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Payer Trends in Spine and Orthopedics: Embracing the Power of Artificial Intelligence and Emerging Technologies

By Scott Allen, Senior Vice President, Managed Care Contracts

The Becker’s 20th Annual Spine, Orthopedic, and Pain Management-Driven ASC Conference brought together industry leaders, physicians, and healthcare professionals to explore the exciting innovations shaping the field of spine and orthopedics. One standout topic that captured attention was the transformative role of artificial intelligence (AI) in revolutionizing healthcare delivery, specifically in spine and orthopedic procedures and pain management techniques.

Virtual reality and augmented reality applications are revolutionizing multiple aspects of spine surgery, while implantable sensors in orthopedic devices are bringing the power of data capture to improve patient outcomes. Surgeon collaboration with spinal companies in navigation and robotics is also expanding, with a focus on ergonomic wearable heads-up displays and robotic platforms for less invasive surgeries.

However, ambulatory surgery centers (ASCs) have to navigate payer trends in spine and orthopedics to effectively leverage these technological advancements. Here are five key insights into payer trends to keep in mind for 2023 and beyond.

Technology-driven outcomes, cost-effectiveness, and value-based care 

Payers recognize the significance of quality outcomes and patient satisfaction in the outpatient setting. This focus is shifting payer contracts from fee-for-service models to value-based reimbursement structures.

Business intelligence programs are helping ASCs establish Key Performance Indicators (KPIs) to track and improve metrics such as value-added protocols, patient satisfaction, and revenue cycle efficiency. By tracking value-care metrics, ASCs can negotiate better reimbursement structures under value-based care models.

ASCs that demonstrate improved outcomes and cost-effectiveness through technologies like virtual reality, robotics, and AI may also benefit from favorable reimbursement models. Embracing these technologies can streamline procedures, reduce complications, and potentially lower costs, therefore opening up opportunities to increased payer recognition and reimbursement incentives.

Enhancing patient engagement and education

Educating patients on the value of technologies like stereotactic navigation, robotics, and augmented reality to improve surgical precision and efficiency can increase the likelihood that a patient will want to book a surgical procedure at your facility.

Virtual reality and augmented reality applications can also play a crucial role in patient engagement and education. ASCs leveraging these technologies can provide immersive experiences to patients, allowing them to better understand their conditions and procedures. Payers may recognize the value of these technologies in patient education and support their utilization through reimbursement incentives.

Advances in revenue cycle accuracy 

As payer scrutiny of claims intensifies, particularly with surgical implants, ASCs must adopt robust coding and managed care contracting practices to ensure proper documentation and minimize denials or reimbursement delays.

Leveraging advanced coding technologies, partnering with surgical revenue cycle management companies, and actively managing payer contracts can optimize coding accuracy and enhance revenue capture.

Machine learning programs can further improve coding and documentation accuracy, particularly when new payer guidelines require updating your facility’s established coding and billing procedures.

Predictive analytics for readmission and complications

Predictive analytics empowered by AI technology offers a multitude of benefits for ASCs, making it an attractive solution for payers. One area where payers find significant value is in patient risk assessment and cost savings. By utilizing AI-driven predictive analytics, ASCs can optimize patient selection and mitigate potential readmissions or complications, aligning with payers’ goals of cost reduction and quality care delivery.

Since AI algorithms can analyze comprehensive patient data, ASCs can identify high-risk individuals who may require additional attention or intervention. This proactive approach enables ASCs to implement targeted preventive measures, reducing the likelihood of complications and subsequent readmissions.

By leveraging AI-powered predictive analytics, ASCs can demonstrate their commitment to patient safety and efficient healthcare delivery. The ability to accurately identify patients at higher risk of complications not only enhances the quality of care but also yields cost savings for payers. These positive outcomes align with payers’ interests in improving patient outcomes while managing healthcare costs.

Rising demand for outpatient procedures

Payers recognize the cost-effectiveness and patient satisfaction associated with ASCs, which continues to result in a shift from traditional inpatient settings to outpatient facilities.

As ASCs embrace emerging technologies, digital data collection becomes instrumental in gathering valuable insights for making data-driven decisions.

For ASCs looking to add spine and orthopedic procedures, there are several data-driven practices to determine the profitability of new cases including conducting a case costing analysis and reviewing existing managed care contract terms. When renegotiating contracts with payers, emphasizing these strategies will ultimately work to your advantage to improve reimbursements and contract terms.  

Final thoughts on payer trends

AI is emerging as a game-changer in healthcare, offering valuable applications such as patient selection optimization, surgical procedure enhancement, and postoperative outcomes tracking. As enabling technologies like stereotactic navigation, robotics, and augmented reality become more accessible and cost-effective, they pave the way for widespread adoption across the healthcare industry.

The rapid growth of AI and emerging technologies in spine and orthopedics holds immense potential for enhancing patient care and advancing the outpatient setting. By embracing these transformative technologies, ASCs can position themselves at the forefront of innovation and improve reimbursement opportunities.

Are you looking for ways to improve your revenue cycle management? Take the first step towards optimizing your revenue cycle process by requesting a revenue assessment from our team of RCM experts. Request a demo