Five details:
1. Working on behalf of a patient with an Employee Retirement and Income Security Act plan, the ASC sought preauthorization for the surgical services.
2. The hernia-related procedures were authorized individually before they were performed and the same procedure codes were properly billed after the treatment, according to court documents.
3. The surgery center claims that as an out-of-network provider, the $117,652 bill was sent to Viant, a third-party pricing company, for repricing. The ASC said it received a $12,478.66 payment for one CPT code only; United Healthcare paid $5,794.90, and $6,689.76 was applied toward the patient’s coinsurance and deductible.
4. Contrary to the original authorization for all procedure codes, the repricer only paid on the main procedure code and considered all other procedure codes as lesser included charges which were not paid separately, according to the complaint. Lesser included charges is a feature for contracted providers, which the ASC said it is not.
5. United Healthcare did not respond to Becker’s request for comment.
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