From an ASC that allegedly hid malpractice suits from an insurer to another that accuses a commercial payer of reimbursing $190,600 less than the cost of a spine surgery, here are three ASC-insurer disputes that grabbed headlines in October:
1. A Berkshire Hathaway insurance company asked a California court to rescind the professional liability policy of an ASC accused of not disclosing seven malpractice lawsuits in its renewal application. One of the lawsuits was brought by a patient who accused a physician at the ASC of performing surgery on a patient one day before he surrendered his license. The insurer said that it would not have entered into an insurance contract with the ASC and surgeon if it had known about the seven malpractice suits.
2. A New Mexico 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 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 many 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. A Florida surgery center 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. The surgery center could receive more than $89,000 for Aetna's alleged refusal to disclose the information, according to court documents.