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Monica Daniel – Choosing the Best Option: Opening an ASC, OBL, or Hybrid-Facility
85 Plays8 months ago
Monica Daniel is the Principal & Founder of Axiom Integrated Services and has been consulting and helping ASCs for over 25 years. Over the last few years, Monica has seen an increase in interest and the development of OBLs (office-based labs) and that’s what we’re diving into today. We’re covering the differences between an ASC, an OBL, and a hybrid facility, the key factors to consider when choosing the most suitable option for you, how reimbursement differs, and other OBL trends Monica is seeing.
After my conversation with Monica, we’ll switch to our Data & Insights segment. Today, we’ll break down the average number of days it takes ASCs to bill, which is defined as the number of days between the date of service and the date the claim was made. And I’ll share some tips to help you close the gap and reduce your turnaround time.
We are just a few weeks from #ASCA2024 in Orlando! HST has so many fun things planned for the show, so we hope to see you all there. When you swing by our booth (next to ASCA’s at Booth #709), you can take a quiz to win a prize and give all our products a test drive. We also have two sessions for you to add to your agenda:
- Thursday, April 18th: Unleash the Power of Data to Transform Your ASC
- Friday, April 19th: How to Prepare for and Navigate Board-Level Conversations
Learn more & schedule time with HST! https://www.hstpathways.com/asca
Resources Mentioned:
- Download HST’s State of the Industry Report to get your hands on even more data: https://www.hstpathways.com/resources/surgery-center-industry-report
Brought to you by HST Pathways.
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Transcript
Introduction to ASC Industry and Guest
00:00:01
Speaker
Welcome to This Week in Surgery Centers. If you're in the ASC industry, then you're in the right place. Every week, we'll start the episode off by sharing an interesting conversation we had with our featured guest. And then we'll close the episode by recapping the latest news impacting surgery centers. We're excited to share with you what we have. So let's get started and see what the industry's been up to. Hi, everyone. Here's what you can expect on today's episode.
Meet Monica Daniel and Her Experience
00:00:30
Speaker
Monica Daniel is the principal and founder of Axiom Integrated Services, and she has been consulting and helping ASCs for over 25 years. And over the last few years, Monica has seen an increase in interest in the development of OBL's office-based labs.
00:00:47
Speaker
And that's what we're diving into today.
ASCs vs OBLs: Understanding the Differences
00:00:50
Speaker
So we're covering the differences between an ASC and OBL, and then also the option of a hybrid facility. We're also talking through the key factors to consider when choosing which structure is right for you, how reimbursement differs and other OBL trends that Monica has been seeing. And after my conversation with Monica, we will switch to our data and insight segment. And today we'll break down the average number of days it takes ASCs to build
00:01:17
Speaker
So the number of days between the date of service and the date the claim was made. And then I'll share some tips to help you kind of close that gap and reduce your turnaround time.
HST's Participation in Aska Event
00:01:27
Speaker
And lastly, we are just two weeks out from Aska in Orlando, which is super exciting. HST will be at booth 709 and we have a really fun prize that anyone can win. We'll have all of our products available for walkthroughs. And then we actually have two speaking sessions this year. So one is on Thursday, April 18th.
00:01:47
Speaker
titled, Unleash the Power of Data to Transform Your ASC that Will Evans will give. And then we have a second one on Friday, April 19th titled, How to Prepare for and Navigate Board-Level Conversations. And that is actually a panel. So Nick Latz will be the moderator, and then our two panelists will be Tina Piotrowski and Dr. David Shapiro.
00:02:10
Speaker
So if you want to learn more, just go to hscpathways.com slash ask for all the logistics. And then I do really hope you'll all swing by the booth to say hello. So I hope everyone enjoys the episode and here's what's going on this week in surgery centers.
Key Components of ASCs and OBLs
00:02:28
Speaker
Hi Monica, welcome to the podcast. Good morning. Thanks so much for coming on today. Can you share a little bit about yourself with our listeners, please? Sure, sure. So my name is Monica Daniel. I am the president of Axiom Integrated Services out of Chicago, Illinois. We are a healthcare consulting company that's been in business for 25 plus years, really in the ambulatory sector.
