State medical association files lawsuit on allegations of overbilling
Wednesday, June 17, 2009
The Tennessee Medical Association is suing a company that has accused doctors of billing for more services than they provided.
The association last week filed a lawsuit in Davidson County Circuit Court against Franklin, Tenn.-based Health Research Insights, which specializes in recovery of payments made on overbilled claims. The suit also lists as defendants the Metro Board of Public Education in Nashville, that hired the company to look into school employees' medical claims, and BlueCross BlueShield of Tennessee, which administers Metro Schools' self-funded health benefits plan.
The TMA maintains that Health Research Insights unfairly accused physicians of fraud and demanded reimbursement for alleged overpayments that have not been proven, said Yarnell Beatty, general counsel for the TMA.
The lawsuit states Health Research sent letters to doctors accusing them of overbilling BlueCross for medical services, he said.
NEW LEGISLATION
A bill, SB0549, which recently passed the state Legislature but has not yet been signed by Gov. Phil Bredesen, requires inquiries into allegations of overbilling be led by the insurance company contracted with the physicians, not an outside company. The bill is in response to concerns from physicians about what they say are unwarranted allegations of overbilling from companies that specialize in recovering payments for inflated medical claims, said Rae Bond of the Chattanooga and Hamilton County Medical Society. Those companies also have ignored state law that limits retroactive payment denials to a window of 18 months after a claim was paid, she said.
In some cases, doctors are accused of classifying a patient's visit as a "complex" visit that would warrant more payment, rather than an "intermediate" or "simple" visit. TMA officials say Health Research could not know these classifications were unfair without looking at the doctors' records of those visits.
"We're saying that they're speculating," Mr. Beatty said. "Health Research is saying, 'Well, you're guilty until proven innocent.'"
Thad Perry, chief executive of Health Research Insights, did not return a call Tuesday seeking comment.
BlueCross officials have said they have no connection to Health Research and emphasized the insurer is not accusing the doctors of overbilling, according to a news release from the TMA.
Scott Wilson, spokesman for BlueCross, said Tuesday the company cannot comment on a pending lawsuit.
Typically a discrepancy over payment would be worked out between the insurance plan and the medical provider, but Health Research is asking for repayment based solely on insurance claims records, which do not give details of what happened at an office visit, Mr. Beatty said.
Due to federal privacy regulations, the doctors cannot release the medical records to Health Research since they have no contract with the company, Mr. Beatty said.
In response to these kinds of accusations from "overpayment recovery" companies, a bill that recently passed the Tennessee Legislature requires overpayment recovery to go through the third-party administrator of the insurance plan, which in this case would be BlueCross, said Rae Bond, executive director of the Chattanooga-Hamilton County Health Department.
"I think the primary concern is protecting patients' private health information and also just ensuring fair treatment for physicians," she said.
