schedule

blocks all or most available time


surgeon, practice or specialty
Modified Block Schedule

combination of Open and Block
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11
Modified Block Schedule
flexibility
 early release time – 7 days – 72 hrs
 may make exception for Gen & GYN
 permits scheduler to fill schedule “holes” (avoid
phantom scheduling)
 Goal: 70-85% utilization
 Utilization management quarterly - MEC

DQM
12
Modified Block Sample
Room 1
Room 2
Room 3
Procedure Room 1
Monday
AM
GYN
GEN
ORTHO
PAIN
Monday
PM
GYN
OPEN
ORTHO
OPEN
Tuesday
AM
EYE
EYE
ORTHO
PAIN
Tuesday
PM
EYE
EYE
OPEN
OPEN
Wednesday AM
GYN
GEN
ENT
COLON
Wednesday PM
OPEN
GEN
ENT
OPEN
Thursday
AM
EYE
EYE
ENT
COLON
Thursday
PM
EYE
EYE
OPEN
OPEN
Friday
AM
HAND
OPEN
ORTHO
PAIN
Friday
PM
HAND
OPEN
ORTHO
OPEN
DQM
13
OR Utilization Management
Number of hours of OR time actually used /
number of hours of OR time available (not
including turnover time??)
 If benchmarking use survey’s definition
 Permits management of blocks and decisions
about scheduling
 Goal 70-85%

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14
Policies & Procedures


Scheduling Procedures
 describes requirements for scheduling
 paperwork required
 means of communication
Pre-surgical worksheet
 demographic information
 pre-op orders
 insurance information
 schedule request – procedure(s)
DQM
15
Policies & Procedures

HIPAA patient communications policy



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
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
continuum of care
getting patient permission
what can be communicated
HIPAA Communications Form
Pre-operative Testing Guidelines
Anesthesia Alerts
Aborted Cases Checklist
Advanced Directives – policy / form
DQM
16
Policies & Procedures


Credentialing and Privileging
Observers in the Operating
Room
DQM
17
Networking




Schedulers from other ASCs
Schedulers from physician offices
Attendance at seminars
Resources:
ASC Association
 AAAHC

DQM
18
Scheduler & Marketing

Scheduler’s Manual



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provide to office scheduler
scheduling policies and protocols
forms / passwords if electronic
list of required elements to schedule
payor contract information
HIPAA Communications form
ASC contact information - cards
DQM
19
Scheduler & Marketing



Budget for Scheduler
Marketing Plan
Schedule events

Scheduler’s Breakfast or Luncheon
twice annually
 catered with door prizes
 educational session
 hosted by ED, CD, BOM, patient accounts and
scheduler

DQM
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Scheduler & Marketing

Visit Practice – scheduler, patient accounts and
Manager

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
1-2 times per year
take lunch
deliver small tokens – candy
include all offices – not volume driven
Scheduler is first impression !!
DQM
21
Advanced Directives
DQM
22
Payor Contracts
From: Executive Director & Scheduler
Update: 10/1/2005
Any Surgery Center Scheduling Information
Financial Class
7
9
23
12
5
4
1
15
12
9
8
Type
TeamCare
CIGNA
CHAMPUS
Partners
Worker’s Compensation
Blue Shield
BCBS Auto Workers
Medicaid
Medicare
Choice Care
United Health Care
Worker’s Compensation
Commercial
Self-Pay
Description / Comment
Teamsters Direct Contract
PPO Product
Standard & TriCare
HMO/PPO/POS
BCBS
AICI
Traditional
Preferred Care
Premium Preferred
Blue Access (PPO Product)
Risk-based and PCCM
All
All
All
All
All
Effective
Date
01/01/2005
01/01/2005
06/22/2004
06/26/2004
10/01/2004
10/01/2004
10/01/2004
08/15/2004
06/22/2004
06/22/2004
09/01/2004
03/24/2004
02/14/2004
02/14/2004
02/14/2004
We will continue to keep your offices updated as changes occur. If you have any questions, issues or concerns or wish
to schedule surgeries, please contact the surgery center. The surgery center staff will continue to assist in every way and
will continue to confirm insurance coverage and/or limitations of scheduled procedures.
DQM
23
Canceled Case Billing?
Any Surgery Center
Aborted/Cancelled Case Checklist
Patient Name:
Patient ID:
I. When was the case aborted/cancelled?
 Before registration
 After registration/Before IV


Physician:
After IV or Med given in Pre-Op
After admission to surgery
II. What was responsible for the aborted/cancelled case?





