Several compelling reasons drive single-specialty ASCs to transition to a multi-specialty model, including risk diversification, enhanced OR utilization, improved physician recruitment and retention, and increased profitability through economies of scale.
While expanding to a multi-specialty ASC model offers multiple benefits, ensuring your revenue cycle meets five key considerations is essential to maximize value from expanded services.
- Review Payer Contracts. It is critical to review all payer contracts to ensure the following:
a. The services are covered in the contract. This may happen if the payer contract is broad and does not specify the current services or has a specific allowable amount. If the services are not covered, it is important to start to work with your payers before you start to provide services.
b. If services are covered complete a profitability review to ensure that the allowable amount will cover your costs.
c. New services often involve new vendors and new equipment. It is important to evaluate all components of the new service to ensure any vendor-supplied implants or devices are covered. - Patient Access and Authorization. Adding services increases the complexity of the financial verification and authorization process. Instead of the front desk team memorizing a few codes, they now will most likely have to rely on job aids and payer websites to determine whether procedures need authorization in order to be covered. For example, some payers have a specific authorization verification process managed by a third-party reviewer versus with the plan directly. This process can vary depending on the patient’s insurance, adding an additional layer of complexity.
- Coding Specialization. While single-specialty ASCs can rely on a single coder with relevant specialization, multi-specialty ASCs tend to outsource coding upon transition to ensure a high level of expertise across all services performed. Typically, it is challenging for a single coder to be an expert in all areas due to the complexity of ASC services. For example, a coder specialized in orthopedics may not fully grasp the complexities of pain and spine coding. Since ASCs often do not require a full-time coder for each specialty, outsourcing provides access to needed expertise while paying only for the time used.
- Denials and Payer Requirements. Recognize that reimbursement patterns and denial rates vary by specialty due to payer policies. Although denial rates are influenced by several factors, common challenges for multi-specialty centers include specialty-specific medical necessity criteria, site-of-service requirement variations, and bundling/unbundling issues.
a. Inconsistent Medical Necessity Criteria Each specialty has different medical necessity guidelines, and payers may apply these inconsistently. What’s considered appropriate for an orthopedic procedure may not align with criteria for ophthalmology or pain management, creating confusion during the review process.
b. Bundling and Unbundling Issues Multi-specialty ASCs are more likely to encounter complex billing scenarios where procedures from different specialties might be performed on the same patient or during related visits. Payers may inappropriately bundle services or deny legitimate separate procedures as “duplicative.” - Physician Network Status. As an ASC increases in specialty this is often in conjunction with recruiting additional physicians or expanding the services provided by the current team. It is important to ensure these new providers are credentialed with each payer to avoid denials.
Successfully transitioning from a single specialty to a multi-specialty ASC requires careful, proactive planning and robust management across all revenue cycle functions to realize benefits such as risk diversification, improved utilization, and increased profitability. The five key considerations outlined—payer contract review, patient access optimization, coding specialization, denial management, and physician credentialing—are interconnected elements that must work together seamlessly. A weakness in any one area can undermine financial success. By addressing these revenue cycle considerations before expansion begins, ASCs can ensure they’re prepared to deliver both excellent patient care and strong financial performance across all service lines
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