Spine practices vs. insurers: 2 disputes making headlines

Payer Issues

A Florida ASC and a Minnesota practice made headlines in January as the physician groups pushed back against commercial payers in issues relating to spine care.

Two payer-physician battles to know in spine:

1. Surgery Center of Viera filed a lawsuit Jan. 20 against Cigna. The Melbourne, Fla.-based ASC is seeking $434,000 for reimbursement of spinal surgery to treat a patient with "chronic (and progressively worsening) debilitating back pain," according to court documents. The center alleged that Cigna determined the surgery was medically necessary but only reimbursed about $75,000 on a billed amount of $405,373.

Cigna allegedly used a "mystery re-pricing program" in calculating the reimbursement amount, rather than a previously established re-pricing contract that should have resulted in an 80 percent reimbursement rate, or $350,693, according to the ASC, which also accuses the insurer of dodging a legal responsibility to produce applicable records related to the reimbursement and its calculation.

2. The Center for Pain Management in Alexandria, Minn., remains out of network with Blue Cross and Blue Shield of Minnesota after the insurer ended its contract over safety concerns in October.

Blue Cross' review of the practice examined 20 elderly patients, 19 with spine pain, who the insurer said should have been treated in the hospital. The patients received transforaminal epidural steroid injections or radiofrequency ablation without complications. Blue Cross also accused the physicians of unnecessarily inflating the cost of care with spinal injections before treatment.

The practice, which includes multiple locations and an ASC, disputed Blue Cross' claims and said it wants to resolve the issue.

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