Ambulatory Surgery 101: What You Need To Know About Costs and Coverage

As more routine medical procedures move out of hospitals and into outpatient centers, you may find yourself considering an ambulatory surgery center, or ASC, for your next elective procedure.

ASCs can provide significant cost savings and convenience compared to hospital outpatient departments. Here’s what you need to know about what ASCs offer, procedures performed, insurance coverage, and steps you can take to navigate costs.

What Is an ASC?

Ambulatory surgery centers are freestanding facilities focused on providing surgical, diagnostic, and preventive procedures to patients who do not require overnight hospitalization.

ASCs offer savings by concentrating on specific outpatient services rather than providing emergency services or procedure suites like hospitals. There are over 6,200 Medicare-certified ASCs nationwide today, up substantially from 4,000 centers in 2004.

Procedures Performed at ASCs

The decision for having your procedure performed at an ASC versus a hospital will depend first on whether it is a good fit based on the procedure type and your health status. Your physician can advise if an ASC is appropriate in your case.

ASCs perform scheduled, non-emergency, “elective” surgeries across specialties. Medicare currently covers 4,684 procedures delivered at ASCs. Services span areas like:

• Orthopedic surgeries: knee arthroscopy, hand/wrist procedures, shoulder repairs
• Gastrointestinal: colonoscopy, upper GI endoscopy
• Eye: cataract surgery
• Cosmetic surgery: scar revision, mole/lesion removal
• Urological: cystoscopy, vasectomy
• Gynecological: hysteroscopy, laproscopy.

Medicare Coverage and Costs

Medicare Part B covers eligible procedures performed at ASCs. To look up potential costs for a given procedure:

1. Verify the procedure’s CPT code with your physician
2. Use Medicare’s Procedure Price Lookup tool

This will show Medicare’s payment rate to the ASC and your estimated coinsurance responsibility.

For example, Medicare pays $341 for cataract surgery at an ASC, versus $549 in a hospital. That lower reimbursement gets passed as savings to you through a reduced coinsurance payment.

Private Insurance Coverage Considerations

Those with private insurance or Medicare Advantage plans will need to check directly with their insurer on ASC procedure coverage and estimates. Key questions to ask:

• Is the procedure covered at an ASC?
• What are my estimated out-of-pocket costs?
• Is this specific ASC in my network?

Going to an out-of-network ASC may result in higher charges from that facility. The No Surprises Act requires ASCs to provide a “good faith estimate” of costs for self-pay patients.

Common ASC Fees Beyond Insurance

While a large portion of ASC charges go to your insurer, additional common fees include:

• Separate anesthesia billing: for medications, physician services
• Copays/deductibles per your plan’s policies
• Facility fees: rent, overhead, equipment costs
• DME: crutches, compression stockings
• Lab tests, pathology reports.

You may also owe additional costs if extra procedures beyond the original plan arise. Your insurance would cover fees for any medically necessary additions.

Choosing the Best Setting

ASCs can offer advantages around cost, efficiency, and convenience for many common outpatient procedures. As you weigh options with your physician, consider:

• Your health status and risk factors: Are you a candidate for outpatient surgery?
• Procedure type: Does an ASC offer this service, or is a hospital required?
• Cost comparisons: Will you save significantly on coinsurance with an ASC?
• Insurance coverage: Do you have adequate benefits for the ASC option?

With over 6,200 ASCs open nationwide, chances are there is a specialized center equipped to meet your specific procedural needs. Going in eyes wide open on costs and insurance should help you choose the optimal setting for care.

In this issue:

Getting Your Money’s Worth: When Return of Premium Life Insurance Makes Sense

Who Will Care for You? Long-Term Planning for Your Golden Years

Getting the Most from Medicare: When Medigap Makes Sense

Ambulatory Surgery 101: What You Need To Know About Costs and Coverage

Are You Making These 4 Life Insurance Mistakes and Putting Your Family At Risk?

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