Becker s ASC 22nd Annual Meeting The Business & Operations of ASCs

Transcription

1 Becker s ASC 22nd Annual Meeting he Business & Operations of ASCs Managed Care Contracting for ASCs 10 Key Steps resented By I. Naya Kehayes, MH, rincipal October 22, 2015

2 Key Steps 1 5: DRAF \ (pptx) WD

3 1 Step 1: Assess ayor Value A S S S S H VA L U O F H AY O R» Do your physician users have a contract with the ayor?» Alignment with payors enhances access» Do not sign a contract just to get access to patients!» Contract must represent revenue value that is economically feasible to provide services DRAF \ (pptx) WD

4 1 Step 1: Assess ayor Value (continued) A S S S S H VA L U O F H AY O R» How much volume does the payor represent?» What is the average cost per case of providing surgery?» What is the average net rev/case represented by the contract?» Does the value of the contract represent a loss?» How does the payor compare against other payors you are doing business with in the market? DRAF \ (pptx) WD

5 2 Step 2: valuate ayor Mix W H A IS AY O R M I X A N A LY S I S?» Ranking amongst payors 1: What percentage of business does the payor represent? Volume Charges Receipts 2: How does this payor rank compared to others? DRAF \ (pptx) WD

6 2 Step 2: valuate ayor Mix (continued) VA L U A AY O R M I X» What roduct lines are you contracted for with the payor? roduct Lines 1) HMO 2) O 3) Medicare/Medicaid 4) xchange» Are you losing cases because you do not participate in all products? DRAF \ (pptx) WD

7 2 Step 2: valuate ayor Mix (continued) VA L U A AY O R M I X» xisting Volume vs. new Volume? Why is this important?» Can you access new surgeons if you are aligned with their contracts and all products?» Are you losing to follow cases if you do not participate in all products?» How will new volume impact cost and contract value? DRAF \ (pptx) WD

8 3 Step 3: Assess ASC Value in the Market ASSSS ASC VALU IN H MARK» What Value Does your Surgery Center rovide to the ayor s Network?» How many other ASCs in the market?» How many hospitals in the market?» What makes your surgery center different? Doctors Special quipment Multi-specialty vs. Single Specialty DRAF \ (pptx) WD

9 4 Step 4: valuate Case Mix VA L U A C A S M I X» What is the case mix of your surgery center? By specialty Cases vs. procedure counts Case mix of the payor i.e., Medicare mix vs. commercial mix» Why is this important? DRAF \ (pptx) WD

10 4 Step 4: valuate Case Mix (continued) VA L U A C A S M I X» Does your center perform cases with extraordinary cost that need to be addressed in negotiations? High cost case mix xamples: Orthopedics: ACLs, Shoulder Repairs, Uni Knees, otal Joints, Open Reductions Spine: ACDFs, Lami s, LIFs N: Balloon sinuplasty, BAHAs, Cochlears DRAF \ (pptx) WD

11 4 Step 4: valuate Case Mix (continued) VA L U A C A S M I X» High cost case mix xamples: ain: Neurostims & Spine Generators GYN: Hysterecotmies & Ablations General: Lap Hernias, Lap Choles, Breast Reconstructions Ophthalmology: Retina, Corneal ransplants DRAF \ (pptx) WD

12 5 Step 5: Assess ayment Methodologies ASSSS AYMN MHODOLOGIS» What questions should you ask the payor about payment methodologies? Current Medicare vs. Medicare Groupers? What Year ACs? Area Adjusted vs. National? Date of ublication Multiple rocedure Logic vs. Add Ons? Implants? High Cost Supplies Flexibility with payment method? Carve Outs? DRAF \ (pptx) WD

13 5 Step 5: Assess ayment Methodologies (continued) ASSSS AYMN MHODOLOGIS» Why is this critical to your success? mpowers you to collect the data and structure a proposal for the services provided Reduces timeline for negotiation Asking payors for a method or logic they cannot administer is typically a waste of time DRAF \ (pptx) WD

14 Key Steps 6 10: Adding New Services DRAF \ (pptx) WD

15 Adding New Services DRAF \ (pptx) WD

16 6 Adding New Services Step 6: Consider Managed Care Impact arly CONSIDR MANAGD CAR IMAC ARLY» What do you have to think about from a managed care perspective BFOR adding new services instead of after (payor strategy)? Does your current contract structure support the new service line? Or any case types within the new service lines? Are you adding new specialties? Are you adding hospital based cases? ayor Due Diligence ASC approved lists DRAF \ (pptx) WD

17 7 Adding New Services Step 7: Adding New Service Lines A D D I N G N W S RVIC LINS» Are you targeting new services that will move out of a hospital or out of another ASC? What payors can you immediate start working with to gain experience with the new cases? What about workers comp? Are you currently out of network with any payors? DRAF \ (pptx) WD

18 8 Adding New Services Step 8: ayor Due Diligence AY O R D U D I L I G N C» What do you have to determine when conducting payor due diligence? Does the payor have interest in expanding your relationship? Does the new service line really save the payor money when you move it out the hospital? What do you mean, spine won t save us money in the ASC? DRAF \ (pptx) WD

19 9 Adding New Services Step 9: New Service Line Cost to ASC and ayor NW SRVIC LIN COS O ASC AND AYOR» What information do you need to evaluate financial implications and relevance to negotiations?» ASC Cost Capital expenditures and operating expenses? Break even volume and how long will it take to achieve? Impact of co-morbidities? Will you really see all of the volume that the physicians claim are ASC eligible? $ DRAF \ (pptx) WD

20 9 Adding New Services Step 9: New Service Line Cost to ASC and ayor (continued) NW SRVIC LIN COS O ASC AND AYOR» What information do you need to evaluate financial implications and relevance to negotiations?» ayor Cost Does adding the new service require the payor to change the medical policy? Does adding the new specialty requires changes to claims processing infrastructure? Add on codes, carve outs, implants Impact on market, other facility negotiations $ DRAF \ (pptx) WD

21 10 Adding New Services Step 10: Charge Master/Fee Schedule Impact CHARG MASR/F SCHDUL IMAC» Does your current fee schedule support the new service line & how can this impact negotiations? Market fee schedule due diligence Charge adequacy with respect to cost ayors view of charges Looking for discounts from charges Demonstrating cost effectiveness to the payors DRAF \ (pptx) WD

22 Questions I. Naya Kehayes rincipal DRAF \ (pptx) WD