The ASC’s of Hospitals Without Walls

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In March of 2020, just after the government acknowledged the onset of the Covid-19 pandemic in the U.S., the Center for Medicare & Medicaid Services (“CMS”) issued an Interim Final Rule (“IFC”). The IFC provided thirty (30) immediate rule changes and temporary waivers using its special Public Health Emergency waiver authority under Section 1135(b) of the Social Security Act. One of these waivers authorizes hospitals to provide care in “temporary expansion sites.” This “Hospital Without Walls” policy allows hospitals to provide and bill hospital services in those alternate healthcare facilities. That’s where ambulatory services centers (“ASCs”) come in.

As many hospitals reserved their bed space for Covid-19 patients (while properly isolating non-Covid-19 patients), many elective surgeries were rescheduled or completely canceled. These elective procedures included major surgeries such as total hip, knee, and shoulder replacements. Although not life threatening, these postponed elective surgeries created needless suffering for countless patients whose surgery and recovery was placed on indefinite hold. Some hospitals planned to resume elective surgeries by dedicating preoperative, operating room, and recovery room staff and space to elective patients. However, that structure still risked exposing patients to the hospital environment and its current risks. Patients who require an overnight stay, or longer, would need to be isolated from other patients to avoid infection, but that was impractical, since COVID-19 patients would still be in the same facility as the elective patients. Enter the ASC. Due to their facility standards, professional personnel, equipment and generally close proximity to hospitals, ASCs are positioned as a clear alternate location for hospital services which can provide a controlled environment, adequately far away from those already infected with the virus.

In fact, CMS specifically identified ASCs “as a critical resource to assist in expanding capacity for inpatient and outpatient services for patients requiring a higher level of care.”  As a result, “[c]onsistent with the Hospitals Without Walls strategy,” CMS expects ASCs to “coordinate” with local and state healthcare systems to “help meet surge needs in their community;” and, as part of the CMS blanket waivers, Medicare-enrolled ASCs can “enroll as hospitals and provide inpatient and outpatient services to address the urgent need to increase hospital capacity to take care of patients.”

In the Hospitals Without Walls program, hospitals and ASCs work together so the needed care is provided at the ASC, but billed by the hospital, as if the service was provided in the hospital, by hospital staff. As a result, all types of surgeries can be performed at the ASC. The waiver does require the availability of nursing staff twenty-four (24) hours a day, plus the availability of proper equipment and access to consulting physicians, if needed. These requirements are usually not met by an ASC. However, because the ASC operates under the hospital’s license, nurses from the hospital can be reassigned to the ASC to supplement ASC staff, and the medical staff at the hospital can provide services to the patients at the ASC using their hospital privileges. These visits can also be provided remotely by telehealth.

The billing for the surgery would be based on the designated status, inpatient or outpatient, and paid at the Inpatient Prospective Payment System (IPPS) or Outpatient Prospective Payment System (OPPS) rate to the hospital, including any other add-ons such as exams. The hospital would then pay the ASC at an agreed-upon rate. As the hospital rate for almost all surgeries is significantly higher than the ASC rate, both parties could be made whole from such an arrangement – and, of course, the physical location does not alter the physician’s professional fee. Since the ASC would operate under the hospital’s license, the patient’s medical record and all billing information must be available at the hospital.

As a Caveat, an ASC which enrolls with CMS as a Medicare hospital will temporarily lose its designation as a Medicare-certified ASC. However, this should not have an adverse impact on whether the ASC can continue charging for non-Medicare ASC services which are paid by third-party insurance companies or “cash pay” patients, as the facility remains Medicare-certified, which is the applicable condition precedent for most accreditations/private payor contracts.

ASCs that wish to enroll to receive temporary billing privileges as a hospital should call the COVID-19 Provider Enrollment Hotline to reach the contractor that serves their jurisdiction, and then complete and sign an attestation form specific to the COVID-19 Public Health Emergency. For more information on enrollment and to find your jurisdiction’s hotline number, click here.

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