Are Hospitals Entitled to Reimbursement for anesthesia services?
The following article was written by Callagy Law’s Legal Team, and will focus on many common questions and concerns surrounding new developments, legal matters, and other procedures within the field of healthcare law Medical Revenue Recovery, PIP, Workers Compensation, and Commercial Insurance. Our mission is to answer any questions and give knowledge to many different aspects of these matters.
Anesthesia is a way to control pain during a surgery or procedure by using medicine called anesthetics. General anesthesia is used to ensure comfort and safety during certain types of procedures. Anesthesia effects and helps control a patient’s breathing, blood pressure, blood flow, and heart rate/rhythm, among other things.
When you get general anesthesia, in layman’s terms, “put under,” you are completely unconscious and immobilized. General anesthesia may be administered via gas, an IV line or a combination of both. Typically, major/complex procedures that require a long period of time to perform require general anesthesia.
A patient may present to an Ambulatory Surgery Center (ASC) or a Hospital facility to undergo these types of major/complex procedures. In a case where a patient presents to a Hospital facility to undergo a procedure, the Hospital provides the anesthesia and necessary supplies. The hospital provides the equipment, supplies and sometimes staff required to safely and effectively deliver anesthesia services during the procedure. The specific resources that the hospital provides vary depending upon the type of anesthesia the patient requires and the patient’s particular medical condition. The staff will also vary according to the hospital. Sometimes the staff are outside anesthesiologists working in the hospital, and sometimes, they are hospital employees.
So how is this billed to the insurance carrier? In the case of the outside anesthesiologist, they will bill separately for his or her professional services, as will your surgeon and the other physicians who provide services for you while you are hospitalized. They will bill for part of the services, called the professional component. The hospital will issue a separate bill for all of the services and items the hospital provided during your hospitalization and that bill will include charges for the hospital’s role in the delivery of anesthesia services based on the specific type anesthesia services a patient receives. The hospital’s bill is for what’s called the technical or facility component.
An insurance carrier may attempt to argue that the Hospital improperly submitted what constitutes duplicate billing of anesthesia for the date(s) of service that are at issue. Usually, this is based upon the fact that the anesthesiologist, who administered the anesthesia services on the date(s) in question, had already submitted his/her independent bills for the “same” instance of anesthesia services for the procedure. This is incorrect, as both the anesthesiologist and hospital are each billing only for their portion of the services provided.
The insurance carrier may also attempt to argue that pursuant to N.J.A.C. 11:3-29.4(o)(7) anesthesia materials, including the anesthetic itself, and any materials, whether disposal or reusable, necessary for its administration are not entitled to a separate charge. As such, the Hospital facility would not be entitled to reimbursement for anesthesia because anesthesia services were “bundled” into the main surgical code. However, this is not always the case.
There are several arguments that Callagy Law has successfully advanced where arbitrators in NJ No-Fault (PIP) arbitrations have determined that such anesthesia services are separately reimbursable to the hospital. Namely, if the procedure was an inpatient procedure, if it was an emergency procedure, or if it was an outpatient surgical procedure, where the main surgical code billed was not on the Hospital Outpatient Surgical Facility (HOSF) fee schedule. In each of these examples, there are strong arguments to be made that the technical/facility portion of anesthesia should have been reimbursed to the Hospital, despite the carrier’s arguments to the contrary.
Therefore, Hospital facilities are sometimes entitled to separate reimbursement for anesthesia services in addition to the anesthesiologist’s separate and distinct bill for his/her own personal services.
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Hospital Anesthesia Services Potentially Recoverable! | Callagy Law
