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Ambulatory Surgical Services Provided Under California Workers’ Compensation

Ambulatory Surgical Services Provided Under California Workers’ Compensation: An Assessment of the Feasibility and Advisability of Expanding Coverage

Barbara O. Wynn
John P. Caloyeras
Nelson F. Soohoo
Copyright Date: 2014
Published by: RAND Corporation
Pages: 102
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  • Book Info
    Ambulatory Surgical Services Provided Under California Workers’ Compensation
    Book Description:

    Report examines whether common workers’ compensation inpatient procedures with short lengths of stay should be added to California’s Official Medical Fee Schedule for ambulatory surgical centers. Authors analyze ASC health and safety requirements, assess how Medicare criteria for whether procedures can be safely performed on an outpatient basis apply to workers’ compensation patients, and consider alternatives for setting fee schedule allowances.

    eISBN: 978-0-8330-8714-0
    Subjects: Health Sciences, Law

Table of Contents

  1. Front Matter
    (pp. i-ii)
  2. Preface
    (pp. iii-iv)
  3. Table of Contents
    (pp. v-vi)
  4. Figures
    (pp. vii-viii)
  5. Tables
    (pp. ix-x)
  6. Summary
    (pp. xi-xviii)
  7. Acknowledgments
    (pp. xix-xx)
  8. Abbreviations
    (pp. xxi-xxii)
  9. Chapter One. Introduction
    (pp. 1-6)

    California’s workers’ compensation (WC) system provides medical care and wage-replacement benefits to workers suffering on-the-job injuries and illnesses. An injured worker is entitled to receive all medical care reasonably required to cure or relieve the effects of his or her injury. The term “payer” refers to the entity that is paying for medical care provided to an injured worker. It is usually a commercial insurer that provides WC coverage to an employer or a self-insured employer.

    Ambulatory surgical centers (ASCs) are freestanding facilities where surgeries are performed on patients who are discharged within 24 hours, most often without a one-night...

  10. Chapter Two. Overview of ASC Regulatory Framework and Facilities
    (pp. 7-18)

    In this chapter, we first focus on the regulatory framework applicable to ASCs. The health and safety standards that ASCs must meet to provide services in California are of particular interest. The underlying issue is whether the standards are sufficient to assure that ASCs perform only procedures that can safely be performed in a non-hospital setting and that there are adequate processes in place if a medical emergency occurs. Because most ASCs are physician owned, the rules on physician self-referral are also a factor in determining whether there are sufficient safeguards against inappropriate referrals to an ASC for an “inpatient...

  11. Chapter Three. Coverage Policies for Surgeries Performed in ASCs
    (pp. 19-25)

    The OMFS sets the maximum allowable amounts for medical services furnished under WC. For ambulatory services, the OMFS is linked to the Medicare hospital outpatient prospective payment system (OPPS), which does not include fees for an “inpatient only” list of procedures that are not covered as outpatient surgery. Under California’s WC program, there is no standard policy by which providers are paid for “inpatient only” procedures conducted in either the HOPD or ASC setting. The OMFS incorporates Medicare’s “inpatient only” procedures list but also allows the procedures to be performed in ambulatory settings if the physician and payer reach an...

  12. Chapter Four. Analyses Using Administrative Data
    (pp. 26-40)

    We examined several medical administrative data sources to inform the issues related to expanding the list of procedures that might be provided in an ASC setting (see Table 4.1). Our analyses focused on a) the workers’ compensation population and b) commercially insured patients of working age.

    Our first objective was to identify high-volume WC procedures that are “inpatient only” but might be potential candidates for being performed in an ambulatory setting. We used Addendum B of the Medicare hospital outpatient prospective payment rule to determine which CPT codes are defined by Medicare as “inpatient only” (see Appendix Table A.1 for...

  13. Chapter Five. Evidence from the Literature
    (pp. 41-54)

    We conducted a search of the MEDLINE-indexed literature to determine the level of evidence available supporting the appropriateness of performing hip and knee replacements and spinal fusions in the ambulatory setting involving multi-level fusions, autografts, or instrumentation. When screening search hits for papers of interest, we also reviewed articles that touched on issues discussed and analyzed in this report. These issues include postoperative length of stay experienced by patients, possible issues with same-day discharge to the home, as well as protocols to prospectively identify patients appropriate for same-day discharge. Our search algorithms are provided in Table 5.1.

    Our search of...

  14. Chapter Six. Payment Policies for “Inpatient Only” Procedures
    (pp. 55-63)

    Under current OMFS policies, “inpatient only” procedures are covered as an exception that permits a payer to authorize payment for an “inpatient only” service in an ambulatory setting at an agreed-upon rate when medically appropriate. If any services are to be removed from the “inpatient only” list for WC patients, an OMFS allowance is needed for those services. In this regard, Section 74 of SB 863 requires DIR to consider a fee set at 85 percent of the Medicare fee schedule amount for the service when performed on an inpatient basis.

    If medically appropriate, covering “inpatient only” services in an...

  15. Chapter Seven. Discussion of Findings and Recommendations
    (pp. 64-69)

    This study examines the feasibility and appropriateness of including procedures that Medicare has determined to “inpatient only” procedures on the OMFS. The questions that we were asked to investigate included the following:

    What policy considerations should be addressed in allowing certain “inpatient only” services to be performed in ASCs?

    Which “inpatient only” services can be safely performed in the ASC setting for WC patients?

    If an OMFS allowance were set for “inpatient only” services that are performed in an ASC, what multiplier to the Medicare inpatient rate or other fee schedule methodology should be considered? What are the projected cost...

  16. Appendix
    (pp. 70-76)
  17. References
    (pp. 77-80)