Office-based surgery centers are facilities that perform “any surgical or other invasive procedure, requiring general anesthesia, moderate sedation, or deep sedation . . . where such surgical or other invasive procedure . . . is performed by a licensee in a location other than a hospital . . . excluding minor procedures and procedures requiring minimal sedation.”1
Office-based surgery centers are not considered Article 28 facilities. Insurance companies have continuously argued that because office-based surgery centers, as non-Article 28 facilities, are unable to bill Workers’ Compensation or Medicare, they cannot bill no-fault either.
This is simply not true. The State of New York Insurance Department stated in an informal opinion that “whether a service is reimbursable under No-Fault is not determined by whether such service is specifically reimbursable under the Worker’s Compensation fee schedule.” In fact, Section 5108 of the New York State Insurance Law explicitly acknowledges the possibility that there may be health services not included in the Workers’ Compensation Medical Fee Schedule. Additionally, Section 5108 designates the Superintendent to promulgate fee schedules for such services.
Office-Based Surgery Laws
Physician practices performing office-based surgery (“OBS”) are required to obtain and maintain full accredited status by an agency designated by the Commissioner of Health. Obtaining and maintaining full accredited status will allow OBS centers to bill for the medical services they render.
The New York State Department of Health designated the following organizations as the accrediting agencies of OBS centers:
For more information regarding eligibility for accreditation, please visit the sites listed above.
Because OBS centers are not healthcare facilities under Article 28, accreditation by one of the above-mentioned agencies does not require an insurer to pay a facility fee.
Rate of Reimbursement for OBS Centers
Courts have struggled to decide the rate of reimbursement for services rendered in OBS centers. Fortunately, Regulation 83 lends some guidance:
If a professional health service is performed which is reimbursable under section 5102(a)(1) of the Insurance Law, but is not set forth in fee schedules adopted or established by the superintendent, and . . .
(b) if the superintendent has not adopted or established a fee schedule applicable to the provider, then the permissible charge for such service shall be the prevailing fee in the geographic location of the provider subject to review by the insurer for consistency with charges permissible for similar procedures under schedules already adopted or established by the superintendent.
Accordingly, although OBS centers are not Article 28 facilities, we base the rate of reimbursement on the Products of Ambulatory Surgery (“PAS”) classification system—specifically, the PAS codes listed for an Article 28 facility that is closest in geographic location to the OBS center for which we are billing.
We are experts in no-fault billing and collection. For more information about our billing for office-based Surgery centers, call us at (516) 427-5400 for an immediate, free consultation.
New York State Public Health Law § 230-d. See https://www.health.ny.gov/professionals/office-based_surgery/law/230-d.htm.