Outpatient Surgery Magazine

Marking Madness - April 2013 - Subscribe

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 39 of 157

OSM560-April_DIGITAL_Layout 1 4/5/13 2:28 PM Page 40 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 4 0 | O U T PAT I E N T S U R G E R Y M A G A Z I N E | A P R I L 2 013

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