As more insurers balk at spine surgery pay, ASCs fight back

Two ASCs have recently filed lawsuits against different payers over reimbursement for spinal procedures. 

On Jan. 20, Melbourne, Fla.-based Surgery Center of Viera filed a lawsuit against Cigna and Strategic Enterprise Solutions seeking $434,000 for reimbursement of spinal surgery to treat a patient with "chronic (and progressively worsening) debilitating back pain," according to court documents. 

The center alleges Cigna determined the surgery medically necessary but only reimbursed about $75,000 on a billed amount of $405,373.

The suit, filed in Florida Middle District Court in Orlando, also alleges Cigna used a "mystery re-pricing program" in calculating the reimbursement amount, rather than a previously established re-pricing contract the center says should have resulted in an 80 percent reimbursement rate, or $350,693.

Additionally, the Center for Pain Management in Alexandria, Minn., remains out of network with Blue Cross and Blue Shield of Minnesota after disputing the payer's conclusion that spine cases should have been in the hospital. 

The payer terminated its contract over safety concerns in October. The Blue Cross review examined 20 elderly patients, 19 with spine pain, who the payer said should have undergone their treatments in the hospital. The practice, which includes multiple locations and an ASC, disputed Blue Cross' claims and wants to resolve the issue. 

The patients received transforaminal epidural steroid injections or radiofrequency ablation without complications. Blue Cross also accused the physicians of unnecessarily inflating the cost of care with spinal injections ahead of treatment.

Mike Hatch, attorney for the Center for Pain Management, said the practice used mild anesthesia because transforaminal epidural steroid injections and radiofrequency ablations include painful needle sticks.

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