This Week in Surgery Centers: Mel Gunawardena – What an Experienced RCM Expert Needs to Know

Ep. 96: Mel Gunawardena – What an Experienced RCM Expert Needs to Know

Here’s what to expect on this week’s episode. 🎙️

In our latest podcast episode, Mel Gunawardena, SYNERGEN, shared actionable insights into optimizing revenue cycle management (RCM) for ASCs. Here are the highlights:

Start Early: Accurate patient demographics, insurance verification, and medical records are critical at scheduling to prevent delays.

Master Eligibility & Prior Auth: Only 78% of insurance eligibility checks and 24% of required prior authorizations are completed industry-wide.* Educating providers and implementing standardized processes can bridge this gap.

Collect Upfront: High-deductible plans make upfront patient collections essential for maintaining profitability. Use estimations and store payment information when possible.

Streamline Claim Submission: Focus on coding accuracy, include implant invoices, and track high-cost items to avoid revenue leakage.

Denial Management Playbooks: Codify solutions for payer-specific denial codes to reduce rework and speed up cash flow.

Leverage Technology: AI and automation can enhance eligibility checks, coding accuracy, denial management, and patient payment strategies, all while reducing costs.

In-House vs. Outsourced RCM: Assess your internal capabilities and KPIs, such as days outstanding, bad debt, and net revenue per case, to determine whether an outsourced, hybrid, or in-house model best suits your ASC.

Catch the full conversation for deeper insights into these strategies and the transformative role of technology in RCM!

*Source: HST’s State of the Industry Report

#SurgeryCenters #RCM #TWISC

Episode Transcript

[00:00:00] Welcome to this week in Surgery Centers. If you are in the ASC industry, then you are in the right place every week. We’ll start the episode off by sharing an interesting conversation we had with our featured guest, and then we’ll close the episode by recapping the latest news impacting surgery centers.

We’re excited to share with you what we have, so let’s get started and see what the industry’s been up to.

Erica: Hi everyone. Here’s what you can expect on today’s episode. Mel Gunawardena is the co founder and managing partner at Synergen Health, and he is here to share with us a few things that every RCM expert needs to know. Mel sat down with Nick Latz to talk through the best practices every ASC should adopt, how technology can streamline the process, and the pros and cons of keeping RCM services in house or outsourcing.

Erica: In our news recap, we’ll cover a new surgical tech training center that just opened up, what to watch [00:01:00] out for in your payer contracts, a new controversial decision by Anthem, and of course, and the new segment with a positive story about a new game changing asthma treatment that just came out. Hope everyone enjoys the episode and here’s what’s going on this week in surgery centers.

Nick: Mel, welcome to the show.

Mel: Hey, Nick. Thank you. Thanks for having me.

Nick: So Mel excited to talk to you today about revenue cycle management and some best practices within the revenue cycle management space before we jump in to get started Q help us understand for, in your view, what’s really the high level objective of revenue cycle management.

Mel: Yeah, I think in health care, you the health care providers are providing services and at the end of the day, they got to get paid for the services they rendered. So that entire process where there’s a patient coming in and paying cash or whether they have insurance, [00:02:00] that entire process of, submitting claims to the insurance carrier and collecting those funds.

Mel: Basically following the money for the healthcare provider is the RCM process in a nutshell. It’s an, and doing that efficiently and in a compliant manner and to collect the funds that they do is the key component in the RCM operation and process.

Nick: Got it. So it sounds like getting paid getting paid in a compliant manner and getting paid on time and in full, it is a big part of what we’re trying to drive here.

Mel: Exactly.

Nick: So with that in mind I want to talk to you about some of the specific best practices from your perspective and where you sit and what in the market, what are a handful of best practices you think that are important for. ASC specifically as they think about their revenue cycle management processes.

Mel: Yeah, I think there are multiple best practices, but I think it starts [00:03:00] from the very beginning. Where from the time a patient is scheduled, I think getting the right information So I would say the first thing is getting the accurate information from the referring provider So one is you know, making sure that you understand and document the information Procedure of the procedures they plan to do getting the right and accurate demographic information is very important of the patient or the responsibility party.

Mel: Getting the right accurate insurance information is important. And then other one is getting the medical records from the referring provider and people ask us, why do you need that it’s sometimes when the insurance carrier is, denying a claim and asking for additional information It’s important for you to have those medical records in hand at the time that you are scheduling that patient So that’s very important.

