The market tension between providers and health plans appears to be intensifying as more providers drop network contracts and choose to serve patients on an out-of-network basis. A new trend appears be emerging, relating specifically to denials or recoupment of previous payment for the facility fee associated with services performed in facilities that do not require separate licensure under state law or Medicare certification. Whether this trend is representative of a new strong-arm tactic to muscle providers to the table on rates for their network or indicative of the private insurance market seeking to take more aggressive action on claims payment and audit issues is not readily apparent.
Facilities like cardiac catheterization facilities or diagnostic imaging services performed in a physician's office are recognized for payment by the Medicare program. Indeed, until recently, the private insurance industry typically provided coverage consistent with services otherwise covered by the Medicare program. Nevertheless, several private insurers recently have cited non-licensure as the basis for requiring refunds or initiating recoupment actions for the facility fee associated with the provision of services in instances in which the facility is not contracted in their network.