Develop own surgery center vs keep office procedures

[geauxg8rs]

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I have an office based practice but am thinking of wanting to build my own building so I can stop renting and be an owner of the building.
In doing this process, should i look to make the procedure room into an ASC? Is there a procedure volume that others have used to make this work financially? I would like advice from others who have gone through this growth process

 

[drusso]

I have an office based practice but am thinking of wanting to build my own building so I can stop renting and be an owner of the building.
In doing this process, should i look to make the procedure room into an ASC? Is there a procedure volume that others have used to make this work financially? I would like advice from others who have gone through this growth process

 

[gaseous_clay]

I have an office based practice but am thinking of wanting to build my own building so I can stop renting and be an owner of the building.
In doing this process, should i look to make the procedure room into an ASC? Is there a procedure volume that others have used to make this work financially? I would like advice from others who have gone through this growth process

In which state do you practice? Does it have a CON? Can you build a single specialty center or does the state require a multi-specialty ASC? You really have to know your state specific regs as these are the main things that vary from one center to another. CMS regs are universal. Also, do you have plenty of capital? These things aren’t cheap, but the costs can vary based on these state regs. What’s your payor mix? Once you get estimated costs to build and operate (overhead), then you can estimate the number of procedures you need to do in order to generate positive cash flow. Use Medicare facility fee schedule for each case as a conservative estimate.
Furthermore, you can’t just convert an existing office based procedure room into a surgery center unless it meets specific requirements. I would advise getting a consultant.

 

[geauxg8rs]

In which state do you practice? Does it have a CON? Can you build a single specialty center or does the state require a multi-specialty ASC? You really have to know your state specific regs as these are the main things that vary from one center to another. CMS regs are universal. Also, do you have plenty of capital? These things aren’t cheap, but the costs can vary based on these state regs. What’s your payor mix? Once you get estimated costs to build and operate (overhead), then you can estimate the number of procedures you need to do in order to generate positive cash flow. Use Medicare facility fee schedule for each case as a conservative estimate.
Furthermore, you can’t just convert an existing office based procedure room into a surgery center unless it meets specific requirements. I would advise getting a consultant.

State lifted CON two years ago. No requirement for it to be multi specialty ASC. I am working with a consultant. Of course the consultant thinks it makes sense. I am just doing my due diligence.

 

[pmrmd]

You want the ASC for the procedures that require a faculty like Vertiflex, SCS implant, and maybe Intercept. Don’t be the schmuck that does everything in the ASC though, like facet blocks and routine ILESI that don’t require that site of service.

 

[gdub25]

I will reply more in depth when I have more time, in clinic now, but I have been pursuing building a surgery center for the past year and a half. I’ve traveled the country, visited a half a dozen doctors and practices that have built their own, am currently a minority owner of one myself, and I feel that I can give you some accurate advice. Mine should be operational in the next 5 to 6 months and I’m going through the licensing and credentialing stuff now. I can tell you right now however that the one common thing that I’ve heard from every one that I’ve talk to you is that they will not make as much money as you think they will. Still a very good business decision but not the thing that’s gonna let you retire in five years.

 

[lonelobo]

So will your patients appreciate the much larger co payments and charges that come with procedures done at an ASC as compared to office?

 

[drusso]

You want the ASC for the procedures that require a faculty like Vertiflex, SCS implant, and maybe Intercept. Don’t be the schmuck that does everything in the ASC though, like facet blocks and routine ILESI that don’t require that site of service.

Can you elaborate?

 

[pmrmd]

Can you elaborate?

Sure. Simple procedures don't need to be done in an ASC. He can continue doing office procedures for facets, most ESIs, etc. In my view the more we as a specialty utilize expensive SOS for simple things the sooner it will be seen as abusive and not worth the cost to payers. Also as Lobo intimated above patients know the difference when they get a simple procedure for a usual copay and when they get a simple procedure for a large facility fee. It reflects poorly on the physician and perhaps the field.

 

[Ferrismonk]

Can you elaborate?

Sure. Simple procedures don't need to be done in an ASC. He can continue doing office procedures for facets, most ESIs, etc. In my view the more we as a specialty utilize expensive SOS for simple things the sooner it will be seen as abusive and not worth the cost to payers. Also as Lobo intimated above patients know the difference when they get a simple procedure for a usual copay and when they get a simple procedure for a large facility fee. It reflects poorly on the physician and perhaps the field.

