Benefits for the Conversion of OBL to a Hybrid OBL/ASC

Partner News | Published: Thursday, June 4, 2020


By:

Robert J. Zasa, CEO, ACA Cardiovascular, LLC and      rzasa@acacardiovascular.com

Heather Combs, RN , COO, ACA Cardiovascular          hcombs@acacardiovascular.com 

Interventional cardiovascular procedures have transitioned rapidly to the outpatient surgery setting over the last two years. When the Center for Medicare and Medicaid Services (CMS) approved PCI procedures in the outpatient surgical segment, this escalated the migration to an ambulatory surgery center (ASC) setting. As of March 2020, there have been approximately one hundred (100) CPT codes which are currently grouped in the cardiac procedure category and are approved by CMS to be performed in an ASC. From a clinical perspective, these procedures are performed in a safe environment and this access to care has saved many patient lives. From a fiscal perspective, these procedures performed have been cost-effective and has saved thousands of dollars for Medicare as well as other payers. In the past, these procedures were performed (and in many cases still are) in a hospital Cath Lab or hospital – based outpatient surgery area at a much higher cost. This negatively affects the patient’s out-of-pocket costs due to the much higher fee charged to the patient. Properly equipped ASCs which hold true to Medicare and State regulations provide the cardiac patient quick access to care, but also serves to support providing a lower cost solution within a safe environment.  These patients are treated in a concentrated environment where there are fewer patients seen per day, which receive personalized care from dedicated health professionals within a safe setting. CMS quality measurements and ASCQR data continues to document lower healthcare acquired infection rates compared to patients treated in hospitals.

Operating as an OBL/ASC Hybrid maximizes the efficiency and profitability of the facility. Navigating the reimbursement requirements with MCR can be a challenge. Several cardiology procedures continue to have better reimbursement in an OBL setting, while others are higher in an ASC.  The hybrid model not only supports a flexible model which begets achieving maximum reimbursement for a procedure, it allows physicians operational efficiency mechanisms for the facilities and physician schedules. Operating as an OBL and an ASC on separate designated days will utilize and maximize the same staff, optimization of supplies which leads to improved cost savings, all while ensuring standardization of processes that will support positive clinical outcomes. 

Payer contracting holds an advantage and can be seamless since many OBLs have existing payer contracts with the same payers needed for an ASC Relationship. I would be remiss not to note that the ASC must contract with the payers as a separate entity. Typically, it is not difficult to contract because many of the payers already have a relationship with the physicians through their practice contracts. ACA Cardiovascular has the acumen and the experience to secure and accelerate contracting. Because of past experience which highlights operating ambulatory surgery centers in multiple states, our company can affirm that commercial payers recognize the cost-saving benefits of using an ASC/OBL hybrid facility model. Commercial payer contracts have been covering cardiology procedures (which now includes the recent PCI coverage), prior to Medicare approval, only to exclude California as the exception. In this geography, PCI procedures, along with diagnostic cardiac catheterization cannot be performed and will not be reimbursed for these procedures. The other Medicare-approved procedures can be done on the ASC side of the Hybrid. 

The most apparent benefit of converting to a Hybrid outpatient surgical model is the increased financial performance (revenue and profit margin) which can be achieved. Depending on what type procedures the physician group expects to perform, there can be a significant increase in revenue and profit when forming a Hybrid. ACA provides a financial feasibility review for its clients to validate the project and qualify if the proposed service mix serves to support a viable investment. As a consulting firm, ACA Cardiovascular emphasizes due diligence to confirm a project for the client as well as protecting the time and reputation of the firm. Good financial planning on the front end is necessary to gain the benefits of the Hybrid model. As the cardiology service line continues to migrate out of the hospital setting and into the ASC arena, the necessity for physicians to establish their own facility will continue to increase, and this will allow them the opportunity to capture the multiple benefits that an OBL/ASC Hybrid can provide.