Payers claim Houston hospitals lower patient rates by increasing insurers' bills

Some payers have accused Houston hospitals of offering out-of-network patients competitive, in-network rates for medical services, then hitting their insurance companies with higher out-of-network bills, reports Statesman.

In the Houston area alone, at least a dozen lawsuits have been filed in recent years against private hospitals that offer patients competitive, in-network rates by upping rates to insurers, reports Houston Chronicle.  

A recent lawsuit involved insurance giant Aetna and North Cypress (Texas) Medical Center. Aetna filed suit against the hospital in February 2015, accusing North Cypress of implementing a fraudulent billing scheme.

The complaint alleged North Cypress implemented an out-of-network strategy that waived Aetna policyholders' out-of-network responsibilities through a prompt payment discount plan and grossly overcharged the insurer for reimbursement. The suit claimed North Cypress committed healthcare fraud in more than 44,000 claims, causing the insurer to overpay North Cypress by $120 million.

Aetna said it filed suit against NCMC after it noticed a spike in patient claims from the hospital, in which patients were charged in-network rates and the insurer was billed out-of-network rates, according to Statesman.

U.S. Senior Judge Kenneth Hoyt of the Southern District of Texas ruled in favor of NCMC in a decision issued June 15. The judge dismissed Aetna's allegations and denied the insurer's request for damages.

More articles on revenue cycle management issues: 

Revenue cycle management — a four-step approach to developing an effective compensation plan for hospitals and health systems
Attorney: Site-neutral payments will increase cost for other payers

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