Some centers resort to taking legal action

Many insurance companies that aren’t paying the full patient bills sent to them from ambulatory surgery centers (ASCs) seem to have taken the stance, "let em sue us," says Thomas J. Pliura, MD, JD, physician and attorney at law in Le Roy, IL. So that’s exactly what some surgery centers are doing, he says.

One lawsuit has been filed in Illinois, and another is pending, Pliura adds. One center has submitted $900,000 in billed charges to a payer and has received $57,000 from the payer.

"It puts the patients legally on the hook for the bill, but [payers] are taking advantage of the fact that the health care providers will very rarely pursue claims directly against the patients," he says. "The companies know that the centers don’t do so because that will give them a bad name and fear their business might suffer if other patients learn about the lawsuits."

The legal way around this dilemma is to file directly against the insurance company on behalf of the patient, using the patient assignment as a legal tool, Pliura explains.

In the lawsuit that’s been filed, the centers allege failure to pay a contractual obligation, federal and state antitrust violations, restraint of trade violations, and violation of the Consumer Fraud and Deceptive Practice Act, he adds.

"We also believe it is illegal for an insurance company to enter into a separate agreement with a hospital to try and keep a competing surgery center out of a particular market," he adds. "It seems several insurance companies are now attempting to squeeze out facilities that refuse to become contracted facilities with the particular companies by entering into agreements with hospitals, etc., to keep the noncontracted facilities out of the market."

Patients pay extra money to their payer to have the privilege of using noncontracted providers, he says. "Insurance companies are taking the higher PPO [preferred provider organization] payments from the patients, yet they are secretly prohibiting patients from utilizing noncontracted providers," Pliura notes. In essence, these companies are trying to exclude noncontracted providers and make the patients use only "contracted" providers, even though the patients have been paying extra money to buy a policy that allows them to go out of network, he says.

"Insurance companies across the country seem to have taken the stance they will simply ignore health care payment obligations," Pliura says. Many insurance companies are deciding arbitrarily to simply make a token payment — even if the facility does not have a contract with the insurance company — and assume the surgery center will accept the payment as full payment for the bill, he says. "This is ridiculous, in my opinion, but rarely do the surgery centers take the time to pursue the matter," Pliura says.

As an increasing number of ASCs begin to experience this "squeezing down," these facilities will begin to pursue claims against the insurance companies directly, he predicts.

Some consumer groups are concerned that a health care monopoly is developing that drives up cost, says Rob Schwartz, executive director of the Colorado Ambulatory Surgery Center Association in Denver. There have been discussions about approaching the state attorney general, he says.

"Any actions that target surgery centers and attempt to lock them out is wrong and anti-consumer," Schwartz adds.

Source

For more information, contact:

  • Thomas J. Pliura, MD, JD, Physician, Attorney at Law, P.O. Box 130, Le Roy, IL 61752. Phone: (309) 962-2299. E-mail: tom.pliura@z-chart.com.