Pittsburgh-based Highmark claims Bridgeville, Pa.-based Radiance Surgery Center overbilled it by $1.7 million over two years, according to a Pittsburgh Post-Gazette report.
The dispute centers on claims from January 2010 through May 2012 and relates to supplies that had historically been billed separately. Highmark claims it had notified ambulatory surgery centers that payments for supplies would be bundled into reimbursement for the surgical procedure, but Radiance claims these notifications were unclear.
Documents showed Radiance executives felt Highmark was taking advantage of its market dominance as an insurer by bundling surgical supplies into one payment without raising the payment amount, according to the report.
As a result of the dispute, Highmark began requiring reviews of every Highmark patient's medical record and procedure information before it would reimbursement Radiance. The surgery center claimed this violated their contract. Last week, Allegheny County Common Pleas Judge Judith Friedman ordered Highmark to reimburse those claims, pending a hearing scheduled for Nov. 12-13.
Attorneys for Highmark and Radiance did not disclose many details of the case, but they did share some comments in the Pittsburgh Post-Gazette report. A spokesperson for Radiance said "efforts by insurers to recover payments from providers for services rendered to covered patients — particularly when they involve many claims over a long period of time and/or involve a number of providers — can call into question the insurer's own business practices," according to the report.
W. Dennis Cronin, Highmark's vice president for financial investigations and provider review, said the payer is "concerned that there are more inappropriate billing schemes being perpetrated by Radiance that will result in additional recovery disputes, and we cannot continue chasing Radiance and hoping they are willing to refund the overpayments," according to the report.
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