Pressure continues to mount in the healthcare industry to direct as much delivery of care as possible to ambulatory surgery centers. With this increase, these surgery centers are experiencing explosive growth – and increased scrutiny in business practices.
Critical issues around billing transactions, reimbursements and compliance with governing laws have also taken a prominent place in day-to-day operations. One false move – or even the appearance fraudulent behavior – can threaten the hopes of strengthening the presence of these services in the healthcare marketplace.
Legal Matters Ambulatory Surgery Centers Face
The regulatory environment for ambulatory surgery centers is unique and consists of legal matters related to:
• Anti-Kickback Statute, Stark Law and the safe harbor exception
• HIPAA compliance, privacy and notifying clients when a breach occurs
• Audits and appeals for Medicare, Medicaid and private pay issues
• Conditions of Participation and Conditions of Coverage compliance with Medicare
• Coding and payment regulatory compliance for Medicare and Medicaid
• Licensure issues
• Buying and selling equity interests
• Initial development of a center, including structuring joint interests with hospitals, health systems or other physicians
• Corporate governance, compliance policies, daily operations and structural issues
• Transactional and contractual arrangements
While this is not an all-inclusive list, it does represent legal matter that can hit these centers from different angles.
How Legal Matters Can Affect the Business of Ambulatory Surgery Centers
Establishing a joint venture with other healthcare entities such as hospitals and physicians may seem like a straightforward process. However, several compliance issues may interrupt the flow. For instance, a physician who sells her facility to a different entity that benefits from physician referrals can entangle the process.
Another transaction could cause issues as well. Buying or selling interests in an ambulatory surgery center requires due diligence. The existing entity must be thoroughly vetted to ensure it has remained compliant with requirements for submitting Medicare claims and other regulatory standards.
In addition, there are necessary steps for properly transferring certificates of need or Medicare billing privileges.
Many would-be legal issues could be avoided – or minimized – with compliance plans in place before an issue arise. Preparation keeps ambulatory centers in compliance with the Stark law and the anti-kickback statutes. Referrals and how centers receive payments are rarely questioned.
The word “audit” is intimidating even for an entity that has everything in place. Knowing what to do when faced with a letter from a government entity. Whether it is a fee-for-service claim, under or overpayments, or error rate audit, centers need to prepare an answer if the determination is less than favorable.
Appeals for claim denials is another legal matter that ambulatory surgery centers can face. A prepayment review or suspension can be financially damaging when the primary focus should be on delivering medical services to patients. The best thing would be to have a properly worded response for an audit or claim denial.
Lawyers for Ambulatory Surgery Centers Use Experience and a Personal Approach
Helpful to crafting a strong response is to have legal representation from lawyers who are experienced in this form of healthcare services. A tailored approach based on the specific needs and issues of these centers can lead to the best possible outcome.