Midlands Orthopaedics & Neurosurgery
Employers / Benefit Advisors FAQs
SITE OF SERVICE MATTERS!
The ASC opened in 2006 adjacent to the main clinic location of Midlands Orthopaedics & Neurosurgery to offer patients a highly specialized and efficient outpatient alternative to hospital-based surgery for routine orthopedic procedures like knee arthroscopy, ACL repair, rotator cuff repair, wrist fracture repair, carpal tunnel and bunionectomy. No one imagined within only six years, our surgeons would be offering joint replacement and spine surgery in an ASC setting.
A three-pronged approach including minimally invasive surgical techniques, improved pain management and immediate rehabilitation promote rapid recovery from these complex surgeries, making the ASC setting a viable option for many patients.
The foundation of a successful outpatient joint and spine program must include clinical appropriateness, safety and efficacy; but the site of service cost differential is a significant driver of program growth. Self-funded employers and their benefit advisors are increasingly aware of the savings potential available by incentivizing patients to seek care from private practice physicians at ASCs whenever possible, whether or not a bundled arrangement exists.
For example, hospital outpatient departments in South Carolina are paid approximately $2,623 by Medicare for a simple knee arthroscopy, while Medicare pays SC ASCs $1,149 for the same procedure – a 56% difference. Private physicians and ASCs are also paid less than hospitals by traditional insurance carriers. Local hospitals may be paid 250-300% more than an ASC by commercial insurance carriers for the same surgery.
Our outpatient surgery program includes bundled case rates for approximately 100 orthopedic and spine surgeries, but purchasers may also achieve significant savings simply by shifting the site of treatment from hospitals and hospital-based providers to private physicians and ASCs even if those claims are filed to a traditional carrier.
As in any activity one attempts to master, developing expertise takes time and repetition. Studies confirm that patient outcomes for particular procedures are linked to the volume of those procedures a surgeon performs.
We are pleased to be a regional leader in ASC surgery.
- Total ASC surgeries performed 2006-2020: 43,879
- Joint Replacement surgeries performed 2012-2020: 3,399
- Advanced Spine surgeries performed 2012-2020: 968
- Spine Discectomy & Decompression surgeries performed 2012-2020: 972
- 62% of all surgery by our physicians is performed in an ASC setting: 3,657 cases in 2020.
Infection risk is reduced in the ASC setting simply because otherwise healthy patients presenting for an orthopedic or spine surgery are not comingled with patients who are fighting infectious disease as often occurs in hospital settings. Patient convenience is enhanced as access to the freestanding ASC does not require navigating a hospital complex or parking garage.
Joint Replacement Cumulative Infection Rate (3,399 surgeries) 2012-2020: 0.24%
Advanced Spine Cumulative Infection Rate ( 968 surgeries) Cervical, Lumbar & SI Joint Fusions, Cervical Disc Replacements and Spinal Cord Stimulator Placements 2012-2020: 0.31%
Cumulative Infection Rate for All Surgeries Performed 2006-2020 (43,879): 0.27%
2-4% of all inpatient surgeries in the US result in surgical site infections according to Patient Safety Network.
- Midlands Orthopaedics and Neurosurgery ranks #1 in South Carolina in Newsweek’s America’s Best Ambulatory Surgery Centers 2021
- AAAHC accreditation
- 2020 Validation Institute Health Value Awards Winner
COORDINATION OF CARE MATTERS!
Midlands Orthopaedics & Neurosurgery is pleased to offer bundled case rates for orthopedic and spine procedures to facilitate cost-effective, high-quality medical care for employers and employees. Rather than separating costs for each service, the bundled case rate includes all services provided over the prescribed episode of care. Any additional services that are recommended or required as part of the surgery will be clearly delineated and agreed upon prior to surgery. Some bundles include the cost of implants. For others, implants will be charged at cost (copy of invoice provided) after the surgery, but an implant estimate will be given pre-operatively.
All services are performed at Midlands Orthopaedics & Neurosurgery offices and The Surgery Center at Midlands Orthopaedics & Neurosurgery on an outpatient basis. Some procedures do include one overnight stay. Patient eligibility for outpatient joint replacement and advanced spine procedures is determined by overall health status.
What’s the Process?
We will need to know the CPT codes or procedure names you would like quoted; the location of the patient; and the name/contact info of the person to whom we should respond.
To proceed after receiving the initial quote, our Nurse Case Manager will request patient demographics, any existing medical records and imaging. A surgeon in our practice will review to determine if he agrees with the previous diagnosis or if he requires additional information before accepting the case.
If the surgeon accepts the case, a formal Letter of Agreement will be provided outlining all services included in the case rate; any optional services or supplies that are required or recommended; the recommended time the patient should remain in Columbia post-operatively; and expectations for physical therapy and follow-up visits.
Upon receipt of a signed Letter of Agreement, the surgery date will be confirmed, and preoperative clearances/labs orders will be issued.
A face to face consult with patient and surgeon will be conducted prior to surgery. This consult will be scheduled based on patient’s proximity to Midlands Orthopaedics & Neurosurgery.
Consults may be scheduled before the decision for surgery is confirmed if the patient lives within easy driving distance of Columbia, SC. This visit costs $150, which will be attributed to the bundled rate if surgery is scheduled.
Patients who prefer not to travel for the consult visit in advance may meet the surgeon the day prior to surgery if we have been able to schedule it based on medical records received.
