On Wednesday a case was filed in the Middle District of Florida by Surgery Center of Viera, LLC against Cigna Health and Life Insurance which alleged that Cigna incorrectly processes claims and underpays them due to a practice of “bundling” charges for a higher discount.
When a patient receives medical treatment, the procedures that are performed by the treating doctor are recorded in a standardized format for billing purposes on a form known as a HCFA, or Health Care Finance Administration form. Each procedure is labeled with a standardized code drawn from the Healthcare Common Procedure Coding System (HCPCS).
When contracts are written for reimbursement of services, frequently the pricing is dependent on the HCPCS code and the level of difficulty or skill involved in performing that procedure. However, some procedures in the HCPCS system are related to one another or are so routine as to be considered a part of a more complicated procedure.
For example, placing stitches has its own procedure code, but is considered an intrinsic part of performing surgery and in that context is not reimbursed separately, a practice known as “bundling”. The plaintiff alleged that Cigna took unauthorized bundling discounts on the reimbursement of bills from the plaintiff, resulting in a much lower contractual payment than was contemplated. While conceding that Cigna had two possible contractual pricing structures, the plaintiff alleged that Cigna underpaid under both potential contracts.
Surgery Center of Viera is suing for breach of contract, failure to provide explanation of processing decisions, quantum meruit and unjust enrichment. The plaintiff is represented by Callagy Law.
