Becker's ASC Review

38 CODING & BILLING Executives, Physicians at Dallas Hospital Indicted in Massive Kickback Scheme By Ayla Ellison P hysicians, founders, executives and inves- tors of physician-owned Forest Park Medi- cal Center in Dallas have been charged in a federal indictment for their alleged involvement in a bribe and kickback scheme, according to the Department of Justice. e scheme, which began in 2009 and ran through 2013, involved paying surgeons, lawyers and oth- ers for referring patients to FPMC, which was an out-of-network facility with payers. "FPMC's strategy was to maximize profit for phy- sician investors by refusing to join the networks of insurance plans for a period of time aer its formation, allowing its owners and managers to enrich themselves through out-of-network billing and reimbursement," according to the DOJ. According to the indictment, FPMC's referral coordinator owned a shell entity called Unique Healthcare that was used to funnel kickback pay- ments to surgeons in exchange for referrals to FPMC. Most of the referred patients had insur- ance plans that provided high reimbursement for out-of-network care. Another FPMC employee sold Medicare and Medicaid referrals to a non-FPMC facility. ere were a total of 21 defendants charged in the scheme, including the hospital's founders and executives. ose involved paid and/or received about $40 million in bribes and kickbacks for re- ferring patients. e fraud resulted in more than $500 million in patient charges and FPMC collect- ing more than $200 million. Each of the defendants is charged with one count of conspiracy to pay and receive healthcare bribes and kickbacks. If convicted, they each face up to five years in federal prison and a $250,000 fine. More than half of the defendants face various other charges, including conspiracy to commit money laundering, violations of the federal Travel Act and offering or paying and soliciting or receiv- ing illegal remuneration, according to the DOJ. n Anthem Exec Testifies During Trial, Plans to Use Cigna as Tool to 'Aggressively Compete' Against BCBS Plans By Mary Rechtoris D uring the DOJ's antitrust trial against the Anthem, Cigna merger, an Anthem executive testified that the company plans to use Cigna as an avenue to compete in new markets, according to Bloomberg. Here are five takeaways: 1. Morgan Kendrick, Anthem's president of national accounts, said Cigna will give Anthem a means to compete against Blue Cross & Blue Shield As- sociation plans throughout the United States. 2. Anthem is a member of BCBS and therefore cannot currently vie for business against BCBS. However, if the acquisition comes to fruition, An- them plans to use Cigna to "aggressively compete." 3. Ms. Kendrick provided the testimony on behalf of Anthem following the DOJ making its case against the merger, saying the deal would serve to both consumers' and providers' detriment. 4. During its case, DOJ's defense team said only a portion of larger payers can provide coverage to the nation's largest employers. However, Ms. Kend- rick said large employers are seeking more options in both large carriers and regional and new payers. Anthem presented an economics expert, Lona Fow- dur, who said that employers have other options aside from Anthem, Cigna, UnitedHealth Group and Aetna, thereby critiquing the DOJ's claim. 5. U.S. District Judge Amy Berman Jackson questioned Ms. Fowdur during her testimony, asking if smaller payers are realistically receiving a large chunk of business or losing out to the bigger insurance players like Anthem. n 18 Statistics on ASC Payer Mix By Laura Dyrda H ere are 18 statistics on payer mix at ASCs based on the VMG Health 2016 Intel- limarker Multi-Specialty ASC Study. Payer mix as a percentage of gross charges 1. Medicare: 29 percent 2. Medicaid: 7 percent 3. Commercial: 59 percent 4. Worker's compensation: 9 percent 5. Self-pay: 4 percent 6. Other pay: 5 percent Payer mix as a percentage of cases 7. Medicare: 33 percent 8. Medicaid: 10 percent 9. Commercial: 51 percent 10. Worker's compensation: 4 percent 11. Self-pay: 5 percent 12. Other pay: 9 percent Payer mix as a percentage of collections 13. Medicare: 19 percent 14. Medicaid: 7 percent 15. Commercial: 65 percent 16. Worker's compensation: 5 percent 17. Self-pay: 10 percent 18. Other pay: 9 percent n

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