Ambulatory surgery centers (ASCs) are facing unprecedented scrutiny as payers lean on artificial intelligence and advanced analytics to identify billing anomalies.
But compliance doesn’t need to be overcomplicated, industry experts advise.
“We’re just seeing an increased focus on program integrity,” health care attorney Robert Saltaformaggio said on the Advancing Surgical Care Podcast.
Both federal and commercial payers are driving this surge, using AI tools to flag potential compliance issues.
“The government is using AI to really scrutinize providers,” Saltaformaggio said. “It’s robots battling robots at times. But the robots don’t always get it right. And that puts the burden on providers to push back.”
The most pressing areas of concern include anti-kickback violations, documentation lapses and exclusion checks. Failing to address these can expose surgery centers to penalties, clawbacks and investigations.
“Medical necessity and documentation guidelines are constantly evolving,” Saltaformaggio said. “You need to keep your staff, both clinical and administrative, up to date.”
A ‘collaborative’ relationship
Before things escalate to audits, ASC operators should make sure they are navigating licensing, certification and accreditation surveys, which occur on a regular cycle, with ease.
“One of the things we look for across everybody is that they are very familiar with the rules and statutes that apply to them,” Tracy Schmidt, a surveyor with Arizona Health Care Compliance, told Ambulatory Surgery Center News. “We’ve worked really hard over the past couple of years to provide a collaborative relationship.”
Schmidt, who surveys 200 to 250 facilities each year, said that surveys should not be viewed as adversarial.
According to Schmidt, surveyors evaluate ASCs differently than hospitals. While hospitals are often judged on patient readmission rates, ASCs are scrutinized on safe discharges and proper outpatient workflows.
The key to success lies in maintaining a clear checklist of required policies, quality management processes and up-to-date administrative information, she said.
“We want to work together so everybody gets the safest care,” Schmidt said. “[ASC operators] can be successful with surveys if they view it that way, as opposed to a punitive approach.”
Common pitfalls
Katie Pierson, regulatory specialist at Ambulatory Healthcare Strategies, told ASC News she has seen too many centers fall into the trap of cramming for compliance.
“My No. 1 tip for everyone is to try your best to be survey ready every day,” she said. “A lot of times, … the three-year survey period is coming up, or whatever your cadence is, and now all of a sudden, you have three years’ worth of work to do in a three month time period.”
That scramble creates stress for staff and providers and risks overlooked deficiencies, she said.
Instead, operators should distribute compliance responsibilities across the team rather than leaving everything to the administrator, Pierson said.
“Although they do have ultimate oversight, it’s really important and key to get every team member involved in some aspect of being survey ready,” she said.
Even with strong systems in place, certain pitfalls persist year after year, Pierson added.
“Infection control is always cited as No. 1 or No. 2 in a survey,” she said.
ASC operators can be like bad drivers, picking and choosing which rules to follow when in a rush, Pierson said.
“The surveyors have the complete opposite mentality,” she said. “They want everything strictly followed – non-negotiable.”
Credentialing is another area where facilities often stumble.
“You let somebody’s license lapse, or you don’t check, you know, the OIG every month, or something like that. Now you’re noncompliant,” Pierson said.
The problem can be compounded by turnover in ASC leadership. Administrators may believe they have done a phenomenal job preparing paperwork, only to be told by surveyors they are missing critical elements.
ASCs face unique challenges compared to hospitals, because they are expected to manage the same regulatory requirements with far fewer resources, Pierson said.
“It’s running every single aspect and department of a hospital with a quarter to a 10th of the amount of people,” she said. “That means administrators or nurses may be tasked with facility checks, medical gas inspections and outlet testing, … duties that in hospitals are assigned to specialized staff.”
Finding the right fit for an ASC
This lean structure also affects policy development.
Too often, ASCs rely on hospital templates without realizing the standards don’t match, Pierson said.
“Sometimes we’ll be reading folks’ policies and seeing the words, you know, admitted to the unit, or … ‘blah, blah, blah’ at that hospital. This is what we do. And you know, so then we have to say your policy literally says the word ‘hospital’ in there,” she said.
Medication safety policies, for instance, must reflect ASC realities, where nurses, not pharmacists, manage storage, ordering and narcotic tracking, she added.
Beyond compliance, operators should think carefully about patient selection, Pierson said. While hospitals can transfer patients to inpatient rehab, ASCs must discharge all patients to their homes.
“From a patient-selection standpoint, … the medical piece is only a part of the pie,” she said. “We really have to look at it from, do you have somebody at home? Do you have … all the things that you’re going to need to be able to recover in your home safely?”
That focus on discharge planning is essential as ASCs expand into higher-acuity procedures like total joint replacements, she added.
Ultimately, Pierson said, surveys should not be a mystery.
“They are an open book test at the end of the day,” she said. “You have the CMS regs. … You have the accrediting regulations and standards. … You have your state regulations. So get to know them. Be familiar with them. It is what you are going to be held accountable to during any kind of survey.”
And at the core of survey preparedness is an environment where employees feel safe raising issues before they escalate, Saltaformaggio said.
“You want a culture where staff feel comfortable raising compliance concerns,” he said.
