Emily Studebaker, JD
REIMBURSEMENT ROUNDUP
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O U T P AT I E N T S U R G E R Y M A G A Z I N E O N L I N E | D E C E M B E R 2 0 1 4
Billing Technicality Could Cost
Group of Surgeons Millions
You won't believe why United Healthcare
is asking these docs to repay facility fees.
A
group of Texas surgeons
is suing to stop a giant
insurer from recouping
several years' worth of facility
fees and withholding millions of
dollars in reimbursements — all,
the doctors say, because of a
small billing technicality. Instead
of billing United Healthcare as
licensed surgical centers, as state
law required, the surgeons billed
as physician associations. And
because of that, the giant insurer
says the doctors weren't entitled to the facility fees they received. In
addition to sending the surgeons overpayment demand letters for the
facility fees, United has also withheld millions of dollars in payments
and underpaid scores of other claims, according to court documents.
Here's how the billing blunder came about. The doctors belonged to
a physician association called DAC Surgical Partners. DAC entered
into an exclusive-use agreement with an ambulatory surgical center
whereby the surgeons paid the ASC a leasing fee for the exclusive use
of an OR. For most of the physician associations in this case, that ASC
was The Palladium for Surgery-Houston, according to the lawsuit the
surgeons filed against United
in 2011. United's stance is that the physician associations were not
BILLING BLUNDER? United Healthcare is
playing hardball with a group of surgeons it
says failed to follow state regulations.