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.
COST MATTERS!
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 and take advantage of the bundled surgery prices.
For example, Medicare pays hospital outpatient departments in South Carolina 40-60% more than ASCs for the same procedures. 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 reduced bundled case rates for approximately 100 Orthopedic and Spine surgeries. 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.
EXPERIENCE MATTERS!
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 have more freestanding ASC Surgical experience than any other practice in South Carolina. The cumulative totals below are current as of 12/31/2023:
- Total ASC surgeries performed: 55,166
- Joint Replacement surgeries performed: 6,105
- Advanced Spine surgeries: 1,584
- Spine Discectomy & Decompression surgeries: 1,330
- 66% of all surgery by our physicians is performed in an ASC setting
QUALITY MATTERS!
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 could often occur in a Hospital setting.
Our ASC cumulative surgical site infection rate is .25%; whereas 2-4% of all inpatient surgeries in the US result in surgical site infections according to Patient Safety Network.
Patient convenience is enhanced as access to the freestanding ASC does not require navigating a hospital complex or parking garage. If traveling from out of state we can also work with you to find a place to stay nearby in Beautiful Downtown Columbia.
COORDINATION OF CARE MATTERS!
Our private physician practice also incorporates Digital X-ray, MRI, Bracing and Physical Therapy. As with all care rendered by our physicians, our charges for these services are dramatically less than those of Hospitals or Hospital-employed Physicians. Utilizing these In-house services speeds treatment because reports are immediately available to the treating Physicians. Our imaging techs are highly skilled in positioning and image capture techniques best suited for Musculoskeletal diagnosis. Therapy is enhanced because Therapists and Physicians share the same medical records and work in the same offices making collaboration seamless. We are offering bundled pricing for Physical and Occupational Therapy as well. When ASC surgery is needed, our practice staff collaborates quickly with the ASC team next door and overall coordination of care improves as patients engage with Scheduling, Clinical and Financial representatives within one office setting for different services.
SURGICAL BUNDLES
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?
Request a preliminary quote by clicking here.
We will need to know the name of the Procedure that 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 Care Navigator will request patient demographics, any existing medical records and imaging reports and/or discs. 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 Estimate and Letter of Agreement will be provided outlining all services included in the case rate and any optional services or supplies that are required or recommended. We will include the recommended time the patient should remain in Columbia post-operatively and expectations for Physical therapy and Follow-up visits after surgery. We can then offer Physical therapy bundled pricing.
An in-person, phone or telehealth 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.
Upon receipt of a signed Letter of Agreement, the surgery date will be confirmed and preoperative clearances/labs orders will be issued. The bundled case rate payment listed on the Letter of Agreement will be expected within 30 days of the surgery being performed.
Getting Started
- Plan or Employer Representative submits request for preliminary quote.
- To proceed following receipt of the preliminary quote, Plan or Employer representative provides introduction to the person who will coordinate care for the patient. Our Care Navigator will facilitate scheduling for the practice.
- Employer will provide contact information (name, phone and email) for Employer representative who will approve the Letter of Agreement if different than the patient liaison referenced in number 2.
- The representative will need to submit Patient demographics, medical documentation and imaging studies to support the need for surgery as well as general medical history if available. Imaging film AND reports are necessary.
- New Patients will be asked to fill out a New Patient Packet.
- Our Care Navigator will communicate directly with the designated Plan Representative to coordinate next steps.
Contacts
Accounting Liaison:
Lynde Bledsoe
Business Office Director
lynde.bledsoe@midorthoneuro.com
Phone: 803-933-6138
Program Oversight:
Ron Chorzewski
Chief Executive Officer
ronc@midorthoneuro.com
803-933-6687
You may reach the entire team via the email address bundles@midorthoneuro.com.
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.
first
Your content goes here. Edit or remove this text inline or in the module Content settings. You can also style every aspect of this content in the module Design settings and even apply custom CSS to this text in the module Advanced settings.
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.
Bundles
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.