Crossing State Lines for Medical Care

At the 2016 WCRI Annual Issues Symposium, Dr Rebecca Yang and Dr Bogdan Savych from WCRI presented the findings from a very narrow ongoing study that focused on claims from New York City that sought medical care at ambulatory surgical centers (ASC). This study was triggered by the fact they were seeing over a 30% increase in ASC payments from 2011 to 2012 with no change in fee schedule. The study only looked at claims where the worker worked and lived in New York City and had received medical care in New York City.

The study found that in 2011, around 20% of ASC surgeries were done on New York workers were done in New Jersey. In 2013 that number jumped to almost 50%. The treatment in New Jersey was not subject to the New York fee schedules, so this was resulting in nearly 300% higher costs for knee and shoulder surgeries. This appears to be exploitation of a loophole in the New York fee schedule because it does not schedule rates for out-of-state providers.

For comparison, they looked at Pennslyvania workers in the counties that boarded New Jersey. They found no significant utilization of ASCs in New Jersey for the Pennsylvania workers. However, the Pennsylvania fee schedule specifically applies to out-of-state treatment.