Becker's Spine Review

48 OUTPATIENT SURGERY Minnesota Hospital Association challenges Blue Cross policy shifting services to ASCs By Rachel Popa T he Minnesota Hospital Associ- ation accused Blue Cross Blue Shield of Minnesota of break- ing the law through policies that limit access to colonoscopies and other services in hospitals in favor of hav- ing them in lower-cost settings, like ASCs, according to a letter from the association cited by the Minneapolis StarTribune. Three details: 1. Through its policies, Blue Cross Blue Shield of Minnesota won't cover such services as endoscopies and colono- scopes in-network at a hospital if an ASC or outpatient clinic within 25 miles offers the same services but at a lower cost. The insurer argued that the pol- icies are identical to those imposed by Medicare for its beneficiaries, and that it is its job to steer patients to low- er-cost settings in light of rising health- care costs. Blue Cross Blue Shield also said that hospitals can meet outpatient clinic pricing to allow patients to have the procedure in the hospital. 2. The hospital association said that the restrictions, which also require patients to get prior authorization for more than 250 services, will limit pa- tients' access to medically necessary treatments and diagnostic services and make the process of getting care more expensive. The association said Minnesota law doesn't allow Blue Cross Blue Shield to discriminate against in-network hospital provid- ers, and that the new policies may break unfair and deceptive trade practice laws. 3. Minnesota Attorney General Keith Ellison said his office will "dig into" the association's concerns. n Optum adds new partnership model to outpatient strategy with latest health- system deal - 3 insights By Angie Stewart E den Prairie, Minn.-based Optum broke from its pattern of acquiring physician practices, outpatient clinics, urgent care facilities and surgery centers with plans to take over John Muir Health's non-clinical functions, according to Forbes contributor Bruce Japsen. Three insights: 1. The new partnership model was intended to allow the Walnut Creek, Ca- lif.-based John Muir to remain independent while providing quality care. About 540 John Muir Health employees became part of Optum, the health services unit of UnitedHealth Group, as part of the deal. 2. Optum's executives expect other local health systems will be interested in similar partnerships where Optum takes on IT, revenue cycle management, an- alytics, purchasing and claims management services, Mr. Japsen said. 3. During Minnetonka, Minn.-based UnitedHealth Group's second-quarter earnings call, OptumInsight CEO Eric Murphy indicated the new partnership is a sign of ones to come. "We're already in discussions with several high-performing independent com- munity-based systems and look forward to establishing continued partner- ships, similar to John Muir Health, with health systems across the industry," Mr. Murphy said. n Delaware pain physician indicted in $12.7M Medicare fraud scheme: 4 details By Laura Dyrda T he Department of Justice unsealed an indictment against a Wilmington, Del.-based pain physician for allegedly participating in a scheme to defraud Medicare of millions of dollars. Four things to know: 1. Frederick Gooding, MD, president and CEO of Gooding Medical Corp., based in Wilm- ington, was charged with 11 counts of healthcare fraud and arrested Aug. 1. 2. Dr. Gooding was charged with billing Medicare for medically unnecessary procedures in- cluding injections and aspirations. In some cases, the procedures were not provided, and Dr. Gooding is accused of falsifying medical documents to make it appear that he delivered medically necessary services to Medicare beneficiaries, when that was not the case. 3. From January 2015 to August 2018, Dr. Gooding is accused of submitting fraudulent claims that resulted in $12.7 million in payment. 4. Dr. Gooding appeared in court on Aug. 2, but a trial date has not been set. n

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