00:02:54
Speaker
for the most part, dealing with brand new surgery center startups, office-based labs, office-based accreditation, ASC accreditation, so anything really in that ambulatory sector is where we reside.
00:03:07
Speaker
Awesome. And I'm really excited that you're on today because we have covered a lot about outpatient growth, but we have not talked about OBLs at all yet. And I know that's such a hot topic and important topic right now. So for our listeners who may not be familiar or might just need a refresher, could you explain the difference between an ASC and OBL and then even a hybrid facility?
00:03:33
Speaker
Sure, sure. So I think some of the key elements to an ambulatory surgery center would be
00:03:39
Speaker
State licensing. So in some states, there is the mandate that you must be a licensed facility within that state. We still do have in some states where there is a certificate of need or a CON that is required. That's typically required before you even start construction of that surgery center. So that's one component. And another component I would say is Medicare certification. So as a surgery center, you can go and become accredited or certified as a Medicare facility.
00:04:10
Speaker
Within that component of those Medicare requirements, there is a little thing called co-mingling of patients. I'll get into that because it plays into our hybrid component in a minute, but that is a real key component under Medicare. And I think those are kind of some of the top areas as well as being able to bill a facility fee as a surgery center.
00:04:31
Speaker
Now, if we get into what's more of an office-based lab or an office-based surgical suite, that's really considered as more of an extension of a physician practice. Physicians have their practice, they see their patients, and they can do surgical procedures within that space. There are some requirements in certain states where we have thresholds. For instance, they will not allow you to do more than 50 percent of your overall patient volume as surgical volume.
Hybrid Facilities: A Deep Dive
00:05:01
Speaker
So those are some things to consider. I think another piece to that puzzle is the anesthetic component. So in some states, you have to watch where your level of anesthesia is, whether that's maybe they only allow you to do local anesthetic. It may only be that they allow you to do conscious sedation within some states. So that's another piece to the office-based side.
00:05:25
Speaker
And usually in those settings, we will see mainly that that's kind of an extension of the physician practice, and that's also constructed as a part of the physician practice itself. So that's the OBL office-based surgical side. Now we get to the fun piece of the ASC and the OBL hybrid. And that's really the, I would say, the best of both worlds. It's the combination of both the ASC and the OBL. So
00:05:53
Speaker
The facility itself would need to be constructed as a surgery center, meeting all of those life safety requirements, going through licensing if needed, going through Medicare certification and anything of that aspect. And then it really only acts as a surgery center on certain days of the week. So that means maybe on Monday and Tuesday, we're going to act as a surgery center. Then the OBL kicks in on Wednesday through Friday. And so that OBL will be
00:06:23
Speaker
where we're going to do those OBL cases Wednesday through Friday. And this is the piece of the co-mingling. So because of the fact that Medicare says that we cannot co-mingle patients, meaning if I have surgical patients, they need to be there just for surgery as a surgery center. You couldn't have office-based patients being seen at that same time.
00:06:45
Speaker
So we try and in this OBL hybrid, you will have lease agreements that will structure so that things are kept very, very separate between these two entities. So that kind of gives you the basis of all three of those components and kind of how they're structured.
00:07:02
Speaker
Yeah. And, or most of those restrictions just kind of checks and balances just to make sure, because you had mentioned the 50%. I think that's interesting that. So a physician who sees somebody at their practice can only technically send 50% to, for surgical procedures.
00:07:20
Speaker
it is more that they can only do 50% of their surgical volume within their facility. So if I had, let's say, 1,000 patient visits, I could only do 499 surgeries within my practice itself. I gotcha. And that's just in some states. Yeah. So it's one of those things too, where we want to look at in any state when we go in to assist a client, we're looking at what their
00:07:45
Speaker
surgery center mandates are, we're looking at what the office-based mandates are to make sure that they're compliant with any of those.
Growth Trends in OBLs and Hybrids
00:07:53
Speaker
Okay, perfect.
