The outpatient surgery gap in our Medical Fee Schedule is causing comical results in outpatient surgical center billing.
Editor’s comment: Someone is going to have to step up and stop these abuses. Is anyone troubled by the fact the surgeon is getting a small fraction of the cost of the room where they are doing all the work?
Example A.
- Claimant goes for routine shoulder surgery. The physician/surgeon’s charges under the Illinois Medical Fee Schedule for four procedure codes total approximately $6,000.00.
- The outpatient or ambulatory surgicenter, from the Kankakee area, is not bound by the Medical Fee Schedule and charged more than $44,000!
- Even at the 76% discount provided by the Medical Fee Schedule, the cost remains prohibitive and we feel clearly represents gouging.
- As we previously reported, we feel such charges represent costs in excess of $10,000 per hour for providing the room, lights/supplies and waiting room magazines.
Example B.
- Claimant needs and receives routine injections to the spine.
- The physician/surgeon only gets $624.91 for CPT 64483 and $399.95 for CPT 64484.
- The Ambulatory Surgery Center from Chicago bills $14,000+ for procedures that take about twenty minutes.
Example C.
- Claimant undergoes “mini-open” repair shoulder surgery. The physician/surgeon charges and is paid about $6K for the same coding in Example A above.
- A different Ambulatory Surgery Center in Chicago bills $17,000 for procedures that take less than one-half of a day.
- This is dramatically lower than Example A above but the cost still doesn’t justify the services being provided.
Please understand there are a number of methods to stop this silliness. One is to try to set surgeries and other outpatient procedures outside of Illinois! We hate to make such recommendations to our clients and readers but, if the Illinois WC system is going to continue to allow Ambulatory Surgery Center costs exceeding $10,000 per hour, you could fly a patient to Europe and get the same treatment there!!!
We also point out there is no reason, none, that Illinois business should pay dramatically more simply because they accept the claim under workers’ compensation. There is no chance that Blue Cross/Blue Shield® or any similar group medical provider would consider such amounts for ASC services.
Our concern is this problem was caused by the 2005 Amendments to the Act and seeing case after case where there are abuses present cries for further reform. Obviously, just closing the gap is the easiest method to move forward. As it has been three years since enactment of the 2005 Amendments, it is hard to imagine why nothing has happened.
If you have thoughts, comments or questions, please send a reply.