I know this is debated ad-nauseum, but I don't see things changing anytime soon. Insurances are just glad to get things out of the hospital. ASCs are cheap by comparison.

 

[SommeRiver]

I have ownership in an ASC and still go out of my way to do basic injxns in the clinic.

BCBS actually sent out a notification they won't cover most injxns in an ASC any longer. Interestingly, they'll cover a lumbar TFESI but not a cervical ILESI.

 

[SommeRiver]

I can tell you right now however that the one common thing that I’ve heard from every one that I’ve talk to you is that they will not make as much money as you think they will. Still a very good business decision but not the thing that’s gonna let you retire in five years.

Truth right here.

It depends on the ASC though.

Our main ASC is paying out A LOT in dividends (bigger even than what I make per year)...Our second ASC is more of your typical ASC that generates a solid amount of profit, runs efficiently, lean in its expenses relative to its profitability, and earns great dividends, but not like the main facility. Not even close.

 

[geauxg8rs]

I have ownership in an ASC and still go out of my way to do basic injxns in the clinic.

BCBS actually sent out a notification they won't cover most injxns in an ASC any longer. Interestingly, they'll cover a lumbar TFESI but not a cervical ILESI.

But will BCBS cover them in a hospital instead? Or do they only cover in office?

 

[Sig123]

I have ownership in an ASC and still go out of my way to do basic injxns in the clinic.

BCBS actually sent out a notification they won't cover most injxns in an ASC any longer. Interestingly, they'll cover a lumbar TFESI but not a cervical ILESI.

Can you post that BCBS notification if you are able?

 

[lonelobo]

BCBS actually sent out a notification they won't cover most injxns in an ASC any longer. Interestingly, they'll cover a lumbar TFESI but not a cervical ILESI.

That doesn't make a lot of sense.....many people don't have office based procedure suite

 

[SommeRiver]

I was notified today by someone in our admin...I'm running it down now.

Supposedly it starts June 1st.

Spine codes are 22558, 22612, 22846, 22850, 22852, 22856, 62321, 62323, 64490, 64493, 64633, 64635.

Edit - *******...This is bad information and I'm pissed. This is NOT "most injections" but is very confusing.

62321? DaFuq?

 

[Sig123]

I was notified today by someone in our admin...I'm running it down now.

Supposedly it starts June 1st.

Spine codes are 22558, 22612, 22846, 22850, 22852, 22856, 62321, 62323, 64490, 64493, 64633, 64635.

Edit - *******...This is bad information and I'm pissed. This is NOT "most injections" but is very confusing.

62321? DaFuq?

Those codes don't make much sense for sure.

22558? Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression)

If this really is true -- they seem to want to push to the hospital for some reason.

 

[drusso]

Those codes don't make much sense for sure.

22558? Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression)

If this really is true -- they seem to want to push to the hospital for some reason.

Can you think of a reason why they would push hospitals?

 

[SommeRiver]

I don’t want to spread false info guys, but that was relayed to me by our ASC director today.

I'm trying to get my hands on the actual statement by BCBS.

Full disclosure - She is an idiot and has made my life hard in the past. Very stupid person.

 

[gaseous_clay]

Truth right here.

It depends on the ASC though.

Our main ASC is paying out A LOT in dividends (bigger even than what I make per year)...Our second ASC is more of your typical ASC that generates a solid amount of profit, runs efficiently, lean in its expenses relative to its profitability, and earns great dividends, but not like the main facility. Not even close.

Is this a functional of procedure volume?

 

[gaseous_clay]

State lifted CON two years ago. No requirement for it to be multi specialty ASC. I am working with a consultant. Of course the consultant thinks it makes sense. I am just doing my due diligence.

What about the answers to the rest of my questions?

 

[SommeRiver]

Is this a functional of procedure volume?

Definitely, and the cases brought to that ASC matter as well.

If you can get a dozen or more orthopedic surgeons going balls to the wall you're going to make money hand over fist assuming your staff has the motivation to turn the rooms over quickly.

