Outpatient Surgery Magazine, providing current information on Surgical Services, Surgical Facility Administration, Outpatient Surgery News and Trends, OR Excellence and more.
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4 5 D E C E M B E R 2 0 1 4 | 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 REIMBURSEMENT ROUNDUP entitled to recover reimbursements for the facility fees because the physician associations were not ASCs licensed by the state of Texas, and therefore were not permitted by state law to provide the services for which they sought reimbursements. Not entitled to payment? Splitting hairs? Maybe. But that didn't stop United from sending each physician association an "overpayment demand" letter in late 2009, seeking repayment of the facility fees it had paid the associations. United also stopped paying the professional fees, including more than $10 million in pending claims, according to the suit. The doctors took great care to make sure United would pay both the professional and facility fees. Billing agents for the physician asso- ciations would call the insurance company to verify that the surgeries were valid and billable. The billing agents would then make a second call to verify patients' eligibility and coverage. After the costs were confirmed, United would tell the associations how much it would pay for the claim, and then after surgery, pay that amount. This occurred for several years, with United paying the physician associations both of the fees for hundreds of surgeries performed at ASCs. The physician associations filed a lawsuit against United, saying that there was a breach of implied-in-fact contract, negligent misrepresen- tation and violations of the Texas Insurance Code and the Texas Business and Commerce Code, among others. Additionally, the sur- geons allege United underpaid other claims totaling approximately $10 million. The case was consolidated in 2013 with another case against United brought by physician associations with similar allega- tions. In response to the surgeons' allegations, United asserted a number of defenses. Its primary argument was that the physician associations