Mel: Number two, I would say is eligibility, it’s important to get Your eligibility done. I was watching one of the HST state of the industry reports and it states that only 78 percent of the time [00:04:00] insurance is verified. So it’s very important to make sure that you’re checking for coverage and then also checking for, what are the balances?

Mel: What is a co pay? Is co insurance deductible? So it’s important to do that verification of benefits. And although the surgery center might not be doing the prior authorization, usually it’s done at the facility, at the. Physician level got to also make sure that you understand which procedures require prior authorization.

Mel: And you know that, right? Again, this HST data the industry data report showed that only 24 percent of the required prior authorizations are being done. So that’s a huge RCM process. So that’s something that you as a facility needs to To know that as well, and

Nick: just to double click on that one milk is 24 percent is low.

Nick: All right. I think we think eligibility is low at 78 percent but 24 percent really stands out from your knowledge of the process. and the gaps that sometimes exist within the process. Why do you think prior [00:05:00] auth is so low?

Mel: I don’t think the referring providers know what procedures for which pair do require prior auth.

Mel: That’s one of the things that’s happening. So I think educating that physician as well is important. And you as a facility, at the end of the day, you’re carrying the bag, right? And they may be doing the prior authorization for the physician side, but that’s the same thing that you’re using at the, for the billing for the surgery.

Mel: So you need to have your own, template. It’s best practices to have your own template ready so that if you don’t get a prior authorization, you call and request that before you schedule that surgery.

Nick: There’s definitely a dependency on the provider if there’s not a good check and balance, because your point that the ASCs aren’t doing it, but they’ve got to have a check.

Nick: Within their process to get it, right?

Mel: That’s right. That’s right. And a couple other items that I would say as a best practice is collecting patient balances up front, with these high deductible health plans. It could [00:06:00] be the difference between profitable cases or not, right? Making sure that you do the estimation, so it goes hand in hand with the eligibility check.

Mel: Making sure that you’re checking what the patient balances are and doing the estimates and then collecting those funds up front is very important. And even at least having a card on file that’s important. So patient collection up front is very much a key best practice that we state. And then if you go to the.

Mel: The next two steps, I would say is, getting the claims out, obviously coding is an obvious component, but a lot of people miss components in submitting a claim. For example, putting the prior authorization in there it could be an issue. And then also if you’re doing implants and if you have excess supplies, making sure those invoices are part of the billing.

Mel: And included is very important. It could be, a case of whether you’re running profitably or having a case that you’re losing money. So it’s important to have the right information going every time in your bill. And then [00:07:00] finally, I think you got to have a robust denial management process, and in this case, I would say making sure that you have a denial management playbook.

Mel: So especially if you have a denial management or a billing team to ensure that there is consistency in what you’re doing and how people are fixing those claims, we recommend that you have. And document for each pair and procedure and denial code and remark code, you have a fix that’s documented rates and that you can share with your team so that there’s consistency in the way they fix the claims that it’s accurate and timely, and then you can continue to work through it if it’s not working right to improve it or tweak it.

Mel: So I think those are the main items I would consider best practices. And on top of it, of course, you got to have your reporting and analytics. You got to be able to track everything that you’re doing. So I would say those are the key items that I would consider as best practices.

Nick: Yeah, I love that documentation from a denial [00:08:00] management best, best practice.

Nick: And it seems specificity is important there in terms of the type of denial and the next steps that need to happen from that. I gotta imagine that processing a lot of volume helps to have that many reps in that many types of cases in terms of the documentation of some of those edge cases.

Mel: That’s exactly right.

Mel: And I think one of the other key things is that, people The old method is you’re assigning pairs to a certain group of people. So you say, Hey, you work the Medicare claims and you work the commercial United Healthcare claims. And the reason they used to do that is that if you’re continuously doing, working the same type of Hopefully you’re getting used to it, right?

Mel: And we’re saying, no, let’s codify it. So what we’ve done is we’ve codified it, meaning we’ve taken the pair ID, procedure code, denial code, remark code, and sometimes you may even add the diagnosis code and say those combinations. There is a fix. There [00:09:00] is a definite fix how to do that, right? And if you can document takes time for you to do it, that could be thousands of combinations, but the fixes are maybe only six or seven fixes, right?

