In OASC’s August 2023 issue, we featured an article about surgeon Mark Gallardo, MD’s efforts to create his own ambulatory surgery center in El Paso, Texas. “A Surgeon’s Experience Building an ASC, Good and Bad” (https://ophthalmologymanagement.com/supplements/2023/the-ophthalmic-asc-august/a-surgeons-experience-building-an-asc/) showed the practical details that go into constructing a facility in today’s regulatory environment. At the conclusion, he was awaiting state certification to open his ASC. Two years later, we thought we would check in on his progress and ask him what he’s learned.

Certification/Accreditation Takes Longer Than You Think

State certification required multiple attempts over a 4-month time period—involving 3 different state inspectors, Dr. Gallardo said. Once the issues identified by the state had been rectified and he received certification, he was able to open the ASC 1 or 2 days a month in January 2024— for cash-only patients, as the facility needed CMS certification to get credentialed on various commercial and Medicare plans.

“Once you do 10 patients, then you reach out to whatever Medicare accrediting agency you’re going to use.” (Dr. Gallardo went with Accreditation Association for Ambulatory Health Care.) The agency schedules an inspection—Dr. Gallardo said the wait time is about 2 months—to determine if the facility meets all the criteria to qualify for CMS certification.

“Of course they have tough inspectors,” Dr. Gallardo said. “They always have findings as well. We had to make some minor adjustments in the facility but did not require a second inspection. We were asked to send pictures of our changes, after which we were provided our AAAHC certification.”

In addition to facility inspection, the accrediting agency monitored patient care, following a patient from check-in all the way to check-out in order to monitor issues such as documentation and proper sterile technique, Dr. Gallardo reported. Once the facility passes that process, it can immediately provide treatment to traditional Medicare patients; however, it was an additional 2 months before his ASC received a Medicare number. 

“Once you get your Medicare number, you can submit the claims to your regional Medicare administrative carrier (MAC) for these patients and start to apply to all the other insurance plans, including the Medicare Advantage plans,” Dr. Gallardo said.  

The wait times varied widely from one plan to another. “It took us about 8 months to get onto United Healthcare. We got on to Aetna within 45 days; we got on Blue Cross Blue Shield in about 2 months,” he said.

Because panel enrollment is such a long process and errors can be costly, Dr. Gallardo maintained it is crucial to have a team that is knowledgeable and ready to submit the requisite applications. Due to some crossed wires among staff, insurance applications were not submitted immediately after the Medicare number was received and not identified for 4 months. He recommended being proactive in checking in with the people assisting you in insurance panel enrollment, having applications for each plan ready to send out the day the Medicare number is received.

“The whole process for me was a nightmare,” he said. “We just got on all our plans. We’ve been using the facilities since January of 2024 and we just got on one plan 2 months ago, so, it’s a very long process.”

It is a process that finally began to pay off, however. Once he gained access to insurance plans, he went from using the ASC once or twice a month to at least 1 day per week. Now, he said, he’s up to 3 days per week.

“You just have to understand that it's not as quick as you think it’s going to be. There’s a lot of moving parts.”

Consultants Are “Live Savers”

Amidst the confusion and applications and long wait times, “consultants were the life savers for me,” said Dr. Gallardo, who utilized them both during the construction and the accreditation phase. In the application process for insurance plan enrollment alone, they proved themselves invaluable. 

“You don’t want to do that on your own, because the insurance companies want to pay you a fraction of what Medicare pays, sometimes 75% of the Medicare allowable.” 

His solution was to find a consultant who was a contract negotiator. 

“She was able to get us rates that were either commensurate with Medicare or higher,” he said. “She had all the contacts that were necessary, and she was able to follow up on our applications to see where we were in the process and help expedite it.”

Dr. Gallardo also credits consultants with helping his administrator make sure the ASC was stocked with all the necessities. “They gave her a list of everything that needed to be ordered. That was incredibly helpful as well.”

 

As for Billing and Coding...

Getting up to speed on coding and billing for the facility “actually took a little bit,” Dr. Gallardo said. “That was another learning point for me—it’s not a matter of just getting on Medicare and then using your EMR system to start billing. I didn’t understand that there was a clearinghouse we had to get signed up with through our electronic medical record system.” 

“It is essential to know which clearing house is affiliated with your EMR system.”

Setting up the ASC’s specific EMR system to do the billing was also time consuming. And once insurance contracts were received, they had to be uploaded to that clearinghouse to know which insurance plans it can bill. That took months to develop as well. 

“We started to do some in house, but we became a little overwhelmed,” Dr. Gallardo said. 

So, he turned to the same consulting firm he had used for the construction and certification since it also handled billing—as well as obtaining prior authorizations for procedures, and handling and resubmitting denied claims. 

“Again, it’s a big process, so I figured at this point it was better for us to just outsource it.”

Staffing Challenges

Dr. Gallardo had hired an administrator even before opening the facility. Next up was staffing the ASC with nurses and technicians to prepare for opening. But with a still-sporadic schedule for surgery days, hiring qualified support staff was financially onerous.

“I had to make the decision to hire full-time staff so that we would always have a full team available for our OR days and limit the chances of being understaffed,” he said. “I wanted to ensure a quality experience for patients and a very safe and efficient environment, so I decided to add a second full-time registered nurse, a full-time scrub tech and an additional ¾-time scrub tech. This foundation has allowed me to develop a very cohesive team, which in turn provided us with a great working environment that attracted very good PRN nurses and techs.”

 

“You’ll Need to Infuse a Little Capital” 

Because he needed to hire some full-time employees long before he had a full schedule at the ASC, Dr. Gallardo had to make sure that he was able to cover their salaries. And there were other expenses. He said he could not pay himself rent on the facility for the first full year and is only now starting to pay back rent for that period.

“Our new facility housed our clinic and the ASC. Thankfully, the lease that was being paid by the clinic side was enough to cover the mortgage, so we were able to allow the ASC to defer payments until it became financially stable. It took a year to get to a point where the ASC was in a position to safely pay all it’s bills and start paying back rent,” Dr. Gallardo explained. 

As soon as the real estate company is repaid, he will begin repaying his family for the money he infused into the ASC for working capital.

“So, just understand that anyone who wants to do this will have to infuse a little capital to maintain the ASC,” he said. “You will be in debt, but it's a kind of a quick process once you’re up and running; all of a sudden now I look at our bank balance and we’re actually doing quite well.”

Fortitude Required

Now, with accreditation in hand, fully staffed, enrolled in insurance panels, and with coding clearinghouses nailed down, Dr. Gallardo’s ophthalmology-only facility is up and running, open 3 days a week.

“It’s really nice because we were able to choose who we want to work with us as opposed to going to another facility where someone else has full oversight,” he said. “The people I have working here have really taken ownership of the facility and are very proud of providing very safe, compassionate and efficient care. This is in stark comparison to facilities I’ve worked at in the past where it seems as though employees view their position as just a job and not an important component of a larger team. My staff is very involved in decision making, and they have a lot of pride in our success.” OASC