This is specifically for procedures that do not have a Site-of-Service Differential! There are at least 97 hand-and-wrist procedures so this applies to many procedures, not just IOECTR.
This is a Step-by-Step Guide on strategies and approaches to negotiating a “carve-out” reimbursement for In-Office Endoscopic Carpal Tunnel Release with an insurance company. The spreadsheet includes all the information plus additional TABS for backup information. It was updated JAN 2022. I would also recommend the Contract Negotiation Decision Tree. It is more recent and includes both a one-page graphic and a spreadsheet. Below is an example of the step-by-step spreadsheet:
Decide you want to establish an OBSS. (Office-Based Surgical Suite).
Set up an OBSS. Follow all state and medical guidelines and requirements.
This is a contract negotiation document. If you are new, we offer additional information on OBSS setup in Section Two of the Reimbursement Guidebook.
Some call these contract negotiations “carve-outs”. You are asking for special treatment (additional reimbursement for overhead) for specific services or procedures.
If possible, negotiate contracts before you set up your OBSS. You will have to negotiate with each carrier individually.
The main issue is that ECTR (CPT code 29848) does not reimburse at a higher rate when performed in the office (POS=11). As an example, open carpal tunnel release does pay higher when performed in the office but the reimbursement is only about $6.14 more.
Please read this document carefully. If you are new to negotiating reimbursement or many of the terms and concepts please refer to Glossary on the spreadsheet and the separate Reimbursement Guidebook.
Be sure to download and review the One-Page Checklist; the Reimbursement Guidebook includes more in-depth information and explanations.
If you are a large clinic with an experienced contract negotiator use the information that helps and please provide us with feedback on the negotiations so we can continually improve this document.
Every negotiation is different. Every surgeon or clinic has a different mix of issues and benefits. One strategy may work with one insurance carrier and not with another. The key is to be flexible, sell the benefits of an OBSS to the carrier and patients, and watch carefully their response.
There are some calculations where more detail can be provided but one could argue that getting into lots of minutiae can be counter-productive. Focus on the big picture; more information may be necessary depending on their response.
Assess up-front, before you invest in your OBS if you have a lot of leverage with the carriers to extract a favorable price point. A large, dominant clinic in a mid-size city, with surgeons who perform procedures no one else can perform and already has several “carve-outs” successfully negotiated, might be able to “name their price.” A single surgeon, with a modest number of surgeries but seeks to expand his/her number of ECTR surgeries in a large city will have a completely different negotiation strategy.
Use the Contact Form if you have any questions.