July 15, 2020

ASC Industry Awareness

ASCs/OBSs Continue to Grow…Even in 2020!

According to the Ambulatory Surgery Center Association (ASCA), there are approximately 5,700 Medicare certified ASCs in the United States. See here for a state-by-state map of ASCs. In the last five years, ASCs’ total US revenue has grown by 5.7% annually. Statisticians expect ASCs to keep up this pace and perhaps exceed it slightly over the next five years. Even during a very challenging 2020, at least 70 new ASCs were established by June. Convenience, cost, safety, and technology are all factors in the growth of ASCs and Office-Based Surgeries (OBS) in states that provide for them. Even cardiovascular procedures are getting in on the act of shifting from hospitals to outpatient surgery settings.

ASCs and OBSs Are Increasingly Attractive in a Covid-19 World

ASCs and OBSs are proving to be incredibly nimble, safe, cost-efficient, and resilient – qualities that make them enviable in 2020. According to a recent survey of 1,000 surgical nurse leaders in the US, ASCs and OBSs had the lowest rate of patient cancellations due to Covid-19 among surgery provider types. Part of the reason ASCs are emerging well from the lockdown is that they have prepared by adopting strong safety and testing measures. ASCs have become critical partners

for hospitals as they reopen following cancellations and in some states are under pressure to delay elective surgeries again. Employers’ groups are realizing cost and efficiency benefits of ASCs and OBSs over hospital outpatient departments.


Healthcare Industry Trends

Some Carriers Walking Back Remote Coverage

Some temporary telehealth provisions put into play during the lockdown are expected to become permanent. Several states, like New Hampshire, are preparing to expand telehealth services and secure provider reimbursements for them after the pandemic. However, some insurers are seeking to cut telehealth coverage even as the total of Covid-19 patients grows. Recently, telehealth services have been a real boon to care and in some cases have even proven lifesaving. This is both a care and public relations conundrum for insurance carriers as they set and move deadlines on remote visits. Walking back provisions now could cause significant issues since some patients with complications are still choosing to stay home.

Factors in Orthopaedic Surgery Volume

A full 83% of orthopaedic surgeons think patients believe that hospitals are unclean or unsafe, according to a May AAOS survey. When Covid-19 cases were trending downward in early June, patients started going back to take care of the elective surgeries that were postponed – and they still are, though rates of return to surgery are much better in ASCs and OBSs. Thirty-four percent of patients postponed their surgeries by more than three months. Getting practices and surgery centers back to pre-pandemic levels of care is the goal for most surgeons. Seventy percent of orthopaedic surgeons believe they will reach 90% of their pre-pandemic surgical volumes within five months of resuming elective surgeries.


Healthcare Digital Transformation Watch

Healthcare IT Staying Power

Many types of healthcare IT have taken leaps and bounds in 2020 beyond what we could have imagined. Healthcare IT overall has demonstrated its staying power. Nevertheless, the industry is wondering whether aspects of healthcare IT will last in the same form beyond the pandemic. Telehealth technologies got a big boost over the past few months, but will regulatory changes and payments sustain them? There have been several large advancements in healthcare tech in 2020 – including predictive analytics, new “digital front door” patient experiences, AI chat bots, digital contact tracing, and advances in remote monitoring. Yet there is evidence that a majority of Americans are not comfortable with all of them.


Out-of-Network Watch

Groups Pressing Federal Government on Surprise Billing

The US Federal Government’s efforts to end surprise billing have fallen on hard times after a laudable start in 2019. However, business and health groups are pressing Congress to include a surprise-billing fix in the next Covid-19 stimulus package. Benchmarks and mediation have been sticking points for various stakeholders. Price controls are a huge concern for providers. States are adding to Congress’ pressure by tackling the issue. In Georgia, an end to surprise medical billing is within reach. Click here for a state-by-state list of balance billing protections.



Poor Training or Poor Ethics?

   by Sean Laffey, Contego Legal Analyst, from the office Jon Sistare, JD, Contego Attorney

The US Circuit Court for the Third Circuit, which covers the states of Pennsylvania, Delaware, and New Jersey, dismissed a complaint filed by a physician accused of submitting false Medicare claims, stating that his alleged “shoddy training” wasn’t to blame. In 2016, the federal government sued Dr. Labib Riachi under the False Claims Act. Dr. Riachi agreed to pay a hefty $5.25 million fine in addition to forfeiting his medical license for five years.

The suit contended that Riachi did not personally perform or properly supervise physical therapy sessions conducted in his office. Medicare does not pay for procedures performed by unqualified staff. Riachi, however, sued a medical supply company called The Prometheus Group, alleging that the company led him to believe that his actions were appropriate and that he did not need to be there personally for services. The medical supply company had apparently trained Riachi and his staff on the use of the equipment as well as how to bill Medicare for it.

The Third Circuit dismissed this suit, stating that Dr. Riachi failed to specify the basis for fraud or mistakes conducted by Prometheus, pursuant to Federal Rule of Civil Procedure 9(b). Dr. Riachi can be cleared to continue practicing medicine when his ban expires in 2023, per the New Jersey Board of Medical Examiners. These results are the culmination of a decade-long investigation of Riachi by the federal government, which began suspecting Riachi of fraud in 2010.

The lesson to be learned here for billing to any government plan, is that the provider needs to verify with the governmental agency (CMS, Tricare, VA, or any state-level plans) what the requirements are for certain services to be billed and then paid by the governmental agency. The best way to stay clear of governmental investigations is to know the rules of the playing field inside and out.


At a Glance

What Are the Most Common Specialties in Multispecialty ASCs?
#1 Orthopaedics. #2 Pain Management. #3 Podiatry.

Heal Pain on the Rise among Americans in Quarantine
Changes in Routine Behaviors Are Precipitating the Rise

Mental Resilience Can Help You Get Through the Pandemic
How to Build Mental Resilience That Matters

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