12/01/2017

Reimbursement Update

BWC and Medicaid Update Payments

BWC Announces Reimbursement Policy for 2018

The Ohio Bureau of Workers Compensation has released their proposed payment rule for 2018 and had decided to expand ASC –approved orthopedic procedures, yet not follow a previously outlined plan to pay implants separately.

The OAASC and member centers with higher volume orthopedic procedures met numerous times with BWC staff to address issues related to increasing utilization of ASCs for orthopedic procedures. As a part of that process, the BWC heard loud and clear that the biggest obstacle to adding orthopedic procedures is the cost of implants.

That being said, the Bureau decided to add orthopedic procedures at a flat rate without additional compensation for the implants.

Here is the list of the new proposed procedures and corresponding reimbursement:

Most of the reimbursement levels would barely (or not) cover implants and supplies, which is a point that the OAASC emphatically stressed in its letter to BWC officials.

Based on the information provided for reimbursement levels of arthroplasty procedures being added to the ASC fee schedule in 2018, we are highly concerned for ASC participation in the arthroplasty program (with its additional requirements), and therefore utilization of the joint replacement procedures within the higher quality and lower cost ASC setting…

 

When implants costs barely (or don’t) cover the BWC reimbursement, few if any ASCs will be willing to participate in what could be an innovative program. The ONLY way to make this program a success is to address implant costs through invoice reimbursement, a third party BWC approved implant vendor, or reimbursement levels that more adequately cover implant costs.

 

As in the past, he BWC proposes to maintain ASC reimbursements in general at Medicare rates with the 1.9% across the Board increase for all BWC approved procedures.

Additionally, the BWC proposes to:

• Maintain current adjustment factors for Pain Management Procedures at 110% of Medicare
• General orthopedic procedure at 112% of Medicare
• Device intensive procedures (as designated by CMS for device estimated to cost more than 41% of the procedure’s cost) at 114% of Medicare (NEW)

In the end, the OAASC’s request of the BWC remained simple… If another similar surgical setting is being reimbursed by the BWC at a much higher percent of its Medicare rate, than ASCs which provides the exact same services should receive the same percent of its ASC Medicare rate (which they are not).

These changes will go into effect in April 2018

 

Medicaid Continues to Roll Out New Payment System

Ohio Department of Medicaid (ODM) continues to rollout their new payment system for ASCs and Hospital Outpatient Services. To date they have only received a couple of questions about the impact/implementation of the system from ASCs.

A few key things to keep in mind:

• The new payment structure moves away from the current system to a new structure that seems to be somewhat similar to current Medicare APC.  
• The new Enhanced Ambulatory Patient Grouping (EAPG) system is intended to modernize payments of all outpatient services and was developed by 3M Health Services.
• There is NO fee/payment schedule as in the past, but instead a calculation that determines the reimbursement (see the OAASC resources on the link below).
• ODM suggests that all appropriate codes be billed as a part of the new system. Some might be bundled and some might be paid separately depending on the EAPG.
• A free online version of the 3M EAPG guide is available exclusively to OAASC members (see resource link below).
• ASC reimbursements are based on hospital outpatient rates and are roughly 80% of their reimbursements.
• ODM is developing a list of high volume codes and reimbursements as well as a tip sheet. Please email the OAASC any codes that are a concern and any issues you are having.
• Generally all procedures are being reimbursed at a higher level. The OAASC successful advocated for an increase to most GI procedures from the original proposal. Please let us know of ANY issues you are having or questions you might have.

Please vie the OAASC Medicaid Payment Resources here - Ohio Medicaid's New Payment System