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…
ASC Coding, Billing & Collections
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.…
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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…
The founder of a Florida-based healthcare platform has been convicted by a federal jury for operating a scheme that generated false physicians’ orders to defraud Medicare and other federal healthcare programs out of more than $1 billion, the Justice Department…
As reimbursement challenges and administrative burdens continue to squeeze physicians, cash-only and direct primary care models are gaining ground. The growth data backs that up: From 2018 to 2023, the number of direct primary care and concierge practice sites grew…
ASCs are adding service lines, expanding into higher-acuity procedures and taking on cases that once belonged to hospital outpatient departments, but many are still getting paid like it’s five years ago. The culprit, according to ASC leaders, is a passive…
Takeda Pharmaceuticals has agreed to pay nearly $13.7 million to resolve allegations that it paid illegal kickbacks to healthcare providers to induce prescriptions of its antidepressant Trintellix, the Justice Department said in a May 14 news release. The government alleged…