Wiki Office Based Surgery Facility Billing

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csperoni

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Our office has a surgical suite (AAAASF certified). We are NOT Article 28. Our physician claims are billed with POS 11. Other physicians (not part of our group) also use the surgical suite.
A billing company has contacted us stating if we obtain another TID for the surgical suite, they can bill commercial carriers (not Medicare) as an out of network facility under the separate TID on UB04s. This billing company states they are able to get reimbursed from commercial carriers (BCBS, United, Oxford, NYSHIP, HIP) approximately 40% of the time.
Is this legal? And if so, does it actually work? It seems suspicious to me, but my research could not find anything specifically stating it is not permissible. I did find several carrier policies stating facility claims are payable only if Article 28. Since Medicare would not be billed, Stark compliance is not an issue. Any thoughts or input would be greatly appreciated!!
 
Christine, did you receive any replies to this question? I would be curious to know how they propose to bill. What claim forms, what codes, etc. How do they propose the 60% that aren't paid be handled?

Sue
 
This is what i have learned,
If you are doing office based surgery and are licensed as article 28 (the ability to perform surgery with anesthesia) then you have been accredited. The question is -- did you state your facility to be an ambulatory surgical center when you got your accreditation? If you are listed as an ASC with the accrediting company- you cannot bill under POS 11. You would have to bill under POS 24. To me, it sounds like you are established as an ASC if other doctors come to your facility to do procedures. Which, in turn means claims should be billed on a UB-04 and not a HCFA. When you bill procedures as POS 11-- you are getting paid higher (site of service differential) because you are saving the insurance company by not sending the patient to an ASC or bringing in an anesthesiologist. If you are registered as an ASC, and billing with POS 11 you may want to look into this. Especially if the other surgeons that go to your facility to do surgery are sending out their claims out on HCFA reporting POS 24.

If you do office surgeries under local anesthetic only, and are not listed as an ASC, then you do not need accreditation, and you can only bill under local anesthesia therefore, would bill under POS 11. But, in this scenario it is not likely that other physicians would come and do surgery at your facility.
 
Also,
if you allow the billing company to bill out under a different tax id # - i believe you would not be able to report this as in office billing POS 11 because that would negate the purpose of you getting paid more for saving the insurance company money by not using an ASC. I used to work for an ASC and know that they make "really good" money when they bill an insurance as out of network. If the insurance company were to bill on a UB-04 your reimbursement will be the same to your physician as if you went to an outpatient facility. Which is a big difference in payment from what i have seen. But, the owner would ultimately need to decide if the risk is worth it. Lower payment on the physician service for a possible great payment for the use of the facility on approximately 40% of all cases?
Just food for thought........
Hope this helps!
 
The situation I'm looking into is not an ASC, nor is it an Article 28. Do you know where I could find detailed info about this situation?
 
I no of nothing that supports what the billing company is telling you, for the new TID you have to have the type of facility the TID if for for tax purposes, it cannot be a physician office for some things and an ASC for others, it just does not work that way. and Stark provisions apply to situations other than Medicare.
 
it is still office based, unless you are licensed as a surgical center or ASC. Office based is still an 11. The big deal is the taxes are different and the pay rate is different. You cannot be both at the same time you are either an office or you are a surgical center (ASC)
 
My biggest question is - if you are accredited as an office based and bill under POS 11, what are the outside physicians that come to your office surgery suite putting on their claim as place of service? They should not be billing under POS 11 since it is not their office suite that they are performing the procedures. If they are using POS 11 then they are getting the site of service differential. Something just doesn't sound right.

Sorry I couldn't have been more help.
 
After doing a bunch of research, it turns out the issue of billing facility fees for office based surgery is a very hot topic in New York, particularly with regards to No Fault.

Just goes to show that the rules aren't always crystal clear, and while they are in the process of changing, there is a lot of conflicting information available.

If anyone is interested in seeing any of the cases I dug up, let me know.

Oh, and I found out that governmental payors tend to want facility fees billed on a CMS 1500, while the commercial payors seem to prefer the CMS 1450 (aka UB-04, which I keep wanting to call a UB82 - can you tell how long I've been doing this work? lol)
 
Asc vs obs

I am in the same boat here, but what i have found out is that are office based surgery suite is accreditation thru the AAAHC, When i called them to verify if we were listed as an asc or an obs they said there is no distinction between them unless medicare is involved.
so now I am more confused. They said to check with the licensing agency in our state(california)
Well here in California if you are not billing medicare, and are not a hospital asocatied you dont have to be licensed. any help in the matter
 
Mindy, I'm not sure I understand your question. Are your claims being denied? Or are you just figuring out how to bill?
 
the doctors want to be out the faculity charge, they have a tinbut since its a surgical suite,
i feel the pos of 24 is misguiding but the pos 11 is not truly correct. I think I will have to consult with an attorney on this. The more I read the more I get confused
 
Since I started this thread 6 years ago and someone else just posted a reply today, let me update on our specific situation.
1) Regarding this outside company giving us this advice, after research, we decided they are a little too shady, and that many commercial carriers had realized this "suspicious billing" and updated their policies.
2) We continued using POS 11 and getting only the site of service differential. We had decided it was worth the physician's time and patient convenience (and allowed many of the PA visits that day to be billed incident to) to have the expense of the surgical suite, even if it was not a money making endeavor.
3) The outside physicians using the surgical suite were renting space (and employees) from us, so the space was also POS 11 for them.
4) Our practice was incorporated into a large healthcare system. The healthcare system also owns a local true ASC facility, so once AAAASF expired, we decommissioned our surgical suite and do the procedures there.

Summary of my advice:
Don't think your office will make some huge profit incorporating a surgical suite in your practice, unless you have the ways and means to make it Article 28. If you are lucky, you will break even or make a small increase. However, if you have a very busy surgeon who can now do 12 procedures in the time he does 3 in the hospital, or can rent your space/staff to other physicians when you don't need it, proceed with further analysis. If neither applies, or there is a local ASC to accommodate you, then don't waste your efforts.
 
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