Managed Care Ask the Expert Answer – Robotic Surgery

Q: Are commercial payers paying for additional charges billed by hospitals for robotic surgery? At least one payer that pays on a % of charges basis is not paying the charges for the robotic surgery, additional OR time, etc. and prohibiting a provider from billing the patient under the hold harmless provisions of the contract. It seems that the payer wants it both ways-robotics is a non-covered service but the provider cannot bill the patient, even if the patient agrees to pay. From the payer’s perspective however, the surgery is a covered service but charging more because a robotics device was used is not warranted so those charges are denied and the hospital cannot bill the patient.

What’s the experience with this?

A: A majority of procedures that we currently perform are done on an outpatient basis. Based upon the structure of our contracts, we do not have a separate fixed fee for the actual robot. However, the unique supplies required as part of the surgery are included as a component of the surgery bill. More than 95% of our contracts are based upon a percentage of charges structure and the supplies are reimbursed as part of that percentage of charges discount. The two areas where we have experienced difficulty is on OP surgery discounts that include a cap limit or any inpatient admissions where we are reimbursed on straight per diems which do not currently have special carveouts for specialized surgeries. We have not run across contract issues where payors actually consider a portion of the surgery as a non-covered service but disallow billing for those charges.

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