The bundled case rate payment listed on the Letter of Agreement will be expected within 30 days of the surgery being performed. Please let us know if you need an invoice in addition to the Letter of Agreement.
- Plan or Employer Representative submits request for preliminary quote.
- To proceed following receipt of preliminary quote, Plan or Employer representative provides introduction to the person who will coordinate care for the patient. Our Nurse Case Manager, Candace Patton, will facilitate scheduling for the practice.
- Provide contact information (name, phone and email) for Plan or Employer representative who will approve the Letter of Agreement if different than the patient liaison referenced in number 2.
- Submit medical documentation and imaging studies to support need for surgery as well as general medical history if available. Imaging film AND reports are necessary. Email or fax to Nurse Care Manager (Candace Patton) listed below.
- Patient may be asked to complete a New Patient Packet for Employer Directed Bundle.
- Patient is expected to sign HIPAA Medical Record Release.
- Practice Nurse Case Manager will communicate directly with patient and/or designated Plan Representative to coordinate next steps.
Business Office Director
SURGICAL SITES OF SERVICE EXPLAINED
Ambulatory Surgery Centers (ASC) that bill as true ASCs are paid ASC rates by Medicare and all other payers, which are typically 50-60% less than rates paid to hospital outpatient departments.
Hospital Outpatient Departments (HOPD) and Hospital Owned Surgery Centers billing as HOPD are paid via the Outpatient Prospective Payment System (OPPS) by Medicare. Patients are typically discharged the same day from these facilities, but occasionally an overnight stay (less than 24 hrs) may occur. These settings are paid 50-60% more than ASCs for the same services.
Hospital Inpatient Departments are paid via the Inpatient Prospective Payment System (IPPS) by Medicare. Inpatient stays typically include at least two nights in the hospital. This setting is the most expensive.
Physician Offices/Private practice physicians are always paid by Medicare under the Physician Fee Schedule.
Hospitals have been allowed to bill Medicare under the OPPS (cited above) for clinic visits and services rendered by physicians they employ. These rates are 50-60% higher than the Physician Fee Schedule. Not all hospitals have taken advantage of this this tactic, but many do.
These services could be routine physicals conducted in an exam room; or a simple “surgery” performed in an office-based procedure room (injections guided by C-arm imaging or a skin biopsy, for example).
Beginning in 2015 and continuing through 2019, CMS made several attempts to eliminate this site of service differential for physician office services, but fierce lobbying from the Hospital Association has been an obstacle and numerous exceptions have been granted that allow hospitals to continue the practice. Additional information on the topic is found here: http://www.siteneutral.org/category/news/
CMS’ broadest attempt to establish site neutral payments was included in the 2019 OPPS Final Rule, but the DC District Court determined on 09/17/19 that CMS exceeded its authority. The Court granted summary judgment in favor of the American Hospital Association and others in the case brought against CMS.
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How do Medicare’s site of service differentials impact rates paid by private insurance plans?
Medicare payment policy has historically informed what private payers do. Traditional payers, whether BUCAH plans or smaller networks, typically follow Medicare’s lead in terms of site of service differentials.
The actual dollar amounts paid by these plans/networks to providers are generally higher than Medicare, but the site of service differentials still exist. In other words, while the amounts paid for the services differ from Medicare, hospitals and their employed physicians are paid significantly more for the same services than private physicians and ASCs.
Each payer negotiates rates with each provider (health system, ASC and physician practice) so different providers may have different rates within the same network for the same services. This payment inconsistency exists among different hospital systems as well as among different private physician groups and ASCs.
How do direct bundle contracts compare to traditional network rates?
Traditional Network Example:
Surgeon’s practice, ASC and anesthesia provider are all in-network with BUCAH Plan A. BUCAH Plan A insured patient has rotator cuff surgery at ASC and the claim is filed to that Plan. The in-network BUCAH Plan A rates will be significantly less than the hospital outpatient department. This option provides high value for the purchaser (patient and/or employer).
If using the BUCAH network, why should the employer include an incentive for the patient to select ASC surgery versus HOPD if both are options?
For a major surgery, a patient may meet his deductible and possibly meet his out-of-pocket max regardless of the site of service; therefore, changing the site of service does not necessarily reduce his out-of-pocket cost. The plan sponsor, however, will be left to pay the difference between the hospital and the ASC if the patient is offered and elects a hospital site of service. For a total knee replacement in SC, BUCAH plans pay local hospitals between $35,000 – $65,000; whereas our bundled ASC total knee never exceeds $26,500. Waiving a patient’s deductible and co-insurance as an incentive to select a surgeon who utilizes the ASC setting ultimately saves the plan between $10,000 and $40,000 depending on the hospital that would have otherwise been selected.
If the patient’s plan sponsor has a direct contract with us for a bundled surgery, the overall savings as compared to the hospital would be very similar to that achieved by filing the claims through BUCAH Plan A as described above.
Given that the cost is similar, what advantages do direct contracted bundles offer the plan sponsor?
- 100% cost transparency from the outset
- Fixed bundled pricing allows plan sponsor to predictably budget for musculoskeletal surgery based on previous claims history
- Simplified claims administration: one payment for the entire episode of care versus claims paid to multiple providers.
- Concierge experience for patient and administrator as we have a dedicated nursing and financial team to facilitate our surgical bundles.