Patient did not follow instructions

Anesthesia provider



Abnormal Diagnostic
Abnormal Pre-Op Assessment


Not available
Malfunction
Other

Specialist/Surgeon



Equipment
Supply not available
Change in Diagnosis
Pre-Op Assessment
Other
Case open in OR
Other - Explain
DQM
24
Canceled Case Billing?
III. Did we treat patient/expend resources?
 IV started
 Medication given
 Case open (attach preference card)
 Other ________________________
IV. Documentation required to make a decision regarding the billing of this case to a payor?
 History
 Diagnostic
 Physical
Lab
EKG


X-Ray


Other
Comments:
V. Recommendation of Coder:
 Meets criteria – Bill
 Does not meet criteria – Do not bill
Comments____________________________
_____________________________________
Signature – Coder
DQM
Date
25
Canceled Case Billing?
VI. Recommendation of Controller:
 Meets criteria – Bill
 Does not meet criteria – Do not bill
Comments____________________________
_____________________________________
Signature – Controller
Date
VII. If billed to a payor, the Controller will wait for the EOB. After the EOB is received, the
Controller will perform a second review of this case.
$ _________________
 Patient responsible amount per primary EOB
$ _________________
 Patient responsible amount per secondary EOB
 Paid by Insurance $_____________
 Co-Pay $_____________
 Co-Insurance $ _____________
 Deductible $ ____________
 Not covered by insurance
$ ____________
VIII. Bill patient $____________
Write off $ __________ to account # __________
Comments:
DQM
26
Canceled Case Billing?
IX.
 Account paid
 Payment arrangements
Signature
Date
 Account paid in full
Signature
Date
 To collection
Signature
Date
Signature
Date
_________________________________________________
Signature-Controller
Date
X.
 Patient notified
 Letter
 Statement
Signature
Date
 Phone
Signature
Date
Signature
Date
Notes:
DQM
27
Breakeven Analysis
Any Surgery Center
Break-even Analysis
based on best estimates and a conservative approach
2 OR
3 OR
4 OR
Cash Flow required to fund-Monthly
$ 150,000
$ 200,000
$ 250,000
Ave/Receipt/Case
$
$
$
# of Cases needed to break Even-Per Month
# of Cases needed to break Even-Per Week
# of Cases needed to break Even-Per Day
# of Cases needed to break Even-Annually
1,000
1,000
150
38
8
200
50
10
250
63
13
1,950
2,600
3,250
Projected Case Volume at full operation-not full utilization
Cases in excess of break Even
Potential cash flow @ $1,000/case
DQM
1,000
3500
250
$ 250,000
28
Overhead Calculation
Any Surgery Center
Overhead Cost per Case based on 3rd quarter current FY
Fixed Expenses - 2005 Actual:
Payroll Expense
Medical Director
Clinical Expense
22,525
6,686
23,929
Facility Expense
Admin Expense
Debt Service
94,655
44,271
79,123
$271,189
650
$417
12% (NP) budget
Clin Eng/Eqpt Rent/Mtn Cont/MR Con/Stryker/Ph
RM Eqpt/Rad/Credentialing/instruments
#cases/mo Multispecialty mix
Fixed cost per case
DQM
29
PS Case Cost Analysis
Any Surgery Center
Pre-Surgical Case Analysis
Patient Name
____________________________________
Patient ID ________________
Insurance
______________________________________________________________________
Surgery Date
__________________Surgeon ____________________________________
Scheduled Procedure(s)
______________________________________________________________________
CPT code(s) (anticipated) ______________________________________________________________________
Implants (anticipated)
Notes: _____________________________________________________________________________________
___________________________________________________________________________________________
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30
PS Case Cost Analysis
Cost Analysis - Best Scenario
Cost Analysis - Worst Scenario
Estimated Reimbursement
Estimated Reimbursement
Projected Expenses
Implants
Projected Expenses
Implants
Staffing
Staffing
Medical Supplies
Medical Supplies
Marginal Revenue (Loss)
0.00
OR Time (overhead)
Net Income(Loss)
Marginal Revenue (Loss)
0.00
OR Time (overhead)
$0.00
Net Income (Loss)
$0.00
Notes: _____________________________________________________________________________________
___________________________________________________________________________________________
Analysis By:__________________________Date of Analysis:_____________________
Physician Contacted / Spoke with:________________________________Date/Time of Contact:_______________
Physician Decision Comments:__________________________________Date/Time of Contact:_______________
___________________________________________________________________________________________
___________________________________________________________________________________________
* This above analysis was estimated based on all information available at the time the case was scheduled and benefits were verified.
DQM
31
Case Cost Analysis LC
CPT # 47562
Cost / Expenses:
Name of Procedure: Lap Chole
Cost per case
Depreciation Expense
391.50
191.00
N/A
Supplies- Surgeon A (436.39) Surgeon B (346.46)
Anesthesia Implants
Supply costs $
*see attached preference card from AdvantX
Staffing
# staff neededposition
Registration
1
Registration
Pre-op
1
Surgery
hours neededAvg rate/hourCost of staff
11.86
2.97
0.22
RN
1
24.17
24.17
0.22
1
RN
1
25.32
25.32
0.22
Surgery
1
Scrub Tech
1
14.78
14.78
0.22
Rad Tech
0
Rad Tech
0
0.00
0.00
0.22
Recovery
1
RN
1
24.17
24.17
0.22
Phase II
1
RN
1
24.17
24.17
0.22
Overhead / Time in OR
582.50
benefits (22%) Total Staff Costs
0.25
Avg OR time
$54.00
(instrument cost)
hours
0.65
5.57
3.25
3.25
0.00
5.32
5.32
3.62
29.74
28.57
18.03
0.00
29.49
29.49
Personel Costs
$138.94
Marginal costs
$775.44
Overhead cost
$417.00
TOTAL COSTS
$1,192.44
rate/hour
1
Billing
DQM
$417.00
$417.00
32
Case Cost Analysis LC
CPT # 47562 Lap Chole
Overhead / Time in OR
Avg OR time
hours
Medicare reimbursement / case
Insurance A
Insurance B
Insurance C
Insurance E
$775.44
Overhead cost
$417.00
TOTAL COSTS
$1,192.44
rate/hour
1
$417.00
Billing
Reimbursement Calculation:
Marginal cos
%billed to Contractual or average
date
reimbursement
0
0
35
2,590
20
815
30
950
15
3,250
DQM
$417.00
Total reimbursement
0
90,645
16,291
28,500
48,750
Weighted Avg Reimbursement
$1,841.86
Net Income
$649.43
33
Scheduling Decisions

