Commercial Reimbursement for ASCs & Endoscopy
Dominated by Chain Operators
Commercial reimbursement rates for over 2,500 surgery centers and endoscopy centers in Cigna’s national Pathwell OAP network validate that national and regional operators negotiate much higher rates than most independent centers.
This new data from DataRise™ Commercial Reimbursement Data gives us a rare glimpse into what was once confidential information. Virtually all commercial reimbursement data became public under the federal Transparency in Coverage regulations on January 1, 2024.
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Orthopaedic Surgery (Service Code 29880)
Within Cigna’s national Pathwell OAP network, HCA Healthcare and Surgical Care Affiliates (SCA) have the highest reimbursement rates for orthopaedic surgery. HCA’s contract rates were verified to range from 417% to 507% of national Medicare rates for 25 surgery centers in Florida, as well as up to 543% for 12 centers in Texas.
We verified SCA contract rates of 463% of Medicare for three centers in Connecticut and 540% for a large collection of centers affiliated with Texas Health Resources and SCA in Texas.
Regional operators also negotiated quite impressive contract rates. Verified rates for 35 centers operated by Sutter Health in California reported network rates of 390% of Medicare. Verified rates for five centers operated by Hartford Healthcare in Connecticut reported rates at 463% of Medicare.
National operators did not perform consistently in all markets. For example, verified reimbursement rates were much lower for HCA’s centers in Houston, Texas (172%), and Salt Lake City, Utah (165%).
Across seven markets reviewed, USPI’s reimbursement rates in the Cigna Pathwell OAP network are better than many independent centers, but still lower than other national and regional operators at 185% to 206% of Medicare.
Chain Operator Ortho Rates
Cigna Pathwell OAP ASC Network Rates - 29880 Knee Arthroscopy w/Meniscus Repair
Endoscopy (Colonoscopy Service Code 45378)
Reimbursement for colonoscopy services is very different from orthopaedic surgery reimbursement. USPI and several regional operators negotiated quite high rates for colonoscopy compared to their peers.
Verified rates for USPI ranged from 420% of Medicare for 28 centers in three markets up to 467% of Medicare for 74 centers in four different markets.
HCA negotiated rates at 539% of Medicare for nine centers in Kansas and Missouri, but its results fluctuated in other markets. HCA’s colonoscopy rates varied from 308% up to 556% of Medicare for a sample of 62 centers across five markets in Florida, Texas, and Utah.
Regional operators negotiated relatively better rates compared to national operators for colonoscopy services than they did for orthopaedic services. Verified rates were identified for Hartford Healthcare (599% for 5 centers), Memorial Hermann (470% for 15 centers), Sutter Health (552% for 37 centers), and Texas Health Resources/SCA (652% for 37 centers).
Chain Operator GI Rates
Cigna Pathwell OAP ASC Network Rates - 45378 Colonoscopy
Conclusion
National and regional operators of surgery centers and endoscopy centers dominate the upper half of market reimbursement rates. National median and national average reimbursement rates are not reliable statistics for independent centers nor centers operated by national chains. National medians and averages are highly skewed by the differences in rates between independent centers and those operated by regional and national chains.
Distribution of Rates: National Pathwell OAP Network
Summary Statistics: National Pathwell OAP Network
| wdt_ID | wdt_created_by | wdt_created_at | wdt_last_edited_by | wdt_last_edited_at | Statistic | 29880 (Knee Arthroscopy w/Meniscus Repair) | 45378 (Colonoscopy) |
|---|---|---|---|---|---|---|---|
| 1 | wynobe | 11/19/2024 02:35 PM | wynobe | 11/19/2024 02:36 PM | Median Rate (% Medicare) | 132% | 162% |
| 2 | wynobe | 11/19/2024 02:35 PM | wynobe | 11/19/2024 02:36 PM | Average Rate (% Medicare) | 157% | 231% |
| 3 | wynobe | 11/19/2024 02:35 PM | wynobe | 11/19/2024 04:04 PM | Sample Size | 2,522 | 2,581 |
Every commercial reimbursement contract rate for every health plan, provider, market, and service is now in the public domain. Entrepreneurs, developers, financial planners, and consultants can access every commercial reimbursement rate they could ever need for specific markets. Learn more about DataRise™ Commercial Reimbursement Data.
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