00:07:55
Speaker
And we know that there are roughly 6,200 Medicare certified ASCs. That's a number we can pull. We can't put an exact number on how many OBLs or hybrid facilities there may be, but can you try to give us a sense of kind of the growing interest right now? Yes. I can tell you that in our practice itself, probably within the last three to five years, we have seen just a huge explosion on the OBL side. I want to say it started there first. Really, the physicians kind of
00:08:23
Speaker
pushing those cases into their OBL, starting those office-based labs. But now we're also seeing where a lot of those physicians who started those office-based labs are now saying, hey, you know what Monica, I'd like to also build a surgery center because they see that need based on reimbursements and how that's kind of migrating into different areas. So they're taking their office-based labs now to the next level and saying, we'd like to start a surgery center.
00:08:49
Speaker
I think I saw, Erica, where some of the revenue numbers were around $11 billion for office-based labs in 2023, migrating up now until $18 billion by 2030. So you're going to start seeing a lot more of this being shifted into these either OBL or ASC or hybrid sectors. Wow. That's crazy
Choosing the Right Facility Type
00:09:09
Speaker
growth.
00:09:09
Speaker
And what are some of the key factors that should guide a health system or a provider who's trying to choose between an ASC, OBL hybrid? Or I think it's interesting, ASCs might want to outfit an OBL, OBLs might want to expand to an ASC, so so many combos here. Yes, there's a lot of different combinations. And I think one of the key pieces to this is patient population. We'll have physician groups that will come to us, maybe they're currently part of a hospital system.
00:09:39
Speaker
If you have those patients in a hospital system and they can't migrate out with you, then it doesn't make sense for you to try and create an office-based lab, right? So that's one piece to the puzzle. I think another piece is just the fact that I always tell physicians, please walk before you can run.
00:09:57
Speaker
If you are a group and you would like to start an ambulatory surgery center or an office-based lab, let's start with the office-based lab first, if that makes sense. Let's get you accustomed to what that feels like, how that is handled, because there's much less regulatory requirements on that office-based lab than there's going to be in the ambulatory surgery center.
00:10:20
Speaker
So we try and kind of get them, let's walk before we can run. Types of cases is another key component to this. If I have a group of physicians that as we look at what their patient population is and the majority of their cases are reimbursable in OBL, then we should head down that OBL path first. But if a lot of their cases can't be reimbursed in an office-based lab, and it's more of that surgery center,
00:10:46
Speaker
then I want to try and drive them and say, maybe we need to look at the surgery center first. So I think those are key components to it.
00:10:54
Speaker
And then just the expense of it as well. I mean, it's not a cheap option to try and head down that surgery center path because you do have more of those regulatory requirements for your construction. So again, that might drive the factor of maybe we want to start with an OBL. And if someone is right now opening up a surgery center, working on a de novo project, would you recommend that when they're outfitting and doing their construction that they're considering
00:11:21
Speaker
the OBL restrictions just in case they want to go that route. If you have a group of physicians that let's say is looking to do an OBL,
00:11:32
Speaker
It's very hard for you to go from an OBL into an AS because of the fact just with that whole construction, the requirements of a surgery center is going to have. But at the same token, I'll say it's very difficult to say, let's build this as though it's a surgery center because that's a lot of additional expense that maybe you may never go down that path. So if you're going to do it, I'd say do an OBL, but do it in the most cost efficient manner that you can.
00:12:01
Speaker
And when that time comes, if you do think that you want to go for a surgery center, maybe either we're looking at expanding what you currently have or finding a whole different location. Sure. Okay. That makes sense.
00:12:15
Speaker
I'm sure one driving factor of this would be reimbursement.
Reimbursement Differences and Choices
00:12:19
Speaker
So how does reimbursement differ between an ASC and an OBL? Yes. So it's probably one of the biggest driving factors to this whole piece of the puzzle, right? It's just because there are certain codes Medicare has allowed to be done in an ASC. There's certain codes that Medicare even allows for a physician to bill
00:12:39
Speaker
on his professional fees as an additional reimbursement for the OBL. So when we look at this, it really comes back to that feasibility and saying, do I head down the path based on these codes being reimbursed in an OBL? Or do I head down the path of that ASC because these codes can be reimbursed in that ASC? So it's a fine line in both.
