Mark Cuban upended prescription drug pricing in 2022 when he co-founded Cost Plus Drugs, an online pharmacy that posts its full price list publicly, charges a flat 15% markup and $5 shipping, and bypasses traditional pharmacy benefit managers and wholesalers…
ASC Coding, Billing & Collections
The last five months have seen a wave of proposals and policies from CMS related to everything from updates to coverage of pain procedures to fraud crackdowns and claims documentation requirements. Here are five CMS moves impacting ASCs and outpatient…
A Utah podiatrist and two nurses have been indicted on charges of submitting $29 million in fraudulent Medicare claims for medically unnecessary skin substitute services, the Justice Department said in a May 12 news release. Ryan Ellsworth, DPM, owner of…
Last year over 60 major health insurers pledged to streamline prior authorization processes — but few physicians think these pledges have made a difference in PA burden, according to the American Medical Association’s “2025 AMA Prior Authorization Physician Survey” released…
CMS has proposed a mandatory bundled payment model expansion for lower extremity joint replacements under the FY 2027 Hospital Inpatient Prospective Payment System proposed rule. The proposed Comprehensive Care for Joint Replacement Expanded, or CJR-X, model would apply nationwide to…
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Helen Boerman, OD, an optometrist in Brentwood, Tenn., pleaded guilty to defrauding Medicare of $6.9 million. Dr. Boerman used her practice, Brentwood Eye Care, to submit about $11 million in false Medicare claims, and she received nearly $7 million, according…
Elevance Health’s out-of-network provider penalty policy has drawn sharp legislative backlash and opposition from hospitals and physician groups across the country. Here are seven things ASCs leaders and physicians should know: 1. How the penalty works. In-network facilities that use…
Payer denials remain a persistent problem across the hospital industry, but Nashville, Tenn.-based Tenet Healthcare, parent company of ASC chain United Surgical Partners International, isn’t seeing the acceleration that has rattled some of its peers, CEO Saumya Sutaria, MD, said…
A Huntington Park, Calif., physician and his medical practice agreed to pay more than $6.73 million to resolve False Claims Act allegations of performing medically unnecessary vascular procedures on Medicare beneficiaries, the Justice Department said in a May 6 news…
As CMS expands its coverage of procedures in ASCs and technology continues to advance what is possible in the outpatient setting, leaders must carefully balance risk, cost and logistics to meet the moment of ASC development. Two ASC leaders recently…