Revenue




Payor mix – contract status
Collections – days in AR
Billing protocols – within 24 hours DOS
Expense




Preference cards – resource management
Materials expense – GPO
Inventory management
Staffing - management
DQM
34
Scheduling Decisions


Maturity of organization
Organization Policy: Do Case?
perform case cost analysis
 cover Marginal Cost / cover out of pocket &
contribute to overhead
 cover Total Cost
 review reimbursement by payor

DQM
35
Case Cost Analysis - Eye
CPT # 66984
Cost / Expenses:
Depreciation
Supplies
Pack and Medications
Lens
Medications
Cataract with IOL Implant
Cost per case
0.00
Rental Contract
Supply cost
Staffing
# staff needed
Registration
1
Pre-op
1
Surgery
1.5
Surgery
1
Recovery
0
Phase II
1
position
hours needed
Registration
RN
RN
Scrub Tech
RN
RN
Avg rate/hour
0.25
0.75
0.25
0.25
0.00
0.25
13.00
19.55
22.10
16.60
19.62
19.55
Cost of staff
3.25
14.66
8.29
4.15
0.00
4.89
$35.24
benefits (1.25%)
4.06
18.33
10.36
5.19
0.00
6.11
Staffing Cost
Marginal cost
Overhead / Time in OR
Avg OR time (IS data)
Billing
0.25
$417.00
44.05
$575.98
104.25
Total Cost
DQM
10.32
521.61
531.93
$680.23
36
Case Cost Analysis Eye
CPT # 66984
Cataract with IOL Implant
Overhead / Time in OR
Avg OR time (IS data)
Billing
Marginal cost
0.25
$417.00
$575.98
104.25
Total Cost
$680.23
Reimbursement Calculation:
%billed to date reimbursement
Insurance A
Insurance B
Insurance C
Insurance D
Insurance E
100
100
DQM
949.00
$94,900.00
$0.00
$0.00
$0.00
$0.00
WeightAvgReim
$949.00
Net Revenue
$268.77
37
Case Cost Analysis – Ortho
CPT # 23412
Shoulder - Rotator Cuff Repair
Cost / Expenses:
Depreciation
Supplies
Pre-Op supplies & Anesthesia Drugs
Medical Supplies
Implants (Estimate Anchors/Tacks)
Cost per case
450.00
150.00
423.00
400.00
973.00
Staffing
# staff needed
Registration
1
Pre-op
1
Surgery
1
Surgery
2
Recovery
1
Phase II
1
CPT # 23412
Overhead / Time in OR
Avg OR time (IS data)
Billing
position
Registration
RN
RN
Scrub Tech
RN
RN
hours needed
Avg rate/hour
0.25
0.50
1.50
1.50
1.00
2.00
13.00
19.55
22.10
16.60
19.62
19.55
Cost of staff
3.25
9.78
33.15
49.80
19.62
39.10
154.70
Shoulder - Rotator Cuff Repair
minutes
4.06
12.22
41.44
62.25
24.53
48.88
193.37
Marginal cost
hours
0
benefits (1.25%)
rate/hour
1.5
$417.00
Total Cost
DQM
$1,616.37
625.50
$2,241.87
38
Case Cost Analysis - Ortho
CPT # 23412
Overhead / Time in OR
Avg OR time (IS data)
Billing
Reimbursement
Shoulder - Rotator Cuff Repair
minutes
Marginal cost
hours
0
rate/hour
1.5
%billed
Insurance A
Insurance B
Insurance C
Insurance D
Insurance E
Insurance F
25
17
20
9
14
15
100
$417.00
625.50
Total Cost $2,241.87
reimbursement
$966.00
$1,866.00
$2,511.00
