Ambulatory surgery center (ASC) operators should be looking out for anti-kickback violations, documentation lapses and exclusion checks, as administrative claims targeting surgery centers have recently surged.
“We’re just seeing an increased focus on program integrity,” health care attorney Robert Saltaformaggio said on the Advancing Surgical Care Podcast. “There are a number of administrative audits being performed – CERT audits, TPE audits, additional documentation requests, UPIC audits. And they’re expanding across the country.”
Among the dozen-plus risk areas Saltaformaggio addressed during his appearance on the podcast, hosted by the Ambulatory Surgery Center Association (ASCA), he singled out three for special attention: anti-kickback violations, documentation lapses and exclusion checks.
“We’re just seeing an increased focus on program integrity,” he said. “There are a number of administrative audits being performed.”
That surge is being driven by both federal and commercial payers using artificial intelligence and data analytics to flag outliers in billing practices, he added.
“The government is using AI to really scrutinize providers,” Saltaformaggio said. “It’s robots battling robots at times, … but the robots don’t always get it right. And that puts the burden on providers to push back.”
To help ASCs proactively reduce risk and improve compliance, Saltaformaggio said ASCs must prioritize ongoing training.
“Medical necessity and documentation guidelines are constantly evolving,” he said. “You need to keep your staff, both clinical and administrative, up to date.”
Equally critical is fostering open lines of communication to encourage internal reporting, he added.
“You want a culture where staff feel comfortable raising compliance concerns,” Saltaformaggio said.
But perhaps most vital is the practice of regular self-auditing, he added.
“Internal audits help you catch and correct issues before submitting claims,” he said. “Review your billing and documentation practices regularly to identify any patterns that could trigger a larger problem.”
If an audit advances to a federal or commercial investigation, operators should retain legal counsel immediately, Saltaformaggio said.
“At that point, the government may believe there’s a credible allegation of fraud or a serious compliance issue,” he said. “You need legal support to navigate it properly.”
He also urged ASCs to determine whether they are being named as a witness, subject or target, to preserve all relevant documentation, and to always be truthful with investigators.
“Sometimes, it’s not the billing issue that gets providers in trouble,” he said. “It’s the act of lying to the government that leads to even more serious consequences.”
ASC operators should carefully examine any referral arrangements or business contracts, noting that while legal protections known as safe harbors do exist, they are complex and should be reviewed by legal counsel, Saltaformaggio said.
Additionally, failing to check whether employees or contractors appear on exclusion lists can jeopardize claims.
“If someone on the exclusion list is involved in care delivery, that claim could be tainted and subject to recoupment,” he said.
And public payer audits differ from private ones.
“With Medicare or Medicaid, appeal rights are usually spelled out in statute,” Saltaformaggio said. “But with private payers like United or Aetna, your appeal rights depend entirely on your contract. They’re often narrower, and harder to negotiate.”
He advised ASC operators to carefully review their managed care agreements to understand deadlines and appeal levels.
“With a private payer, you might only have 30 or 60 days to appeal, and only one level of review,” he said. “Whereas with Medicare, you may have up to 180 days and multiple appeal levels.”
