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D E C E M B E R 2 0 1 4 | O U T P AT I E N T S U R G E R Y M A G A Z I N E O N L I N E
REIMBURSEMENT ROUNDUP
Private payors are policing their providers.
In addition to govern-
ment-instituted investigations, private payors are starting to
examine their providers' arrangements for compliance. Be sure your
user agreements are compliant with state and federal anti-kickback
laws, whether your facility is accepting federal healthcare or solely
private-payor dollars. Even if you only work with private payors, you
may still incur liability from any otherwise non-compliant arrange-
ments.
Private payors are aware of state licensing requirements.
They may
deny coverage if a provider fails to meet those requirements. In
DAC Surgical Partners, United denied claims because the physician
associations were not licensed by the State of Texas and therefore
were not permitted to provide ASC facility services. Accordingly,
United asserted that the claims submitted by the physicians failed to
meet plan requirements or fell under certain exclusions because of
the failure to meet state licensing requirements.
Understand applicable state licensing and other requirements in
order to avoid having payors deny claims on the basis of non-com-
pliance. In addition, familiarize yourself with coverage requirements
under health benefit plans and insurance policies. Otherwise, a pri-
vate payor may deny claims under a contractual basis because of
failure to meet plan requirements. Check with your attorney to be
sure your facility complies with state licensing and other require-
ments to avoid having claims denied for non-compliance. OSM
Ms. Studebaker (
estudeb ak er@g sb law.com
) practices exclusively in the area
of health law, advising ambulatory surgery centers on regulatory compliance
and transactional matters. She is Of Counsel with Garvey Schubert Barer at its
Seattle office and serves as counsel for the Washington Ambulatory Surgery
Center Association.
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