AS I SEE IT
the patient’s financial responsibility, to all of its patients and should have a written financial policy in place that the facility strictly abides by.
The Legal Landscape: Where Are We Today? The list of strategies used by payers to limit their OON expenses is growing— a trend that only adds to the marketplace uncertainty. Cases alleging illegal self- dealing, fee forgiveness, fraud, kick- backs and referrals in OON reimburse- ment cases all are winding their way through the federal court system now. The case law is numerous and includes some decisions that seem to favor the payers (Cigna vs. Advanced Surgery Center of Bethesda, 2015; whereby the payer claimed that treating an OON patient as though they were in- network was fraud, even though the pro-
vider informed the payer of its approach); and some that seem to favor the provid- ers (UnitedHealth Group vs. Spinedex Physical Therapy USA, 2015; where the court ruled that the provider did not need to bill and collect from the patient before billing and collecting from the payer). A recent case involves a payer claim- ing that its summary plan description contains an “anti-assignment” clause, thus arguing that the assignment of benefits form should be “null and void.” (Trueview Surgery Center One vs. Onesubsea LLC Comprehensive Self- Insured Benefit Plans, 2015). It may be some time before a clear set of all- encompassing best practices emerges. OON reimbursement cases also may
involve laws that differ from state to state, so it can be difficult for large ASC companies or multi-state health systems to adopt a uniform set of guidelines
that can be used at every facility. Still, training, compliance review and pro- cess standardization for these important positions offer the best protection for ASCs in the current environment. By understanding what individual
payers require, as well as the applicable local and federal laws, ASCs that choose to be OON can develop a well- designed OON program to carefully maneuver through today’s complex, ever-changing legal landscape, leaving the facility in position to be highly successful while avoiding costly litigation and remaining compliant.
Nader Samii is the chief executive officer of National Medical Billing Services in St. Louis, Missouri,
www.nationalASCbilling.com. Write him at
Nader.Samii@
nationalascbilling.com
10 ASC FOCUS OCTOBER 2015
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