ASCs as Hospitals Without Walls

Join Bill Prentice, ASCA chief executive officer, and Mandy Hawkins, director of the Surgery Center of Charleston and ASCA Board member, as they discuss the Hospitals Without Walls program and the two ways ASCs can participate in this important new Centers for Medicare & Medicaid Services initiative.  

In this 15-minute episode, Mandy discusses the application process, billing procedures, preliminary talks with commercial insurers and more—a must-listen recording for any ASC considering participating in this program.

Transcript

Bill Prentice:   0:06
Hi, I'm Bill Prentice, chief executive officer of ASCA. Today is Thursday, April 16, 2020, and in today's podcast, I'll be joined by Mandy Hawkins, director of the Surgery Center of Charleston in Charleston, South Carolina. Mandy is also a member of the ASCA Board of Directors. The purpose of today's podcast is to discuss the Hospitals Without Walls initiative announced by CMS last month and the two primary ways in which ASCs could participate in this new Medicare program. Fortunately, it's beginning to look like neither of the Hospitals Without Walls initiatives are gonna be needed on a large scale in the immediate future, given the apparent slowing of the infection and the fact that we're not seeing surge capacity issues with most hospitals around the country. That said, we believe it's important to memorialize how this contingency was developed and could be used, not just for this emergency but for better preparedness in the future as well. Before moving on to my discussion with Mandy about how and what ASCs can do to become a hospital without walls, though, I think it's worth taking a moment to explain how this all came about. In early March when it was finally clear that the COVID-19 virus was becoming a pandemic and could place a huge strain on our healthcare system, ASCA reached out to CMS, the Centers for Medicare & Medicaid Services, and the White House to discuss the best use of surgery centers in a public health emergency, and we've decided that the best thing was to let us do what we do best, which is outpatient surgery. And to a certain extent, this was in response to some things we were hearing about suggestions that ASCs should be repurposed as ICUs, as intensive care units, or have them turn over all their medical supplies and equipment, like anesthesia machines, to hospitals. Now while such actions might have been deemed necessary in some extreme situations if the pandemic overwhelmed local hospital capacity, we strongly felt that both of those ideas would have significant adverse consequences for both patients and ASCs alike. So, we felt instead that we should offer that the most effective and efficient use of ASCs in an emergency situation would be to allow us to ease the burden on hospitals experiencing a surge of COVID-19 patients by enabling us to assume responsibility for some of the care that otherwise would have been performed in that hospital, but can more safely be provided in an ASC off the campus. And again, while it now seems that there will not be a need for this type of capacity building in most areas based upon current projections and we all hope those remain true, we still need to be prepared. So with that introduction, I'd like to now introduce and welcome Mandy Hawkins, ASCA board member and director of the Surgery Center of Charleston. Mandy, welcome to the podcast.

Mandy Hawkins:   3:21
Thank you for having me.

Bill Prentice:   3:23
Happy to have you. So, Mandy, your surgery center has applied for and received a temporary hospital status from your regional CMS administrator and your state health department. Can you tell us about the decision process that led you to apply for that designation?

Mandy Hawkins:   3:39
Absolutely. When this all started, we started to look at this as an opportunity to show our local hospitals, as well as this community, what we are and what we do. So we had the chance to fill a need and we just needed to educate them about that. So the initial talks started to say: Let's take their anesthesia machines. Let's take their equipment. Let's use them as an ICU. But when we sat down as a group and talked, that's not what we do best. We do surgery best, so that's what we should do here. So right away, we're already working with our healthcare coalition, we're working with our hospital association, we're working with local hospitals in the community, and I started to educate them and say, we shouldn't take your critical patients. You could use your operating rooms as your ICU overflow and your staff that's good at taking care of those patients and let us take those surgery patients. We can use your surgery staff, our surgery staff to care for them at our facility and keep those critical patients there. You know, that way, all of us are in a win in the end, and they can see what we can do. So, that's kind of how it started, and they really didn't know what surgery centers could do. Some of my earliest questions were: You have a crash cart? You have a full recovery room? You use anesthesia machines? So it really was a great education. Our hospital association and I are on a first-name basis, local hospitals I worked with my medical team, my CEO has been on the phone with them. You know, we really have built a new rapport that we never had before this all started.

Bill Prentice:   5:30
Mandy, that's really interesting and great to hear. And really good how proactive you were in reaching out in your community and developing those relationships, and certainly that's something that I hope will continue both past the pandemic and hopefully allow others in the healthcare system to understand the value of ASCs. Did you look at—I know you decided to become a hospital without walls—did you consider just contracting with a local hospital and taking some of their cases under some kind of leasing arrangement?

Mandy Hawkins:   6:02
You know, they did reach out to us and asked us if we wanted to do that, and I think we just continued to push the fact that we're good at operating and that's what we're gonna try to offer. We did actually have to close our facility, which we did, of course, stopping all elective procedures. But then we sat down and had the talks. What can we do that's an emergency? So we did. We created our own guidelines in each position how to determine what we could do, which isn't a lot of cases, but there's a significant amount out there. And then working with the hospitals letting them know that we're here for them in the event that there is a big surge.

Bill Prentice:   6:40
Understood. Can you walk us through the application process that you had to go through to become a hospital without walls?

Mandy Hawkins:   6:48
It was pretty easy, actually, believe it or not. The CMS released it on a Monday night, I think, so Tuesday morning, we picked up the phone and reached out to our MAC, which is our Medicare Administrative Contractor. Every jurisdiction has one. There's a website you can pop on if you don't know who it is or where you're at. Ours was Palmetto GBA. Of course, we reached out and they had no idea what we were talking about. However, they know now. So then he said they would follow up with us within a couple of days. And we said we had some questions based on what the attestation had included in it. So about three days later they replied, and said that we just needed to follow our state guidelines and make sure we were in the pandemic policies within our state as well. There were some things in the attestation that I immediately had questions about. One of them was we are not a 23-hour facility, so it says we need to be available for 24-hour nursing services. Can we do it? Absolutely. Why not? Would we have all the things that we needed right up front? Probably not, but the hospital could work with us in that event, and I want to make sure that that would be waived. And another one was respiratory therapy restoration services, you have to have that on site. We don't have it, we are that, you know the nurses do it, anesthesia does it. So I want to make sure that was also on there. Everything else in there, we already do as an ASC with our infection control program, with the antibiotics stewardship, with your pharmacy services, having qualified staff. So we were ready with those questions; they differed us to our state to answer those. So that's when we reached out to the state and that was about five to six days later. They, of course, had no idea what we were talking about. So it took about a day after that, they were in complete agreement with us and supported us, then submitted that attestation to Palmetto GBA, our MAC. The next day they provided us with the approval, gave us a new provider tie-in number, it's a provider tie-in notice, so that we could bill through that. And then two days later, the state road us an email back and said they are in agreement and we can function as a hospital.

Bill Prentice:   9:12
Very interesting. How has the billing worked so far?

Mandy Hawkins:   9:15
So this was this past Friday we got the final approval, and the one thing I didn't mention was every administrator's dream: no on-site survey—best part of the whole thing. So for the billing, we called right back. I have an amazing, I'm very lucky, I have in house billing. I know a lot of centers don't do that anymore. Some of the smaller ones may. We're independent, so we have an amazing billing team. She reached right back out to Palmetto GBA and said, can someone walk us through the process of how to bill? They have been extremely helpful, surprisingly enough. So the one thing to remember when you're doing this: you cannot bill as an ASC and a hospital at the same time. So we are officially a hospital right now until there is no longer a public health pandemic. So with our provider tie-in notice, it's a six-digit number, which is a little less than what we're all used to, they gave us a new bill type so we can bill as a hospital outpatient or as an inpatient in the event that we had to keep somebody for 24 hours. All the professional billing remains the same and you get to continue to bill using CPT codes, so we don't, for us we bill with CPT instead of the DRGs, which is great, so we can continue to do that. And you complete a different form. Instead of our normal HIPAA CMS-1500, I think the new form's called UB-04, it's an HOPD form which most your billing departments are probably aware of. And the fee schedule's right there on their website so we're able to go look at the different pricing. It's all gonna be filed electronically so you don't have to change anything in your practice management system. So hopefully, they also backdated our provider tie-in notice to the day we called them, which was March 31st. So we may be able to go back and bill those first two weeks of surgery as well under these numbers.

Bill Prentice:   11:14
Great, and this has been a lot of really useful information. And as I've said, regardless of whether many ASCs are gonna need to do that going forward and, God willing, very few will have to if we continue to do everything we're supposed to do as a country in terms of social distancing and flattening the curve. But in case other facilities do need to follow this process, I think the information you've provided is gonna be of great value to them. Mandy, over the years, we've heard a fair amount of complaining about the emergency preparedness requirements for surgery centers and other Medicare providers. How has that helped to inform your work in terms of setting up as a hospital without walls?

Mandy Hawkins:   12:00
Being a part of your healthcare coalition has been invaluable throughout this pandemic. I know it was a big obstacle for us to get through to wanna go to these meetings and learn about what they do. They are your best resource. I have been able to get the contacts that I needed at the state level so that they could answer my questions and I could complete that attestation. They've been able to get me supplies. I've applied through our local county emergency management and gotten N95 masks and gowns and face shields. I've gotten some from the strategic national stockpile in order to be able to be prepared to help the hospitals get through these procedures. So such a valuable resource—if you're not a member of your local coalition, please reach out and join.

Bill Prentice:   12:47
Thank you, Mandy. Before we end, is there anything that I didn't ask that you would want to convey to our listeners about this program or your experience?

Mandy Hawkins:   12:58
You know, whether or not we don't have the option to take patients from a hospital, and we continue to perform some urgent and emergent surgeries maybe that we haven't done before, this is a great opportunity for us as a community to show everyone what we can do. We can do procedures that they're doing in the hospital in the outpatient setting. We did a procedure yesterday that we have never done at our surgery center before and it went wonderfully. We spoke with the patient this morning and he was so happy that he didn't have to go to a hospital to have it done. So this could be a huge opportunity for surgery centers to track some valuable data to bring forward in the future.

Bill Prentice:   13:39
That's an excellent point and thank you for mentioning that. And certainly that's something that we'll try and collect going forward because I do believe you're right. I think it will be very powerful with policymakers in terms of getting them to understand the value proposition of the surgery center model and the safety and quality that you provide to your patients. Well, this has been tremendous, Mandy, I want to thank you for being on this podcast. Sharing your knowledge and your experience, as well as your ongoing contributions as a member of the ASCA Board. So thank you for that. If anyone listening has thoughts or suggestions for future topics that we might cover on one of these podcasts, please don't hesitate to send us your thoughts or recommendations. We want to hear from you and make sure that you find these podcasts informative and valuable. I want to thank you for listening and please stay safe and stay healthy.