Mel: So determining the fix based on the combination and providing that as a document to team can be very important and helpful.

Nick: Yeah. And have you found with your own team, Mel, that once, if you get the fix right across those thousands of permutations and combinations, it eliminates a lot of the back and forth around those denials?

Mel: Absolutely. Because you could have multiple secondary denials coming in, right? So you may have to touch the claim multiple times. And especially as an, in a client that, when you’re working with clients that their key thing is, they want cash flow, right? And every time a claim gets denied and you work a claim again, it’s another 45 days added to your rev cycle process.

Mel: So you’re denying that you’re denying the cash flow coming into that facility.

Nick: Yep. Yeah, okay. The other thing I wanted to circle back with you on, you talked about the claim [00:10:00] submission and getting the claim right and you mentioned In plant and supplies, the documentation and the invoice and getting that on there.

Nick: And that’s something that we’ve seen with our clients. It can be a pain point. There could be a mismatch and invoicing process with those. Yeah, I was wondering if you’d help drill into that best practice a little bit in terms of, where did, when it goes wrong, what goes wrong in terms of the implant and supply invoicing and getting out on the claim?

Mel: Yeah, again, I think there is a, they, there are. You could have a claim go out just having the claim information. That means you’re coded the claim and you’re submitting the claim without the invoice, but you’re still getting paid, right? You can get paid for the, for the facility fees, but what you’re missing is that high dollar implant or excess supplies that you’ve used.

Mel: If you don’t have a checks and balances, some kind of a method to track it, right? And here’s a high dollar claim that’s just about to go out, but you don’t know that there’s [00:11:00] a high dollar cost that you just incurred, right? So I think it’s putting that process in place, having again, that’s why I said, having tracking and trending, track that information to see the reporting is very important.

Mel: Sometimes you may miss it. That could be if you’re doing, if you’re a management company processing thousands of claims, you could have one claim go through. But if you have the information and you’re tracking it, you’re tracking things like profitability of a case and reporting on it, you suddenly quickly see that, hey, you’re losing money here, right?

Mel: So that means you missed something. You can quickly go in and do a corrected claim. But I think it’s more about having the checks and balances up front. Having that information up front before you submit the claims to be able to capture that data. So that’s that component that we are talking about.

Mel: And where it’s missed is because, people don’t have the checks and balances before the claims go out.

Nick: Yeah. Okay. That’s helpful framing in terms of kind of best practices through the life cycle. I think oftentimes [00:12:00] revenue cycle is thought of as a people based process, a people based business.

Nick: But more and more there’s. There’s automation and technology that are playing an increasing role. Can you talk a little bit about that in terms of what role does technology play in the RCM process today? And how does that involve it?

Mel: Yeah. So technology can play a huge role. I would say in the RCM process, especially with the costs going up now and the reimbursements are not going, I’m not catching up at the pace.

Mel: The costs have been going up. And we also believe that there are three components in the RCM process. to work in sync to make it effective. So it’s three things. One is what you just mentioned, people. The other one is process and then technology. And from a people perspective, I would say in the last five to 10 years, people have looked to lower their costs by utilizing some kind of offshore operation or leveraging some of that.

Mel: And it doesn’t mean it may have been that the costs have gone down, but it doesn’t immediately mean that’s better quality or better [00:13:00] outcome. So technology is very important, and I feel it’s imperative for you to leverage the proper technology. And if you do that right, you could have better outcome and lower costs.

Mel: And if you look at the entire RCM process, there are so many components that you may be already, clients may be already using, right? For example, eligibility. Eligibility checks can be done, but there is a component for coverage discovery, right? So why does coverage discovery is needed?

Mel: Because sometimes you may have the primary pair, but you may not have the secondary or tertiary pair that has been captured at the time of registration. So if you have coverage discovery, you can get that information as well, right? So sometimes or if they have no coverage, you may run coverage discovery and be able to capture that.

Mel: So that’s one thing that you could use the tools for. If you go down that. Line patient responsibility component tools like clarity where you can load contracts and do estimations. It’s very important. Because it’s you know, people have done so many [00:14:00] surveys and seeing that patients don’t like getting a bill afterwards.

