Here are five recent payor disputes involving ambulatory surgical centers, according to various news reports.
1. NJAASC letter demands Aetna stop patient re-direction among in-network centers. The New Jersey Association for Ambulatory Surgery Centers has sent a letter to Aetna in response to their efforts of re-directing patients from one in-network facility to another, less costly in-network center. "This is absolutely intolerable and shows that Aetna has decided to ratchet up the anti-ASC campaign to new levels," says Jeffrey Shanton, Chair of the Advocacy and Legislative Affairs Committee of NJAASC. "The facility where a patient elects to have his or her procedure performed is not a decision that Aetna should ultimately control or attempt to influence, especially if all the centers in question are in-network. This is consistent with accepted standards of care and professional ethics, as well as New Jersey State Law and public policy."
2. Cigna to terminate contracts with New Jersey one-room surgery centers. Connecticut-based insurance company Cigna is in the process of removing all one-room surgery centers in New Jersey from its network, according to a Cigna contract manager. Jeffrey Shanton, chair of the advocacy and legislative affairs committee for the New Jersey Association of Ambulatory Surgery Centers, reached out to Cigna after a surgery center physician indicated that the insurance company intended to terminate existing in-network contracts with one-room centers. Courtney A. Bennett, contract manager for Northern New Jersey with Cigna Healthcare, responded to Mr. Shanton, "Cigna is in the process of removing all one-room surgery centers from the network."
3. Surgery centers report payment errors following postponement of physician rate cut. Surgery centers across the country have reported that local Medicare contractors have not yet updated their ASC payment files to reflect the recent postponement of the physician rate cut, according to an ASCA release. The failure to update these payment files is causing underpayments for procedures that are tied to physician office rates for certain ASCs. The ASCA is working with CMS to determine when the problem will be fixed. ASCs that believe they have been underpaid are advised to resubmit affected claims.
4. Out-of-network Illinois surgery center battles Aetna over $3.4 million in bills. Oak Brook Surgical Centre and insurance company Aetna are battling in court over $3.4 million in bills, according to a Crain's Chicago Business report. Oak Brook Surgical Centre submitted nearly 280 claims to the insurance company between 2005 and 2010, according to a financial report by the surgery center. Aetna has paid approximately $341,000, or less than 10 percent of the total $3.8 million billed, according to the report. The surgery center contends it reasonably relied on Aetna's assurances that the claims would be covered and that the court should prevent the insurer from rescinding those statements. Aetna disputes the claims of Oak Brook Surgical Centre, which is not part of Aetna's network of providers.
5. Aetna sues 7 California surgery centers over alleged overbilling. Insurance company Aetna is suing seven California surgery centers for a billing system that the payor claims "recklessly subverts" healthcare delivery by allegedly overcharging for certain services. Aetna is suing to prevent the centers from waiving co-insurance payments that patients are supposed to be charged when they use out-of-network physicians or facilities. The company is saying the centers illegally lured patients by not requiring co-payments for out-of-network care and then billed Aetna up to 2,500 percent more than the payments for in-network providers.
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1. NJAASC letter demands Aetna stop patient re-direction among in-network centers. The New Jersey Association for Ambulatory Surgery Centers has sent a letter to Aetna in response to their efforts of re-directing patients from one in-network facility to another, less costly in-network center. "This is absolutely intolerable and shows that Aetna has decided to ratchet up the anti-ASC campaign to new levels," says Jeffrey Shanton, Chair of the Advocacy and Legislative Affairs Committee of NJAASC. "The facility where a patient elects to have his or her procedure performed is not a decision that Aetna should ultimately control or attempt to influence, especially if all the centers in question are in-network. This is consistent with accepted standards of care and professional ethics, as well as New Jersey State Law and public policy."
2. Cigna to terminate contracts with New Jersey one-room surgery centers. Connecticut-based insurance company Cigna is in the process of removing all one-room surgery centers in New Jersey from its network, according to a Cigna contract manager. Jeffrey Shanton, chair of the advocacy and legislative affairs committee for the New Jersey Association of Ambulatory Surgery Centers, reached out to Cigna after a surgery center physician indicated that the insurance company intended to terminate existing in-network contracts with one-room centers. Courtney A. Bennett, contract manager for Northern New Jersey with Cigna Healthcare, responded to Mr. Shanton, "Cigna is in the process of removing all one-room surgery centers from the network."
3. Surgery centers report payment errors following postponement of physician rate cut. Surgery centers across the country have reported that local Medicare contractors have not yet updated their ASC payment files to reflect the recent postponement of the physician rate cut, according to an ASCA release. The failure to update these payment files is causing underpayments for procedures that are tied to physician office rates for certain ASCs. The ASCA is working with CMS to determine when the problem will be fixed. ASCs that believe they have been underpaid are advised to resubmit affected claims.
4. Out-of-network Illinois surgery center battles Aetna over $3.4 million in bills. Oak Brook Surgical Centre and insurance company Aetna are battling in court over $3.4 million in bills, according to a Crain's Chicago Business report. Oak Brook Surgical Centre submitted nearly 280 claims to the insurance company between 2005 and 2010, according to a financial report by the surgery center. Aetna has paid approximately $341,000, or less than 10 percent of the total $3.8 million billed, according to the report. The surgery center contends it reasonably relied on Aetna's assurances that the claims would be covered and that the court should prevent the insurer from rescinding those statements. Aetna disputes the claims of Oak Brook Surgical Centre, which is not part of Aetna's network of providers.
5. Aetna sues 7 California surgery centers over alleged overbilling. Insurance company Aetna is suing seven California surgery centers for a billing system that the payor claims "recklessly subverts" healthcare delivery by allegedly overcharging for certain services. Aetna is suing to prevent the centers from waiving co-insurance payments that patients are supposed to be charged when they use out-of-network physicians or facilities. The company is saying the centers illegally lured patients by not requiring co-payments for out-of-network care and then billed Aetna up to 2,500 percent more than the payments for in-network providers.
Related Articles on Billing, Coding and Collections:
5 Mistakes Surgery Centers Make When Dealing With Payors
Surgery Center of Oklahoma Posts Prices for Common Surgical Procedures
New ICD 10 Deadline Proposed for 2014