Another thing is ensuring your cases are healthy and medically stable so everything runs smoothly and you minimize the time in the room. A morbidly obese pt on oxygen shouldn't be touched in that environment bc they're going to slow everything down. - Intubation is slower, transfers on/off the table are slow, procedures take longer, etc...Our ASC rules are very strict.

...but I agree that ASC ownership isn't always the cash cow that most think it is...

 

[gaseous_clay]

Definitely, and the cases brought to that ASC matter as well.

If you can get a dozen or more orthopedic surgeons going balls to the wall you're going to make money hand over fist assuming your staff has the motivation to turn the rooms over quickly.

Another thing is ensuring your cases are healthy and medically stable so everything runs smoothly and you minimize the time in the room. A morbidly obese pt on oxygen shouldn't be touched in that environment bc they're going to slow everything down. - Intubation is slower, transfers on/off the table are slow, procedures take longer, etc...Our ASC rules are very strict.

...but I agree that ASC ownership isn't always the cash cow that most think it is...

It can be if it’s single specialty. Multi-specialty centers have too many issues with cost containment, block times, staffing, etc. One has way more control of overhead and efficiency in a single specialty center especially when all the physician owners are on the same page when it comes to which equipment to use and which cases they bring. I’ve been an owner in both types of centers and the income I brought home from my single-specialty ASC ownership dwarfed the other.

 

[Agast]

I don’t want to spread false info guys, but that was relayed to me by our ASC director today.

I'm trying to get my hands on the actual statement by BCBS.

Full disclosure - She is an idiot and has made my life hard in the past. Very stupid person.

This sounds similar to what I was told about United Health a few years ago. For a while I was adding to my note that in office procedures were not possible due to lack of equipment but it never became an issue so I stopped. Maybe it only gets flagged if you have an established history of in office injections .

 

[10KHertz]

Pursue the Asc and then sell it to a multinational. That’s where the money is...

 

[lonelobo]

snapping up those one doctor ASC's?

 

[SommeRiver]

So...Does this mean there will be a day when all elective procedures and surgeries will be done in an outpt hospital setting? Why?

 

[gaseous_clay]

So...Does this mean there will be a day when all elective procedures and surgeries will be done in an outpt hospital setting? Why?

Sorry, where does this specifically say they are not reimbursing certain CPT codes billed from an ASC?

 

[SommeRiver]

Sorry, where does this specifically say they are not reimbursing certain CPT codes billed from an ASC?

I wrote those codes above...

 

[Ducttape]

I was notified today by someone in our admin...I'm running it down now.

Supposedly it starts June 1st.

Spine codes are 22558, 22612, 22846, 22850, 22852, 22856, 62321, 62323, 64490, 64493, 64633, 64635.

Edit - *******...This is bad information and I'm pissed. This is NOT "most injections" but is very confusing.

62321? DaFuq?

cervical interlaminar.

yes makes no sense, since fluoroscopy is bundled in those codes.

 

[Chn96]

How about ASC certification , is it JCAHO preferred ?
Contract with various insurances? How about Out of network patients.
Also how you guys deals with high deductible patients in ASC.

 

[Greenbayslacker]

How does one get into investing in an ASC? Do you have the be there from the start and build from the ground up, or are there opportunities to "buy in"?

 

[Ferrismonk]

Often opportunities to buy in, but you need to discuss with owners and usually only if you bring in a lot of cases.

 

[10KHertz]

You own it, create a portfolio of specialists, and sell it. Liquidation Event...

 

[Ferrismonk]

Fwiw, a buddy of mine who does everything in his ASC is getting denials all the time for SI joint injections. He asked if I'm getting the same thing, which I don't. Only difference is I do everything in office. Insurances definitely are starting to take aim at this.

Of note, we're talking simple SI injections, not LBB/RFA.

 

[Greenbayslacker]

Fwiw, a buddy of mine who does everything in his ASC is getting denials all the time for SI joint injections. He asked if I'm getting the same thing, which I don't. Only difference is I do everything in office. Insurances definitely are starting to take aim at this.

Of note, we're talking simple SI injections, not LBB/RFA.

serious question, shouldn’t most procedures, especially in an ASC, have insurance approval prior to being done? How is a denial coming in afterwards?

 

[Ferrismonk]

It's being denied before the procedure.

 

[geauxg8rs]

It's being denied before the procedure.

But these would still get approved if done at a hospital?