At the 19th Annual Ambulatory Surgery Centers Conference in Chicago on Oct. 27, Doug Prochnow, partner at Edwards Wildman Palmer law firm, discussed the $3 million verdict in the landmark Chatham Surgicore v. HCSC case.
Mr. Prochnow helped represent Chatham Surgicore, an unlicensed, out-of-network surgery center, in its suit against HCSC, more commonly known as BlueCross BlueShield of Illinois.
Chatham was seeking damages for failure to pay millions of dollars in surgical facility fees for services delivered to patients insured through BCBSIL. The theory from which Chatham argued its case was promissory estoppel because the insurer made unambiguous promises to the provider to pay for services.
A crux of Chatham's case was that prior to rendering services, employees had called BCBSIL to verify coverage, and with each call coverage had been verified.
"Every time you call that essentially creates an oral contract between you and the insurer for the insurer to pay facility services provided to that patient," Mr. Prochnow said.
The trial was hotly contested and lasted through 10 years of litigation. BCBSIL raised a number of defenses, but ultimately the judge awarded $3 million to Chatham for unpaid fees, plus 9 percent interest on all of their claims over a 10-year period. The total recovery paid to Chatham was nearly $5.9 million.
For other surgery centers struggling with unpaid fees, Mr. Prochnow said to always call the insurance company to verify who will be providing the services, what services will be provided and who will be receiving the services. Keep a written record of each coverage verification call.
"As long as you make these phone calls and document verification coverage, at that point you have an enforceable promise that is [the payor] doesn't pay you directly, you can take them to court and recover," he said.
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Mr. Prochnow helped represent Chatham Surgicore, an unlicensed, out-of-network surgery center, in its suit against HCSC, more commonly known as BlueCross BlueShield of Illinois.
Chatham was seeking damages for failure to pay millions of dollars in surgical facility fees for services delivered to patients insured through BCBSIL. The theory from which Chatham argued its case was promissory estoppel because the insurer made unambiguous promises to the provider to pay for services.
A crux of Chatham's case was that prior to rendering services, employees had called BCBSIL to verify coverage, and with each call coverage had been verified.
"Every time you call that essentially creates an oral contract between you and the insurer for the insurer to pay facility services provided to that patient," Mr. Prochnow said.
The trial was hotly contested and lasted through 10 years of litigation. BCBSIL raised a number of defenses, but ultimately the judge awarded $3 million to Chatham for unpaid fees, plus 9 percent interest on all of their claims over a 10-year period. The total recovery paid to Chatham was nearly $5.9 million.
For other surgery centers struggling with unpaid fees, Mr. Prochnow said to always call the insurance company to verify who will be providing the services, what services will be provided and who will be receiving the services. Keep a written record of each coverage verification call.
"As long as you make these phone calls and document verification coverage, at that point you have an enforceable promise that is [the payor] doesn't pay you directly, you can take them to court and recover," he said.
More Articles on Billing, Coding and Collections:
What Are the Major Disputes With Out-of-Network Payors?
10 Strategies for Effective Payor Negotiations
7 Best Practices to Reevaluate the Revenue Cycle