$1,315.00
$2,332.50
$1,956.00
$24,150.00
$31,722.00
$50,220.00
$11,835.00
$32,655.00
$29,340.00
WeightAvgReim$1,799.22
Net Revenue
DQM
$1,616.37
($442.65)
39
Case Cost Analysis – Ortho
CPT # 64721
Cost / Expenses:
Depreciation
Carpal Tunnel
Cost per case
360.00
Supplies
Medical Supplies (includes $90 disposable knife)
Anesthesia
180.00
100.00
280.00
Staffing
Registration
Pre-op
Surgery
Surgery
Recovery
Phase II
CPT # 64721
# staff needed
1
1
1
1
1
1
position
Registration
RN
RN
Scrub Tech
RN
RN
hours needed
Avg rate/hour
0.3
0.5
0.5
0.5
0.5
1.0
13.00
19.55
22.10
16.60
19.62
19.55
Carpal Tunnel
DQM
Cost of staff
3.25
9.78
11.05
8.30
9.81
19.55
61.74
benefits (1.25%)
4.06
12.22
13.81
10.38
12.26
24.44
77.17
Marginal cost
$717.17
40
Case Cost Analysis – Ortho
CPT # 64721
Carpal Tunnel
Overhead / Time in OR
Avg OR time (IS data)
minutes
Marginal cost
hours
rate/hour
0.5
$417.00
208.50
Billing
Total Cost
Reimbursement Calculation:
$717.17
$925.67
%billed to date reimbursement
Insurance A
Insurance B
Insurance C
Insurance D
Insurance E
Insurance F
25
1
18
25
11
20
100
433.00
751.00
845.00
1,451.00
1,413.00
1,206.00
10,825.00
751.00
15,210.00
36,275.00
15,543.00
24,120.00
WeightAvgReimb $1,027.24
Net Revenue
DQM
$101.57
41
Case Cost Analysis – Colon
CPT # 45378
Colonoscopy
Cost per case
Cost / Expenses:
Depreciation
360.00
Medical Supplies
Supplies
Anesthesia
74.24
12.50
86.74
Staffing
Registration
Pre-op
Surgery
Surgery
Recovery
Phase II
# staff needed
1
1
1
1
1
1
position
Registration
RN
RN
Scrub Tech
RN
RN
hours needed
Avg rate/hour
0.25
0.50
0.50
0.50
0.00
0.50
Cost of staff
13.00
19.55
22.10
16.60
19.62
19.55
3.25
9.78
11.05
8.30
0.00
9.78
42.15
benefits (1.25%)
4.06
12.22
13.81
10.38
0.00
12.22
52.69
(staffing cost)
CPT # 45378
Colonoscopy
Overhead / Time in OR
Avg OR time (IS data)
Billing
minutes
hours
0
$139.43
Total Cost
208.50
$347.93
rate/hour
0.5
DQM
Marginal cost
$417.00
42
Case Cost Analysis – Colon
CPT # 45378
Colonoscopy
Overhead / Time in OR
Avg OR time (IS data)
Billing
minutes
hours
0.5
%billed
Insurance A
Insurance B
Insurance C
Insurance D
Insurance E
Insurance F
$139.43
Total Cost
208.50
$347.93
rate/hour
0
Reimbursement Calculation:
Marginal cost
$417.00
reimbursement
29
21
$433.00
$580.00
20
30
100
$720.00
$596.00
$12,557.00
$12,180.00
$0.00
$0.00
$14,400.00
$17,880.00
WeightAvg Reimb $570.17
Net Income
DQM
$222.24
43
Payor Mix & Contracting
It is imperative that you know your case mix
and payor mix
 Negotiation of payor contracts may be one of
the most difficult and time consuming jobs of an
Administrator
 Marketing to payors cannot be underestimated –
Answer: Why should they contract with your
Center?