Mel: They like to know what is expected up front, right? So having that patient estimation component and having the right tool there, I think it’s very important in our opinion. Yeah. Some of the other tools like coding the AI assisted coding is now becoming more and more mainstream and maybe not for all specialties, but it’s becoming a big component one to reduce the cost and improve the accuracy.

Mel: So these are some of the highlight things have been working. People have been utilizing. I will also think that. There is a lot of opportunity in the denial management speed. This is at the heavy lifting that’s happening. Today, a lot of companies and central billing officers use workflow management systems, but most of those just are used to manage queues, assign claims and track productivity.

Mel: But I mentioned earlier that there is, denial management playbook. So if you can [00:15:00] incorporate it, Into a technology that’s something that we utilize and have the system drive based on those components. I mentioned for example, pair ID, denial code, procedure code, remark code and those combinations and have the fix and the and based on that, if it’s recommending fixes.

Mel: You can now really drive the efficiency and accuracy. And then if you can also integrate with for example, a billing platform and do bulk fixes, right? For example, if there’s a combination and there are multiple claims that have the same combination, and if you can fix it in bulk, now you can really drive efficiency.

Mel: So there’s a lot of technology that’s there that’s continuing to evolve. And if you utilize it right with the RCM in the operations, I think you can really drive That efficiency and the outcomes that you need and also lower the cost,

Nick: right? Overall. I appreciate that walkthrough. And you [00:16:00] mentioned AI.

Nick: And I think it’s something that, all health care technology providers are adding in their product marketing materials and talking about AI enabled. And you mentioned the specific use case around. Coding. Can you double click on how I can help with the coding process and what information, those models can get trained from?

Mel: Yeah. So for AI, for example, machine learning to work, right? So what you got to do is you got to help train it. You got to train the system by one is you got to first look at, When you do a manual coding, what is what are you really looking at? So from a documentation perspective, what’s been documented and how has it been coded manually inaccurately?

Mel: So that’s one thing that you got to look at. And then once you keep training the data and tweaking it. Then, as you get this the, for example, the transcription that’s there, the doc, that is documented of an op report, the manual way of [00:17:00] doing it is reading the op report and then determining how to code it, right?

Mel: So by using AI, what it’s doing is it’s reading it. So you’re digitally reading it. The system is digitally reading it. It’s using machine learning to train the model. And then based on that, and based on the historical data, it will now start recommending here are the codes, right? And you can get 95 plus percent accuracy.

Mel: And if it kicks it off, you can have it go to a manual queue to somebody to review. Even the automated ones, you can quickly manually review and submit it. What is needed is, one, is you got to have enough of a large enough data set. To be able to train it right by utilizing reading somebody has read it manually coded it manually and then you can use it the machine learning to learn it.

Mel: Just like a human learning it, you’re using the machine learning to learn it. And then as it runs more and more data, the accuracy level becomes better and better. So AI assisted coding can really drive the cost down and increase the efficiency. And I think [00:18:00] there are other areas that even in our data management system, we are utilizing AI to look at how the fix is working or not.

Mel: And it’s looking at the data from the back end and coming up and saying, Hey, The fix that you made before is not the fix that is paying. So here are some of the fixes that we are recommending using from the AI is coming and saying, Hey, here’s a fix and I think you’ve got to change the playbook to make the change to, to have the outcome that you want.

Mel: So AI can be used in many ways. One is, one is in the coding part that you were mentioning that we were talking about. We also seeing in the patient side propensity to pay, you can use looking at things like propensity to pay today. The patient collection component is important, but you can look at multiple data points.

Mel: That’s why you’re using, people are using AI here and looking at multiple data point, not your credit scores, right? You can get external data [00:19:00] points and saying, Hey, this patient has a propensity to pay. The patient has the capability to pay immediately. This patient doesn’t have the capability.

Mel: So you can change the model and the method you’re utilizing and how you approach that patient when they come in up front or as well as at the back end. If you’re sending a statement.

Nick: Interesting. So that are with that knowledge that might help you set the strategy of winning how to collect payment.

Mel: Absolutely.

Nick: Yep. Yep. Thanks for sharing those use cases. Want to talk about so specific to the industry, right? A lot of ASEs choose to do revenue cycle in house. Others choose to outsource RCM to a specialist. Okay. And then there’s groups out there that are doing kind of a hybrid, right?

