REIMBURSEMENT ROUNDUP
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were not entitled to recover reimbursements for the facility fees
because the physician associations were not ASCs licensed by the
state of Texas, and therefore were not permitted to provide the servic-
es for which they sought reimbursements.
According to United, the licensed ASCs — such as Palladium, not
the physician associations — provided the facility services. Since the
associations were seeking payment for the ASC facility services that
they could not legally provide, they were not entitled to payment.
United even went as far as to argue that even if the physician associ-
ations were ASCs or had provided the ASC facility services, they still
would not be entitled to a facility fee because the patients' healthcare
plans specifically required that ASC providers be licensed and/or
excluded reimbursement for services provided by an unlicensed
provider.
United also argued that these facility fees were unlawful. According
to United, the physician associations' arrangements with the facilities
where the procedures were performed constituted illegal kickbacks
that violated state and federal laws. According to United, under the
agreements between Palladium and the physician-owners, the sur-
geons — through their physician associations — were allowed to
keep half of the ASC facility fees they collected. United argues that
this created an illegal incentive that encouraged the surgeons to per-
form the procedures at Palladium.
2 takeaways
Now more than ever, it's crucial to pay attention to regulatory require-
ments and to review compliance as private payors are assessing
provider compliance with an eye toward denial of claims. Here are 2
lessons we can learn from this case:
