Unveiling the Complex Tactics Employed by Payers to Deny ASC Reimbursements

In the intricate world of healthcare reimbursements, ASCs are facing a formidable challenge from payers who are deploying a myriad of strategies to delay, deny, or reduce payments. Marjorie Reiter, Administrator of Surgery Center of Central NJ in North Brunswick, sheds light on the increasing number of projects aimed at addressing incorrect or nonexistent reimbursements, particularly concerning new devices and pharmaceuticals utilized in Pre-Op and the OR. Despite billing with what should be the correct codes, these cases are often treated as carve-outs, exceptions to the contract, or outright refusals to pay, necessitating a confrontational approach with these payers. As the center gears up for contract renegotiations, the focus is on modifying language to tackle these issues, enhance inclusivity, and minimize carve-outs. The goal is to align reimbursement practices with Medicare standards, emphasizing that if Medicare reimburses, other payers should follow suit. Of particular concern are the emerging challenges posed by Medicare Advantage plans, warranting vigilant monitoring moving forward.