Nick: Using in person resources or their own resources for some of the process outsource resources from some other pieces of the process, is you work with different clients in the industry that are thinking through in source versus outsource, what do you [00:20:00] think are some of the important?

Nick: Evaluation criteria and considerations for that decision.

Mel: Yeah, I would say it’s a good question and really depends on the needs and the goals of the organization and the availability of resources and whatever capability they have in house, right? Let’s say it’s a management company, right?

Mel: And they have a successful central billing operations. They have centralized most of the components. There was strong RCM team and in those cases, then you continue to support and utilize your internal team. So you’ll have an in source team. Now, however, that assumes that you have experience management team managing the RCM operations.

Mel: You have documented standard operating procedures. You have. Established training programs on boarding staff. You have systems to automate and assist and your costs are low. Your attrition is low and you have a successful scaled operation that you can scale, right? So in that case, there’s no need to go outside.

Mel: But If any [00:21:00] of those items are lacking, right? So we have seen certain management companies who’ve come to us as well said, Hey, you know what? We can’t scale or we don’t have the technology or costs are too high or attrition to getting too high. In those cases where you already have some sort of a management team that is doing some part of our same operations, we would recommend a hybrid model.

Mel: Because they do have some capability within the organization in in, I would say corporate, and you may keep some of those functions internally, for example, contracting or maybe even patient collections component they may do that. Some do their own eligibility checking part of it. So that’s some part that they may keep in house.

Mel: But then the scaling part. The heavy lifting side is, coding, submission of the claims, data management, posting, can be done from an external team. So in that operations, you could use a hybrid model. So that’s [00:22:00] when we see the hybrid model working pretty well. But if you’re a standalone center, right?

Mel: So if a physician groups that come in and said, Hey, you know what? I want to kick off a facility or a few, they have a few facilities. They’re adding a new facility. They don’t have the resources and they don’t have the technology. I would recommend that they utilize an external company the right company to work with because they have the technology, they have the team, they can scale up.

Mel: Also in those cases. As you’re scaling up, right? The if you have your internal team, your cost is fixed or quite you’re carrying a heavy cost, right? And in the outsourced model, usually it’s happens on a contingency fee basis. That being meaning it’s chart you charging on a percentage basis. So as you’re ramping up.

Mel: your revenue, your fees are also ramping up slowly, right? It’s not a high cost at the beginning. So in those cases, I [00:23:00] would say the outsource model works, whether it’s a small, a single facility or a few facilities, they’re adding a new facility. I would say outsource model works. Now, if a management company determines that, Hey, we don’t have a centralized operations, we have a distributed model.

Mel: Where it’s independent centers running their own billing teams and they don’t have that model. Then an outsourced operation could be an option, but we feel for the right management company, a hybrid model works best.

Nick: Gotcha. That’s helpful to think through the different decision factors there. What about independent centers that have in house people doing it today, right?

Nick: And are evaluating, hey, can I get better results from outsourcing? Both from a revenue perspective and or potentially a cost perspective. How do you, and that can be a sensitive discussion obviously because there’s people in place, but from [00:24:00] a, just from a bit, let’s just think about the business side of it.

Nick: What’s the best way to evaluate, Hey, what’s my revenue performance? What are those metrics to look at to help determine if you might be able to do it better a different way?

Mel: Yeah, I think one of the key things is you’ve got to do an assessment, right? I we recommend doing an assessment of on a client.

Mel: A group that is looking to see, how are they doing? Just being the healthcare industry, right? So we Doing a health check is normal, right? It’s obvious thing. So for the physicians, we may feel great, but we don’t know whether we’re doing well or not. That’s why we do all this test.

Mel: I would say to do a rev cycle assessment. There’s an assessment can be done. That will look at things like your days outstanding, your total AR things like paid claim percentage or bad debt, Then your collections, percentage of net revenue. There are a bunch of KPIs that you can look at, net revenue per case based on your specialty denied [00:25:00] trending, where are you at?

Mel: So you can benchmark there are companies that we can, we recommend our clients before we even engage a client. We always do a benchmarking and that’s, I think is important. So if it’s a. Facility that doesn’t know how well they’re doing or not. We recommend them for them to do. We recommend that they do an assessment at least once a year to see whether they’re leaving money on the table.

