3 recent lawsuits involving ASCs, payers

Alan Condon -

From an insurer that allegedly reimbursed an ASC $190,600 less than the cost of a spine surgery to another that accused three ASCs of filing more than $5.7 million in fraudulent claims, here are three high-profile lawsuits involving surgery centers and payers from the past 30 days:

1. Melbourne, Fla.-based Surgery Center of Viera accused Aetna of using an undisclosed "mystery repricing program" to reimburse the ASC $33,380 for a spinal procedure that allegedly cost $223,988. The ASC considered the surgery to be medically necessary for a patient who was covered under a corporate plan administered by Aetna under the Employee Retirement Income Security Act. The suit aims to force Aetna — which approved a prior authorization for the procedure — to disclose its repricing guidelines. ERISA penalizes insurers up to $110 a day for withholding administrative details from suppliers. Viera could receive more than $89,000 for Aetna's alleged refusal to disclose the information, according to court documents.

2. Albuquerque (N.M.) Ambulatory Eye Surgery Center alleges that Chicago-based insurer CNA acted in bad faith when it denied a claim for pandemic-related losses without visiting the property or viewing public information. But a U.S. District Judge said Oct. 13 it isn't clear if the losses are covered by the group's policy with CNA and that the alleged presence of COVID-19 at the property was not enough to show "physical loss or damage," which would typically be covered under the practice's policy. The lawsuit is one of 703 similar disputes between providers and insurers during the pandemic. Most courts sided with insurers and found that government stay-at-home orders did not result in covered losses.

3. Geico is suing three New Jersey ASCs, citing more than $5.7 million in fraudulent insurance claims. The surgery centers are accused of filing thousands of fraudulent claims — including spine surgery, anesthesia services and pain management injections — from 2014 to 2021. The services were allegedly provided to car accident victims eligible for Geico no-fault insurance coverage, according to court records. Geico claims that police reports indicated many of the accidents were low-impact, patients' vehicles were drivable afterward and no one was seriously injured, if at all.

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