Retina Subspecialty Day 2016

    I. Introduction

    A. Three current strategies for multiplying revenue from an ASC

    1. Out of network billing

    2. Contractual joint venture (management agreement)

    3. Anesthesia services

    B. Regulatory Landscape

    1. The Department of Health and Human Services Office of Inspector General (OIG) has issued special fraud alerts dealing with physician compensation arrangements with increasing frequency.

    2. Deputy chief states that OIG is hiring additional lawyers to investigate physicians.

    3. Example of fraud charges in 2015, which included doctors 4. There is also increasing interest in physician compensation arrangements at the state level

    II. Out of Network (OON) Billing

    A. What is it?

    B. Spectrum of OON

    C. Is it uncommon?

    D. Medicare patient facility fee vs. OON facility fee

    E. Claims process and collection

    F. Financial impact

    G. Sounds great, but payers have taken an active stance against OON (eg, litigation by Cigna and Aetna).

    H. Landmines: 1. If any Medicare patient slips through 2. If financial disclosure does not get signed

    III. Contractual Joint Ventures

    A. Definition of contractual joint venture from OIG special advisory bulletin 2003: “A contractual joint venture is any common enterprise with mutual economic benefit.” 

    B. Many are designed to avoid or limit federal issues, so state issues are the most pertinent.

    C. OIG advisory opinion 602: Arrangements that carve out Medicare patients immediately draw the attention of the OIG and may still implicate the anti-kickback statute.

    D. Management agreement: agreement to split revenue from OON billing

    1. Federal fraud and abuse issues: Compliance is contingent on no government patients slipping through the cracks: that requires no human errors! How reasonable of an assumption is that?

    a. Secondary insurers may not be available up front, but may come through after the fact.

    b. Data entry errors

    2. State fraud and abuse issues (eg, AZ law prohibits fee splitting: ASC cannot split fees with licensed health care providers)

    3. State fraud and abuse issue (eg, AZ physician licensing: broader language prohibits MDs from dividing a professional fee for referrals.)

    4. State fraud and abuse issue (eg, AZ law requires physicians to inform patients when they have a direct financial interest.)

    IV. Anesthesia Services

    A. Profit to ASC with anesthesia package

    B. Profit to ASC with anesthesia employees 

    C. Profit to ASC with anesthesia independent contractors