Becker's ASC Review

41 CODING & BILLING Physician sentenced to 18 months in prison for $30M Medicare, Medicaid fraud: 6 key facts By Rachel Popa U .S. District Judge Lorna G. Scho- field sentenced Mustak Y. Vaid, MD, to 18 months in prison for partici- pating in a $30 million scheme to defraud Medicare and the New York State Medicaid program. Here are the key facts in the case: 1. Dr. Vaid falsely posed as the owner of a medical clinic and falsely claimed he had treated and examined hundreds of patients he hadn't seen. 2. He pled guilty to healthcare fraud and conspiracy to commit healthcare fraud, mail fraud and wire fraud November 13, 2017. 3. Dr. Vaid is the seventh defendant and the first physician sentenced aer pleading guilty in this case and a related case. Aleksandr Burman, the leader of the scheme, was sentenced in a related case May 8, 2017 to 10 years in prison. 4. Between 2007 and 2013, Mr. Burman owned and operated six medical clinics in Brooklyn, N.Y., that fraudulently billed Medicare and Medicaid for approximately $30 million for unnecessary medical ser- vices, services that weren't completed or were otherwise fraudulently billed. 5. Under New York state law, medical clinics must be owned and operated by a medical professional. Mr. Burman, who was not a medical professional, hired Dr. Vaid and other medical professionals to pose as nomi- nal owners of the clinics. 6. Dr. Vaid signed fraudulent documents falsely representing him as the owner of Brooklyn, N.Y.-based Ocean Side Medical to CMS, banks and other institutions. n Here's what ASCs need to know about bundled payments — 6 takeaways By Angie Stewart B undled payments can help ASCs increase reimburse- ments while remaining competitive in a value-based environment, according to MNet. Here are six takeaways: 1. ASCs are well positioned to use bundled payment models because they provide similar procedures as hospitals at a lower cost. It's also easier for ASCs to track expenses. 2. Bundled payments encourage patients to choose ASCs for surgeries and encourage payers to move patients to surgery centers, which could boost case volume. 3. These arrangements benefit patients by helping them avoid the co-pays, deductibles and high out-of-pocket pay- ments linked to fee-for-service models. Bundled payments can also significantly cut costs for payers. 4. Bundled payment arrangements haven't gained much traction in ASCs to date. They account for just 30 percent of industry-wide payments by Medicare. 5. For prospective bundled payment models, insurers pay providers a fixed amount for all services upfront, and the pro- vider is responsible for any additional costs incurred later. 6. Under the more widely adopted retrospective model, pay- ers and providers agree on a bundled target price, which is compared to the actual cost post-procedure. If the actual cost is greater than the target, providers receive additional reim- bursement. If it's under target, payers get back the amount they overpaid. n 4 billing & coding updates that could affect ASC reimbursement By Angie Stewart Here are four billing and coding updates with the potential to impact ASC reimbursement: CMS proposal could drastically expand procedure options. CMS proposed several updates to ASC payments in the 2019 proposed payment rule, issued July 25. One of the key changes for ASCs would be to broaden the definition of device-intensive procedures, adding around 131 procedures for Medicare beneficia- ries in the ASC setting. Payment might drop for specialty physician's com- plex cases. CMS' proposed 2019 Medicare Physician Fee Schedule involves significantly lowering reim- bursement for complex cases often seen by specialty physicians during office and outpatient visits. Medicare continues adding codes for interven- tional radiology ASCs. Interventional radiology ASCs have more ways than ever to collect for pro- cedures, thanks to a surge in the number of billing codes supporting these facilities. This year, Medicare added 176 for a total of more than 413 irASC CPT codes. New Jersey enacts out-of-network billing law. The Out-of-Network Consumer Protection, Transparency, Cost Containment and Accountability Act requires healthcare facilities and providers to notify patients if they are out-of-network before scheduling a non- emergency appointment — which would apply to appointments at ASCs. n

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