DQM
44
Payor Mix & Contracting

Who are the big players in the industry? Modern
Healthcare July 23, 2007:
1. UnitedHealth Group
2. Wellpoint (Anthem)
3. Kaiser Permanent
4. Aetna
5. Humana
6.Health Care Service
7. Health Net
8. Aflac
9. Independence BC
10. Highmark
DQM
45
Payor Mix & Contracting

Who are the big players in the
industry? Modern Healthcare July
23, 2007:
11. Cigna Corp
16. Horizon Healthcare
12. BC and BS of Michigan 17. BC and BS of Mass.
13. BS of California
18. Carefirst BC and BS
14. BC and BS of Florida 19. Regence Group
15. Coventry Health Care 20. Unum Group
DQM
46
Payor Contracting Do’s
Market the ASC to the payor – Why they
should include you in network
 Know your ASC – case mix, payor mix, cost
of providing care
 Perform modeling studies: how much can
you save the payor vs same cases performed
at hospital

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Payor Contracting Do’s

Read the entire contract – every version, to
assure changes are not made to the contract
(other than the redline items)

Know what the payor’s reimbursement
schedule really means – if grouper, is it
Medicare or payor defined and get a
crosswalk to ID what CPT codes are assigned
to what grouper
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Payor Contracting Do’s
know if and how they pay for multiples
 know if and how they reimburse for implants
and prosthesis
 know if the payor will negotiate carve-outs or
move codes to a more appropriate grouper

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Payor Contracting Do’s
know the payor’s turn around time for clean
claims – are you in a state that mandates
prompt reimbursement of a clean claim filed
electronically
 know if the contract evergreens – and the
notice required to renegotiate some of the
terms

