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Your Questions Answered! Managed Care Contracting for Orthopedics

By Scott Allen, SVP Managed Care Contracting 

Our recent webinar on managed care contracting for orthopedics featured a live Q&A session, packed with audience questions.  

Although our webinar host and SVP of Managed Care Contracting, Scott Allen, couldn’t get to every question in real time, we’ve compiled the remaining queries here.  

Let’s pick up where Scott left off and dive straight into the answers you’ve been eagerly awaiting! 

Click on the video to view Scott’s answers to the top 5 questions and read his answers to the remaining questions below.

Answer: I’d want to know a little more about this case cap to understand if it is a charge cap or if it is established to an actual case to provide a more detailed response. But for older contract terms, I definitely recommend revising by providing the payer with additional data and benchmark information to improve those terms.

Maybe there are examples you can show where this case cap is interfering with your overall reimbursement. If the cap is too low and case costs are too high, then you can justify why you’d have to move these cases back to the hospital, where the payer will have greater costs overall.

In addition to that, if you do have a percentage of billed charges contract, most of the time there will be language that does allow you to increase your chargemaster.

Answer: Typically ASCs always bill for right and left; we don’t adjust those charges based on right or left side. Essentially you have the same code, just billed multiple times. For pro billing, typically you may have a modifier or you may load a charge that would react to bilateral, but when billing for ASCs, LTRT is standard, and we would put that modifier on the existing charge and code in the system.

Answer: I don’t know of any regulation that requires ASCs to publish rates, but at the state and federal level, there are situations where hospitals must disclose their fees for services.  

For example, HHS requires hospitals to publish services online or face a fine of up to $300 per day. Hospitals are also required to make public the payer-specific negotiated charges for these services that they have negotiated with third party payers, including charges negotiated by managed care plans such as Medicare Advantage plans, Medicaid MCOs, and other Medicaid managed care plans.  

ASCs are not required to publicly post rates at this time; however, the No Surprises Act did require ASCs to provide good faith estimates in advance for patients.  

For uninsured or self-pay patients, ASCs are required to provide cost estimates: 

  • Within one business day after scheduling when the primary item or service is scheduled at least three business days in advance or no later than three business days after scheduling when the primary item or service is scheduled at least 10 business days in advance; or 
  • Within three business days after an uninsured or self-pay consumer who has not yet scheduled requests a good faith estimate.  

You can read more about the No Surprises Act here.  

Overall, knowing hospital rates will help you benchmark your rates, and offering this information publicly in a rate comparison can help you show patients and payers the substantial savings at your facility. 

Answer: Yes. You can be paid for implantable devices per most payer contracts. However, biologics, PRP’s, anything that’s experimental, those would be situations where you wouldn’t be paid. With that said, there are a lot of methodologies out there that include the device portion into the surgery reimbursement. Knowing how you’re paid and what exactly is being applied to the implantable device portion is important to ensure you’re reimbursed appropriately.  

Our webinar “Enhance Your Success with a Managed Care Contracting Checklist for Orthopedics” is now available on-demand on our website.