Mel: And based on that, you’ll see where the opportunity is, right? Is it a question of Is it a coding issue? Or is it there’s people are not working that in our management properly? Or is it a contracting issue? They’ve not they have not done any contract renegotiation in the last two years. If you have not done something contracting renegotiation for the last two years, there’s definitely the opportunity there.

Mel: So it’s a question of where it is. And then determining whether you outsource or not. I think again, it depends whether the team internally has the capability to do that, right? And. It is very sensitive. [00:26:00] But at the end of the day, if you’re not running profit profitably, then you will not have operations.

Mel: You may not have a center at all. And I think in those cases depending on the company that is working, you could have a company come in and say, Hey, you know what? We’ll provide part of the services and you provide the other part of the services, right? It’s depending on how much you can leverage of your internal team and how much can you leverage of external organizations.

Nick: Sure. So

Mel: assessment is very important.

Nick: Got it. Love that. Okay. No final question for you here. And this is when we do each week with our guests. What’s one thing our listeners can do this week? to improve their surgery centers.

Mel: Yeah, so if there’s one thing that to be done, I would make sure that they’re tracking and trending and reporting the most important KPIs for the RCM operations.

Mel: And we believe in the statement that you cannot manage what you don’t measure, right? So it’s really important that you’re tracking your data. So as I mentioned earlier, some of the KPIs are days to days. [00:27:00] Sales outstanding, the DSO, total AR, over 90 days. It’s a good benchmark to look at. Paid claim percentage, bad debt percentages collection percentage of net revenue, and then denial trending, right?

Mel: As a percentage as well as trending. You’ve got to be able to trend it to understand what the root causes are. And then finally, profitability per case. It’s really important that you’re tracking and trending that information. And I would say by measuring, you can really determine the root causes and focus on the areas that you may be having challenges.

Mel: And then based on that, you can really transform your RCM operations.

Nick: Fantastic. Thanks so much for joining us, Mel.

Mel: Thank you for having me. Thanks, Nick.

Erica: As always, it has been a busy week in healthcare, so let’s jump right in. Plaza College in Forest Hills celebrated the opening of its state of the art certified surgical technologist simulation operating room on November 15th. This million dollar facility [00:28:00] is the first of its kind in Queens, and it’s designed to replicate the working environment of New York City’s top hospital operating rooms.

Erica: The New Learning Center aims to address a critical shortage of surgical techs in New York City, a problem that affects hospitals and surgery centers ability to meet the rising demands due to high turnover and just low awareness of the profession in general. The program’s inaugural class of 20 students will receive hands on training in healthcare sciences, surgical techniques, and clinical practice.

Erica: Graduates will earn an Associate of Applied Science degree and a National CST Certification. The ribbon cutting event drew leaders from 11 major hospitals, underscoring the program’s importance to the healthcare industry. Students praise the immersive training environment, calling it essential for mastering the precision and teamwork required in surgery.

Erica: Plaza College Provost, Charles Callahan IV, emphasized the program’s commitment to addressing the [00:29:00] personnel shortage while also providing career opportunities for Queen’s diverse community. Now, with staffing shortages impacting surgery centers, this program will expand the pool of trained surgical techs, which will hopefully have a downstream positive impact.

Erica: And hopefully this facility is a success so that others around the country can follow in their footsteps and we can start to tackle or continue to tackle the staffing shortage problem. All right, next story. In the November December issue of ASC Focus, Rob Kurtz wrote a great article sharing some red flags to look for in your payer contracts.

Erica: The article really stresses the importance of scrutinizing contract language and pushing for favorable terms. So one key area to review is payment updates. So Brandon Fazio, who is the Senior Director of Financial Analysis for ASCs for Community Health Systems, advises insuring contracts linked to Medicare percentages include provisions for annual rate adjustments.

Erica: Without this, reimbursement may lag [00:30:00] behind Medicare’s updates. Susan Majewski, who is the Chief Operating Officer at Bedford Ambulatory Surgical Center warns against multi year agreements, which can delay coverage for new procedure and specialties. Contracts should also clearly define the mapping of procedure codes into payment groupers, as missing details could obscure reimbursement rates.

Erica: They also shared two other gotchas with rising supply costs and stagnant reimbursements. Majewski emphasizes the need for implant carve outs to cover expenses, and then Fazio highlighted trends where payers assigned low default rates for non Medicare covered procedures, potentially making them unprofitable for surgery centers.

