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LEGAL UPDATE
ices rendered there. This facility is accredited. Full disclosure is made
to insurers concerning this arrangement, and the insurers agree in
writing to pay separate facility fees in addition to professional fees
upon the performance of office-based surgical procedures. Routine
billing and claims payment ensue, often for years.
The health insurance industry's recent emphasis on retrospective
audits as a mechanism for cost savings has led to notification letters
asking for facility fee refunds. Not only won't they reimburse officebased surgeons their facility fees in the future, they're also seeking
repayment of previously paid claims.
The insurers cite various explanations for their changing of the billing
rules. In New York, a state in which I practice, insurers are claiming that
no provider, whether participating or non-participating, can bill for facility fees if the facility at issue has not been licensed under Article 28 of the
state's Public Health Law.
No law on the books
But this is a misinterpretation of the law. There is no such statutory
requirement. In fact, there are no regulatory guidelines that either
explicitly permit or prohibit a physician from billing for a facility fee
for a procedure performed in a separate operating room located in a
physician's practice office. (Consult with your legal advisor for your
state's specific regulations.)
The state department of health has issued an opinion noting the
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