Study Recommends No Changes to Workers’ Comp Surgery Fees

Outpatient surgery center reimbursements under California's workers' compensation law should not be changed because few "inpatient-only" procedures are performed at such facilities, according to a RAND study, the Sacramento Business Journal reports. However, the study noted that more efforts should be made to enhance patient protection for procedures performed at ambulatory surgical centers.

The study was conducted for the California Department of Industrial Relations.

Background

According to the Business Journal, Medicare billing codes are not available for some of the services offered at outpatient surgery centers.

As a result, such facilities often must negotiate and settle reimbursement amounts with the state Workers' Compensation Appeals Board (Robertson, Sacramento Business Journal, 4/30).

A law (SB 863) signed in 2012 called for DIR to determine the feasibility of changing the fee schedule to include inpatient procedures that are performed at outpatient centers and report its findings to the state Legislature  (RAND study, 4/25).

Details of Study

For the study, researchers examined:

• Which inpatient procedures safely could be performed in outpatient facilities; and
• The practicality of creating fees for inpatient surgeries on workers' compensation beneficiaries at outpatient facilities.

The study concluded that no procedures should be removed from the "inpatient-only" list of services -- except for certain services related to spinal fusions.

In addition, researchers said that outpatient facilities that are eligible for the state's facility fee are likely to only provide services that would not require an overnight stay (Sacramento Business Journal, 4/30).

According to the study, current fee policies that require prior authorization for performing inpatient-only procedures in an ambulatory setting "are preferable to an across-the-board pricing methodology" (RAND study, 4/25).

Reaction From Outpatient Surgery Center Supporters

Bryce Docherty, a lobbyist at the California Ambulatory Surgery Association, said that the types of procedures performed at outpatient centers are becoming more varied and complex -- such as total hip and knee replacements. However, he noted that many insurers will not cover such procedures if they are performed at outpatient centers.

He said the Rand study "summarily rejected allowing centers to do" such procedures because the researchers believe the services "can't be safely performed on injured workers in the ambulatory surgical center setting" (Sacramento Business Journal, 4/30).