Becker's ASC Review

8 ASC MANAGEMENT Appeals court allows California surgery center to seek $1M+ in unpaid claims By Eric Oliver T he U.S. Ninth Circuit Appeals Court allowed Los Angeles-based Beverly Oaks Physicians Surgery Center to seek unpaid claims from Blue Cross and Blue Shield of Illinois, reversing a decision from a district court, according to a Dec. 17, 2020 court filing. e surgery center performed out-of- network procedures on 14 patients who had employer-sponsored health insurance plans administered by BCBS. Each patient signed a form granting the center the right to col- lect benefits. e center sought preapproval and was told by BCBS it would typically pay between 50 to 100 percent of the claim. Aer performing the procedures, the center submitted a claim to collect Employee Re- tirement Income Security Act benefits. Blue Cross either denied every claim or paid a small reimbursement amount citing its anti- assignment of benefits provision. BCBS did not mention its anti-assignment of benefits provision in pre-approval conversations. e surgery center sought $1.4 million but BCBS paid out only $140,000. BCBS claimed the claims could be denied because its anti-assignment provision was valid and enforceable. e district court agreed and dismissed the complaint. e surgery center appealed. Judge Jennifer Choe-Groves wrote in her opinion that the surgery center had a right to its claims because BCBS did not bring up the provision in preapproval conversations. "If [Blue Cross] representatives would have stated in any of these telephone communi- cations that [Blue Cross] intended to rely upon an anti-assignment clause as a basis to bar payment, [Beverly Oaks] would not have performed surgery center facility services for the ERISA Plan in question, or any of its members or their dependents," Judge Choe-Groves wrote in her opinion. "ese misrepresentations continued over time throughout the administrative review process. Beverly Oaks pleaded that the anti- assignment provisions at issue were ambigu- ous. It pleaded that the representations Blue Cross made about the plan were interpreta- tions of the plan and not amendments or modifications. at was sufficient." n Physician pay hits $360K; group practice falls 13% among general surgeons — 4 key insights By Angie Stewart T he average physician makes $360,104 a year, according to the "2020 Physician and Advanced Practice Salary Report" by LocumTenens.com. The report is based on a September 2020 survey that received 2,080 responses from physicians and advanced practitioners in all 50 states. Compensation figures include only annual salary and bonuses for full- time, permanent employees. Four key insights: 1. The average physician salary in 2019 was slightly down from 2018. The figure increased from 2016-17 and from 2017-18. 2. The average advanced practitioner made $139,750 in 2019, a sharp rise from 2018. Full-time annual salary for these providers had been fluctuating since 2016. 3. For general surgeons in 2019, the average annual salary was $369,524. This represents a drop of 3 percent from 2017-19. 4. Hospital employment among general surgeons increased 6 percent from last year, hitting 58 percent. In stark contrast, the number of gen- eral surgeons in group practice decreased 13 percent. n CMS to require prior authorization for cervical fusion with disc removal By Alan Condon C MS will use prior authorization to reduce unnecessary increases in the volume of covered outpatient spine services this year. Beginning July 1, CMS will require prior authorization for cervical fusion with disc removal as well as implanted spinal neuro- stimulators. The strategy aims to ensure Medicare patients receive necessary care, "while protecting the Medicare Trust Funds from unnecessary increases in volume by virtue of improper payments, without adding new documentation requirements for pro- viders," the agency said in a Dec 2, 2020 announcement. n

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