Cigna filed suit against nearly a dozen Indiana surgical centers on July 6, 2015, alleging the surgery centers bribed Cigna plan members into using their out-of-network benefits by offering co-payment and other fee reductions. This is not the first time Cigna has filed a billing fraud suit against ambulatory surgery centers. Cigna claims that the surgery centers failed to account for the patient payment reductions when submitting claims, thereby subverting Cigna’s cost structures. More specifically, Cigna claims that if a surgery center consistently waives patient payments for out-of-network services (which payments make up part of the usual and customary fee the surgery center submits to Cigna), and accepts Cigna’s payment as payment in full, then the surgery center is actually inflating the usual and customary fee it submits, and is overcharging Cigna for the out-of-network services it provides.
Cigna’s suit claims that Cigna was not aware of the centers’ intention to waive patient payments at the time it paid the centers over $6.5 million dollars in claims. Cigna wants all of its money back. Cigna has stopped making payments to the surgery centers and has requested an injunction against the operation of similar practices by the surgery centers.
The crux of Cigna’s complaint claims that discounting patient payment portions encourages patients to over-utilize out-of-network benefits. To substantiate its position, Cigna claims that the American Medical Association has discouraged “fee forgiving” practices, warning health care providers from offering discounts to patients, and many states have banned the practice.
The outcome of this case will significantly impact the healthcare industry, particularly as it relates to out of network centers and copayment collection issues. Frier Levitt handles out-of-network surgery center litigations and other healthcare provider cases against payors. We have extensive experience counseling clients on copay collection practices and copay collection procedures. Contact Frier Levitt to speak with one of our attorneys.