00:13:03
Speaker
That hybrid is when you have that group that says, Monica, I can do both ASC procedures and OBL procedures. That's when that hybrid becomes very, very important because they can capture on both of those aspects. And that makes a lot of sense then for us to do that ASC and that OBL hybrid. So the reimbursing factor is really, and I think we're starting to also see where Medicare is
00:13:29
Speaker
shifting things maybe from an OBL into an ASC. So where before they were paying in that office based, we're now seeing it shifting into the surgery center side. And that's, I think, a driving piece to where some of those physicians who started an OBL are deciding, maybe I need to do an ASC because I'm going to have to shift these cases
00:13:50
Speaker
into a surgery center soon. That makes sense. So you can kind of back in to your answer of ASC or OBL based on physician skillset and of course other variables as well. We're their patients. Who do they have for patients? What types of procedures are they doing will really dictate which type of facility we probably want to head them down.
Trends and Regulatory Changes
00:14:12
Speaker
Gotcha. And what trends are you seeing right now with these facilities? Any specific states, specialties, what are you seeing right now? Yeah, I think the hard part right now is the fact that we still have so many states that maybe don't allow cardiac procedures to be done or cardiovascular procedures to be done, not even just in an OBL, but maybe even in an ASC.
00:14:36
Speaker
Pennsylvania was one that just recently rescinded some of its requirements that they could only be done in a hospital setting. So you really are looking at, if you're a physician group, you're looking to see, does my state even allow me to do these in an OBL or an ASC environment? So I think that's the trend is starting where we're Colorado recently kind of rescinded some of its restrictions on that and is allowing some of these cardiac procedures to be done in an ASC.
00:15:05
Speaker
But there's also requirements for regulatory reporting. So they want to see what these outcomes look like. They want to make sure that these are being done in a safe environment. And I understand that. I think also no matter what, even if you're doing office-based surgery, might not even just be these procedures. It could be plastics or pain management or whatever. We're still seeing that some states have requirements for accreditation in an office-based setting. So they need to make sure that they're reviewing those state requirements.
00:15:34
Speaker
So I think it's just really a matter of how are we seeing Medicare push things into these surgery centers, into these OBLs. That's probably the biggest trend and how these states are kind of taking it on to say, okay, maybe we do need to lessen some of the restrictions and allow some of these to be done in these settings. So that's, I think, the biggest trend that I'm seeing.
00:15:56
Speaker
Yeah, that's interesting. You had mentioned reporting. Do OBLs have the same level of quality measure reporting and all of that that ASCs do, or it's even less?
00:16:07
Speaker
No, not at all. Because again, they're not really regulated. That's the only regulatory body that an OBL or an OBS has is really whoever they're using is their accrediting body. And the reporting requirements are really going to be more of what is that joint commission, that AAA, the quad A's of the world that maybe are those accrediting bodies, the ACHC's that are out there. What do they mandate they have to report? But that really is just internal.
00:16:36
Speaker
So all of the NHSN reporting that we have to do on the surgery center side of things or the quality metrics or things like that that fall under Medicare, that's not a requirement for an OB. That has to also be a wonderful driving factor for some physicians as well.
00:16:53
Speaker
That's really interesting. It sure is because when you think of a physician practice, we're dealing with lesser staff. Maybe we're only dealing with staff that have our only medical assistants. They don't maybe even have any nursing staff within a physician practice or things of that nature. When we come in, there is sometimes a lot of education that has to go on.
00:17:15
Speaker
when we're getting them prepared, when they're getting them ready for that accreditation. But then also, just like you said, how do we also educate them on maintaining patient safety, maintaining the regulatory requirements that maybe they're not required to do, but we want them to do to make sure that it's still a safe environment for those patients that are coming in.
00:17:36
Speaker
Yes, absolutely.
Improving Operations: Sterilization Practices
00:17:38
Speaker
All right, Monica. Well, I feel like we could talk about this for probably another three hours at least, but- A lot to it, right? A lot to it. Yeah. It's super interesting. I mean, I just think there's so much right now too with procedures being pushed to the outpatient space. So to add this extra component to it, it's just super interesting to see in five years looking back, what will the breakout of ASCs versus OBLs and hybrid facilities be?
