A Florida woman and former Connecticut advanced practice registered nurse has been arrested on charges of submitting more than $1.35 million in fraudulent Medicaid claims for medication management services never rendered, the Justice Department said in a May 22 news…
ASC Coding, Billing & Collections
Prior authorization has been under intense scrutiny in recent months as frustration brews among clinicians and legislators aim to curb the use of AI technology in the practice. Here are five recent developments reshaping the way prior authorization is deployed…
Allstate has filed three federal lawsuits against ASCs and their affiliated providers since mid-April, alleging schemes ranging from kickback arrangements and corporate practice violations to billing for procedures that were never performed. 1. Allstate sued Florida Orthopedics and Neurosurgery, which…
Stark law was written before the internet, EHRs or AI-driven diagnostics existed. But it is still dictating how physicians can structure financial relationships in 2026, and a growing chorus of physicians, legal experts and industry groups say it is time…
CMS’ 2026 Hospital Outpatient Prospective Payment System rule moves Medicare further toward site-neutral payment, as part of an effort to narrow long-standing payment gaps between hospital outpatient departments and ASCs. In the 2026 final rule, CMS also finalized site-neutral payment…
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Major payers are quietly cutting reimbursement by automatically adjusting the complexity codes on claims before payment clears. In the past year, Cigna, Aetna, Anthem and BCBS of Massachusetts have all launched or expanded automatic downcoding programs, algorithmically adjusting higher-complexity E/M…
For independent ASCs, the economics of survival have never been more precarious. Reimbursement rates have not kept pace with inflation, staffing costs have surged and some commercial payers have effectively closed the door on negotiations. Suzi Cunningham knows this reality…
A California physician has been convicted by a federal jury for submitting $45 million in fraudulent Medicare claims for Botox injections that were never provided and obstructing the investigation by altering medical records, the Justice Department said in a May…
Two Massachusetts clinics and their physician founder have agreed to pay $1.4 million to resolve False Claims Act allegations of fraudulently billing government health insurance programs for services never performed, the Justice Department said in a May 19 news release.…
Federal health regulators are pushing back on two widespread assumptions that have long given healthcare executives a false sense of security: that complying with the Stark law is enough to stay out of trouble under the Anti-Kickback Statute, and that…