A recent report in The National Law Review has shown how the Centers for Medicare & Medicaid Services (CMS) and payers are adopting policies that push providers and patients to lower-cost settings outside of the hospital and relatedly to restrict health systems and physicians from retaining elective outpatient surgical services in the hospital setting.
- According to the report, UnitedHealthcare (UHC) and Anthem have promulgated policies that restrict the site of care for elective surgical procedures. UHC’s policy came into force in November 2019 for fully insured groups in most states. As per the policy, UHC only pays for surgical procedures performed in an outpatient hospital setting if such setting is medically necessary based on the acuity of the patient.
- The payer is of the view that steering beneficiaries toward the lower-cost setting will save beneficiaries $500 million and would save UHC over 20 percent in reimbursement to providers.
- Another leading payer Anthem, which has insurance products in 15 states, published a Clinical UM Guideline in August 2020, limiting the use of outpatient hospital surgical facilities. The Anthem guidelines consider the use of outpatient hospital facilities medically necessary only if the procedure is of a level of complexity that it cannot be safely performed in a less intensive setting; or the individual has a clinical condition that may compromise the safety of a lower cost setting.
- CMS is yet to adopt an outpatient surgical procedure site of care policies that restrict certain cases to a non-hospital setting. CMS has, however, developed new payment policies to find ways to reduce the increasing costs associated with healthcare services.
- For 2021, CMS has added 11 procedures to the ASC-covered procedures list, including more total joint replacement procedures. As CMS has an urgent need to address the trust fund’s solvency, moving surgical care that can be performed in an ASC, rather than the hospital, may be one of several crucial endeavors for the future of Medicare, says the report.