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Payor Contracting Don’ts
never sign a contract with a “most favored
nation clause”
 don’t sign a contract without understanding
the termination clause – can you terminate
without cause and 30 days notice
 avoid permitting the payor access to your
financial records

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Payor Contracting Do’s


avoid a contract that says that the payor can make
changes to the contract and reimbursement with 30
days notice
avoid payor language that states that you will be
paid 100% of the negotiated rate or XX% of your
billed charges – unless you are sure all charges will
be higher than XX% of your negotiated rates
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Payor Contracting Do’s
avoid a contract where the payor defines
essential components of the contract and
reimbursement in the Provider Manual and is
allowed to make changes just by changing the
Provider Manual (with or without notification
 avoid allowing a payor to sell or rent your
negotiated contract (silent PPO)

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Payor Mix & Contracting

PPO – a network of providers who agree to
accept a discounted fee schedule to become a
preferred provider to a group of payors under
a contract

the PPO is the contracting intermediary between
the providers and the payors
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Payor Mix & Contracting

Silent PPOs
when a PPO allows non-member payors to
“purchase or rent” the contract with providers
 these payors pay you the PPO’s negotiated
contract rates, even if you are contracted with those
other payors
 can be very difficult to identify a silent PPO
 illegal in some states now

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Payor Mix & Contracting

Silent PPO scenario
patient may present with an indemnity insurance
card that doesn’t identify the patient as a member
of any network
 you bill the usual charge – expecting no discount
or your privately negotiated discount
 the insurance company runs the claim thru a
PPO database or uses a re-pricing agency to
handle the claim

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Payor Mix & Contracting
they apply the lowest reimbursement and pay
you
 if a large enough claim, you may notice, but
this practice often goes unnoticed on smaller
claims

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Payor Mix & Contracting

Contracting language to avoid the Silent
PPO
specify that contract is in exchange for steerage
of patients
 require different coverage for in-network and
out-of-network providers
 require all member ID cards include the PPO
name and that patient must present card at time
of service

Ambulatory Surgery Compliance and Reimbursement Insider, Sept 2006
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Payor Mix & Contracting
require ID of payor’s use of PPO network on
the EOB
 require that a complete payor list be attached to
the contract and updated whenever there is a
change
 require that PPO will forfeit all discounts that
do not comply with the agreement
 require PPO to require all payors to comply
 include a clause that allows the provider to audit
PPO records related to patient activity

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Payor Mix & Contracting
include language that restricts the plan, and any
claims-paying entity the plan affiliates with, from
leasing or selling the payment rates
 include a clause that restricts the sale, access, or
disclosure of the facility’s proprietary discount
information to the payors you specify

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ASC Reimbursement
Things to Think About 2013

ASC average payment set at 56% of HOPD
(varies greatly by specialty)

ASCs paid for 3,300 procedures (some office
procedure)
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ASC Reimbursement

Procedures excluded because:
Poses a significant safety risk to the beneficiary
 Would result in the beneficiary typically requiring active
medical monitoring and care at midnight following the
procedure
 Is on the inpatient only list
 Directly involves major blood vessels
 Requires major or prolonged invasion of body cavities
 Generally results in extensive blood loss
 Is emergent in nature
 Is life-threatening in nature
 Commonly requires systemic thrombolytic therapy
 Can only be reported using an unlisted surgical
procedure code

www.FASA.org
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Summary

Administration



break-even analysis
case cost analysis
payor mix analysis and reimbursement
Physician & office staff – marketing and
education
 Clinical management of resources
 Patient accounts – collections
 Schedule the right cases !!

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Thank You!
Questions?
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Scheduling
Bibliography
1.
2.
3.
4.
McLane, Dawn Q., Ambulatory Scheduling
Strategies, HC Pro, 2005.
Evaluating and Negotiating Payor Contracts for
Success, Today’s Surgicenter Magazine,
November 2006, pg 31-34.
Protect your reimbursement dollars from a ‘silent
killer’, Ambulatory Surgery Compliance and
Reimbursement Insider, September 2006, pp 4-7.
ASCs: We can’t drive 65, Modern Healthcare,
July 23, 2007, pp 6- 7, 16-17.
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