00:18:04
Speaker
Yeah, it really is. I think it's exciting for me when I have one that we build out and you see that cath lab built out in an ambulatory setting and it's just, the physicians are always so happy and it's just, it's a beautiful thing to see. So. Yeah, that's awesome. All right. We do this every week with our guests. What is one thing our listeners can do this week to improve their surgery centers or OBLs?
00:18:30
Speaker
Sure. I would say probably in light of the fact that I think I just finished four surveys in the last week, sterilization. Sterilization is such a huge hit area. I think that any administrator or manager would do themselves some good by digging into their sterile processing area, looking at maybe any gaps that they may have, and pulling every possible instruction for use or manufacturer guideline that they have for any product, any
00:18:59
Speaker
instrument, any piece of equipment to make sure that they're following by cleaning practices or just even operational practices based on those particular items because it's something that every surveyor right now is digging into really, really hard. That is great advice. Thank you very much for coming on today. We appreciate it. Thank you. Thanks for having me.
Boosting Billing Efficiency
00:19:25
Speaker
Welcome to Data and Insights, where we turn data into dialogue and numbers into narratives. So HSC Pathways released a state of the industry report late last year, highlighting best practices, key process steps, and KPIs for every step of the patient journey and for nearly every recurring administrative duty.
00:19:45
Speaker
Most importantly, using our own unique data set from our clients, we were able to extract data points so that anyone in the industry could compare themselves to their peers. Two quick disclaimers, we only pulled data from clients who gave us permission and we omitted any extreme outliers.
00:20:03
Speaker
So after analyzing data from over 450 ASCs across the country, we determined that on average, ASCs are taking 3.6 days to bill. So our data analysts derived this metric by counting the days between the date of service and the date the claim was made.
00:20:22
Speaker
So let's break down that days to bill number just a little further. So you have even more context. So here is, here it is broken out by number of ORs. So ASCs with one OR take four days to bill. Two to four ORs take three days to bill. Five to nine ORs take four. 10 to 14 ORs take three.
00:20:47
Speaker
And then 15 plus ORs take four. So they're all between three and four. There's not a huge amount of difference there, but the range is 3.1 days to 4.4 days.
00:21:01
Speaker
So why does this data point matter? Days to bill is obviously a key indicator of the efficiency of the revenue cycle as the number directly affects the speed at which your surgery center receives payments from payers. And by keeping days to bill low, surgery centers can optimize cashflow and reduce the risk of delayed payments or cashflow interruptions.
00:21:25
Speaker
It's also really important for compliance with regulatory requirements and for maintaining a transparent and efficient billing process. So how can you shorten the number of days it takes to submit your claim, right? Okay, you do your due diligence, you understand your number, but how can we make that turnaround even faster? So utilizing EHRs and practice management systems that are ideally integrated with clearing houses will help to streamline this process significantly.
00:21:54
Speaker
You know, human error is inevitable, but using software and also employing well-trained coders who are well-versed in the latest coding standards and guidelines will help to reduce denials and avoidable mistakes.
00:22:09
Speaker
And when a denial does occur, it's important to take meticulous notes and review everything to avoid making the same errors in the future. And any upfront technology costs will soon be recouped as your days to build number decreases.
00:22:24
Speaker
Some other KPIs to track would be claim submission time, claim denial rates, and then percentage of electronic claim submissions as well. Ideally all, but that's okay if not. And as always, trying to identify some sort of pattern can be super helpful. So are there specific procedures or providers that seem to take longer to get the claim submitted? Insights like that can be invaluable and help you get to the root cause.
00:22:52
Speaker
If you're interested in more data points and use cases, subscribe to the podcast so that you don't miss any upcoming segments or just head to our website to check out the full state of the industry report to get your hands on even more data. And that officially wraps up this week's podcast. Thank you as always for spending a few minutes of your week with us. Make sure to subscribe or leave a review on whichever platform you're listening from. I hope you have a great day and we will see you again next week.