“The breast surgeon was awarded $440,000 for performing a routine breast reduction for which he has historically been paid and accepted between approximately $6,000 to $30,000…………….”
By Doug Aldeen – ERISA Healthcare Attorney and Fractional General Counsel – Visit my website
Happy Mother’s Day.
The New York Times recently featured a story regarding Emblem’s lawsuit against a breast surgeon in New York that alleges abuse of the NSA/IDR process. The complaint ( attached) graphically illustrates how a statute that was intended to reduce the costs of treating with out-of-network providers has been turned completely on its head. The allegations are straightforward. I think the solutions are as well:
Allegations:
The breast surgeon was awarded $440,000 for performing a routine breast reduction for which he has historically been paid and accepted between approximately $6,000 to $30,000 by Emblem or other insurers or self pay patients;
B) The breast surgeon, by choice, does not participate in any of Emblem’s provider networks. In fact, instead of using an Ambulatory Surgical Center (“ASC”) to perform the surgery, the breast surgeon routinely schedules his surgeries at an INN facility;
C) The breast surgeon has been awarded completely irrational amounts in proceedings under the Federal No Surprise Act (“NSA”), where they have fraudulently misrepresented to Independent Dispute Resolution Entities (“IDREs”), among other things, that the cost of a routine breast reduction is $600,000. The breast surgeon’s “billed charge” of $600,000 for a breast reduction – i.e., $300,000 each for the primary and assistant surgeons – is a fictitious, non-market-based charge that bears no relationship to the amount they have regularly accepted from Emblem, other insurers and self-pay patients;
Sunday Morning Bathroom Read Plan Sponsor/Investor Takeaways and Market Implications:
A) Immediately amend the NSA to include a judicial review of any IDR decision. The law currently provides for “baseball style” arbitration with zero ability to appeal an adverse decision. That is un-American.
B) Amend SPD to contract around excessive IDR awards by carving out reimbursement for services that could also be performed in a less expensive setting. (Think: ASC vs. hospital)
C) File a declaratory action and allege that the NSA ( i.e. “US Government”) is forcing plan sponsors to violate their ERISA fiduciary duty by significantly overpaying for medical services without full due process. See #1 above.
D) Restrict and limit the type of “ancillary services” by CPT code that are subject to eligibility for reimbursement under the NSA;
E) Limit the calculation of any IDR award to medical services that could also be performed in a less expensive setting.
F) Investors: HCA stock might be a dood buy
If a breast reduction is worth $440,000, what is a breast augmentation worth?
