Vanguard Plastic Surgery, PLLC (VPS) filed suit on Monday in Broward County, Florida state court against Florida’s Division of State Group Insurance, or DSGI. The complaint comes after DSGI allegedly underpaid the plaintiff following their submission of a claim for a surgery they were required to perform under the Emergency Medical Treatment and Active Labor Act (EMTALA).
The plaintiff is a provider of emergency and reconstructive services. They are board-certified plastic surgeons who perform “skin grafts, flap procedures, microsurgeries, and other surgical services that allow for complex repair of human tissue after trauma, cancer, and congenital defects.” Under EMTALA, physicians who work for VPS are required to treat any individual with an emergency medical condition, “regardless of the individual’s insurance coverage or ability to pay.”
As a coverage provider of healthcare services in Florida, DSGI has conditional agreements to provide reimbursement to their members for their healthcare services. The patient was an insured member with DSGI under their PPO plan, a policy which provides coverage for emergency services performed by the plaintiff.
The patient came to Plantation General Hospital in January 2018, where they presented with “significant complications from a traumatic injury to Patient’s left forearm resulting from a laceration with glass.” The severity of the symptoms the patient presented, including severe pain and loss of sensation, led the plaintiff to deem the injury an emergency requiring immediate medical attention. Absent this medical attention, the plaintiff describes that the patient could have experienced serious impairment or serious dysfunction to their body.
The plaintiff provided medical services to the patient in the form of a complex surgery, which they assert “was necessary to relieve or eliminate the medical conditions for which patient initially sought treatment.” Following the surgery, VPS submitted claims to the defendant for reimbursement which totaled a sum of $53,590.00. The defendant’s claims administrator paid the plaintiff 6.1% of their claim, or $3,254.93. VPS argues that they provided services as they were required to under EMTALA and did so under the impression and understanding that the services would be reimbursed by the DSGI usual rates.
The plaintiff notes in the complaint that the rate paid by the defendant is “significantly less than the rates required by Florida law,” which provides that the defendant must at least pay “the lesser of the billed charges or the fair market value of the services provided.”
The complaint cites violations of six separate sections of Florida law, unjust enrichment/breach of implied-in-law contract and breach of implied-in-fact contract. They are seeking favorable judgment on all counts, prejudgment interest, costs, a trial by jury, and any other relief deemed proper by the Court.The plaintiff is represented by Shapiro, Blasi, Wasserman & Hermann.