Erica: And obviously mastering contract negotiations is vital for surgery centers to maintain profitability and sustainability. Addressing problematic clauses and securing favorable terms will allow you to protect your surgery center’s financial health [00:31:00] in an increasingly complex payer environment. And lastly, our podcast theme for the month of January, 2025 is going to be all about payer contracts.

Erica: And we’re going to cover how to really get in sync with your payers, and even stay one step ahead. hOw to leverage data in your contract negotiations, and a lot more nuances that go into managing contracts. So if this is a sticking point for you, make sure you catch those episodes starting January 7th.

Erica: Okay, third story. Anthem Blue Cross Blue Shield has announced a very controversial new policy affecting patients in Connecticut, New York, and Missouri. It will no longer cover the full duration of anesthesia for surgeries that exceed an arbitrarily determined time limit. This decision, condemned by the American Society of Anesthesiologists, as you can imagine, could leave anesthesiologists uncompensated for critical care if surgeries run longer due to complications or other factors.

Erica: Anesthesiologists play [00:32:00] a pivotal role in patient care, tailoring anesthesia plans based on individual health needs, managing unexpected complications, and ensuring patient safety throughout surgery and recovery. Payment for anesthesia typically considers the total time required from pre op assessments to recovery transitions.

Erica: And under Anthem’s policy, bills exceeding this preset time limit will be denied regardless of medical necessity or circumstance, which is frankly unfathomable. I can’t imagine being an anesthesiologist knowing, like, how do you balance, what is in the patient’s best interest, but also balance, Your time like, your time and getting paid for your expertise.

Erica: So it’s super bizarre Dr. Donald Arnold, who is an ASA board member, called the move a cynical money grab, accusing Anthem of prioritizing profits over patients. This policy undermines trust between Anthem and its policyholders, who expect their insurance to cover all [00:33:00] essential care. Critics argue that the policy not only jeopardizes patient safety, but also penalizes anesthesiologists for providing comprehensive care.

Erica: So this policy could significantly impact surgery centers where timely and safe anesthesia is critical. We just reported two weeks ago on the results from ASCA’s 60 second survey, where the majority of ASCs finally said that they were in a good place with their anesthesia contracts and felt like they had adequate coverage.

Erica: But now with this, ASCs may face increased financial pressure If anesthesiologists refuse to contract under these terms, which will lead to delays or complications in patient care, Anthem’s decision also adds a new layer of complexity to payer negotiations, emphasizing the need for surgery centers to advocate for fair and patient focused policies.

Erica: Again, this only for now impacts Anthem in Connecticut, New York, and Missouri, but I would imagine that we can expect it to expand and, the ASA is urging [00:34:00] patients and providers to voice their concerns to state insurance commissioners and legislators, and we can only hope that other payers will see the backlash that Anthem is receiving and do not follow suit.

Erica: We will definitely keep a close eye on this story and how it evolves and share any updates with you. But I also want to, echo what the ASA is saying let’s all voice our concerns for this and how it could truly impact patient safety. Okay. And to end our new segment on a positive note, researchers have developed the first new treatment for asthma in half a century, offering a potentially game changing therapy for people with asthma.

Erica: In this study, the drug Benralizumab, now, I got that pronunciation from YouTube, so please forgive me if I’ve totally butchered that. I’ll put it in the episode notes and you could see how it’s actually pronounced and spelled. But this drug was found to be considerably more effective at easing asthma attacks than the current steroid tablets.

Erica: So it’s administered as an injection, and when it [00:35:00] was, it reduced the need for further treatment by 30%. Asthma and COPD cause an estimated 3. 8 million deaths per year globally. So treatment for both conditions. I’ve unfortunately barely evolved in the last 50 years, but hopefully that will change with this new study.

Erica: And the study lead professor Mona Baffedale from King’s College, London said, we hope these pivotal studies will change how asthma and COPD exacerbations are treated for the future, ultimately improving the health for over a billion people who currently live with asthma and COPD across the globe. And that officially wraps up this week’s podcast.

Erica: Thank you as always for spending a few minutes of your week with us. Make sure to subscribe or leave a review on whichever platform you’re listening from. I hope you have a great day and we’ll see you again next week.