Outpatient Surgery Magazine - Subscribers

2018 Salary Survey - Outpatient Surgery Magazine - January 2019

Outpatient Surgery Magazine, providing current information on Surgical Services, Surgical Facility Administration, Outpatient Surgery News and Trends, OR Excellence and more.

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Page 26 of 124

surgical business and lead to bankruptcy, but also lead to criminal charges. Under suspicion Fraud and overbilling are serious concerns for CMS and carriers (see "Hospital Improperly Unbundled Orthopedic Surgery Claims"). If they've targeted you for an audit, the payer will calculate the "error rate" based on medical necessity of the sample size you provided and will extrapolate that rate over the months or years of payments. Don't believe that past payments are endorsements of proper billing or docu- mentation. Nor should you believe that a change in billing practice will be sufficient going forward. Once a center is audited, the payer is going to want its money back for work that your center had performed months or years ago. You could even find yourself working just to repay the debt (that you dispute) while you're waiting for your day in court. Both insurers and CMS will use computers for any indication that your center is a billing outlier. They know what a facility like yours should bill, which codes are typically used and have reams of data from across the industry to guide their investigation. If they see some- thing about your billing practices that differs from the statistical norm, it is likely that your center could face an audit. When they ask for those sample records, contact your attorney immedi- ately. You should also contact your carrier, which might cover legal fees in defending these cases. The earlier you take action, the better. In my experience, single providers are often hit with an overpayment demand well into the 6 figures. In the case of a surgical center, it ranges into the millions. These cases are typically very difficult to defend and usually will take years to resolve. They can be a black cloud that hangs over your facility. J A N U A R Y 2 0 1 9 • O U T PA T I E N T S U R G E R Y. N E T • 2 7

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