According to a report in the Star-Ledger, and online at NJ.com, proposed regulations by the New Jersey Department of Banking and Insurance (DOBI) would include personal injury protection hospital outpatient department and doctor office-based procedures for the first time on a fee schedule that includes ambulatory surgery centers, called the OSF.
This proposed fee schedule would utilize the CMS 2011 ASC fee schedule in its entirety, introducing thousands of codes not on the current ASC only fee schedule. It would not, however, place any fee schedule restrictions on PIP inpatient hospital procedures, save for trauma, and therein lies the problem, according Jeffrey Shanton, chair, Advocacy & Legislative Affairs Committee, for the New Jersey Association of Ambulatory Surgery Centers.
"The loopholes they speak of closing (in the report) only concerns procedures in HOPDs, not inpatient hospital," he says. "DOBI, by lumping ASC, HOPD and office-based procedures together on the same fee schedule, but only utilizing the CMS ASC fee schedule as a basis, has created a new loophole."
There are procedures commonly and routinely performed in an ASC setting that are not on this fee schedule, he says. As the proposed schedule covers ASC, HOPD and doctor office-based, the only other venue would be the hospital, and there is no fee schedule to cover hospital-based procedures.
"Thus your typical spine procedures, for example, now performed on an outpatient basis at ASCs will become inpatient hospital cases with all the attendant cost," Mr. Shanton says. "As there is no fee schedule, these would be paid UCR (usual, customary and reasonable fees), which will undoubtedly result in the vast majority of these cases being arbitrated by the hospital. This, of course, will not save money, but add cost, and in addition will generate more arbitrations, something DOBI is trying to cut down on."
Mr. Shanton says NJAASC is understanding and supporting of DOBI in its attempt to reign in cost. "ASCs are the safest, most cost-effective and most efficient setting for these procedures, and should be utilized fully," he says.
Learn more about NJAASC.
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