Cliffside Park, N.J.-based Surgery Center of Cliffside alleges Horizon Blue Cross Blue Shield of New Jersey underpaid the center for a lesion procedure by $58,120.40, court documents show.
Here's what you should know:
1. Surgery Center of Cliffside filed a lawsuit against Horizon Blue Cross Blue Shield of New Jersey and Empire Blue Cross Blue Shield July 3. Empire is a licensee of BCBS.
2. The ASC performed surgery on a patient insured by Empire who had a painful, rapidly growing lesion on the side of her face.
3. In January, prior to the procedure, an Empire representative told Cliffside the insurer would cover 80 percent of Cliffside's facility charge after the patient met a $200 deductible, according to court documents.
The surgery was billed at $60,800. Horizon paid $2,679.60.
4. Cliffside submitted multiple appeals, and Horizon insisted it "correctly paid-out-of-network pricing and policy due to nonparticipating physicians."
5. Cliffside contacted Empire to re-verify the patient's benefits and was again told Empire would reimburse the center for 80 percent of reasonable and customary charges.
6. Empire representatives said during phone calls that Horizon was responsible for pricing claims and reviewing appeals, while Horizon representatives argued the opposite.
On one phone call, an Empire representative said reimbursement is based on the average county rate. A Horizon representative said Empire's plan processed Cliffside's facility fee at 150 percent of the Medicare rate, which Empire denied.
7. The lawsuit says Cliffside still hasn't received "any reasonable explanation" on how Horizon calculated the payment it delivered, or for the decisions on the center's claims or appeals.
"Rather, Cliffside has been stranded in a kind of bureaucratic limbo in which the Defendants each blame the other for the problem. Cliffside has been denied its opportunity to appeal the decision due to bureaucratic issues between the Defendants."
8. As a result, Cliffside claims it is entitled to relief under the Employee Retirement Income Security Act. The ASC is seeking compensatory damages of $58,120.40 and requested a trial by jury.