Procedure coverage and reimbursement for higher acuity procedures
Conservative estimate of 20+ new
high acuity cases annually (1-2 per month)
Significant increase in revenue and profit margins ($2,500-$3,500 per case)
Increased profitability without the need for upfront cash outlay
There was a time when procedures such as total joint replacements were thought to be too complex and risky to be performed in ambulatory surgery centers (ASCs). Today, those facilities have proven that with a highly trained surgical staff, a well-thought-out perioperative plan, and a motivated patient, these procedures can be done successfully in an ASC – and for about half of what they would cost in a hospital.
The primary obstacle that most ASCs like Pinnacle Orthopaedics face is getting the right reimbursement for the procedures to make them viable revenue sources. Pinnacle was initially out-of-network, and the majority of their contracts did not have a provision for implants. This limited the number of cases they could take to the ASC.
In this case study, we will tell you how Pinnacle Orthopaedics worked successfully with IPG, in conjunction with Aetna and Kearny Street Consulting, to enable their physicians to perform total joint replacement and other more complex surgical procedures at their facility.
“The IPG-Pinnacle model is a great success story that we are replicating across Georgia and other Aetna markets to promote the appropriate coverage and reimbursement
structure that supports eligible procedures, like total joints and spine cases to be delivered in the optimal cost and quality setting. Working with IPG allows us to identify those eligible facilities, surgeons and procedures that can be done in a more affordable setting thereby helping us manage our surgical costs to the benefit of our members.”
Director of Network Management