The Arizona Court Supreme Court has declined to review a petition challenging a lower court ruling that SCF Arizona paid a “reasonable amount” to two ambulatory surgery centers. In so doing, the court rejected the argument that SCF violated state law by using a bill reviewer to recommend what to pay.
Canyon Surgery Center and El Dorado Surgery Center (now known as Tucson Surgery Center) filed the petition for review with the Arizona Supreme Court following the Court of Appeals ruling last September that upheld a 2008 Maricopa County Superior Court ruling.
With this decision by the Supreme Court, the Court of Appeals opinion is now the established standard for these types of cases, explained attorney Mark Worischeck of Sanders & Parks, a Phoenix-based law firm that specializes in complex litigation and represents a number of insurers locally and nationally. SCF retained Worischeck and colleague Debora Verdier after the surgery centers filed suit in 2003.
Said Don Smith, president and CEO of SCF Arizona, “This outcome underscores what we believe the public policy should be –that the workers’ compensation system should not be a target for cost-shifting maneuvers and unreasonable pricing schemes.”
The surgery centers sought to force SCF, the state’s leading workers’ compensation carrier, to pay 100 percent of their billed charges, even though the centers were unable to establish that those charges represented the reasonable value of those services.
After the Court of Appeals’ decision, Worischeck said, “The court’s ruling strikes a blow to healthcare providers who seek to impose their unreasonable charges on Arizona’s employers.”
SCF paid the two centers $3.59 million for services rendered to injured workers insured by SCF. Those payment amounts were recommended by Qmedtrix, a third-party vendor.
SCF routinely reviews medical bills for reasonableness where the reimbursement amounts are not established by a negotiated contract or by the Industrial Commission of Arizona’s Medical Fee Schedule. The use of an outside vendor, such as Qmedtrix, to assist in reviewing such bills is standard within the insurance industry.
The surgery centers initially sued SCF seeking an additional $4.69 million. They asked the court to rule that their billed charges were reasonable, even though Canyon accepts 30 percent or less of billed charges from 82 percent of its payers and El Dorado accepts 24 percent or less from 89 percent of its payers. SCF paid almost twice those amounts.
When the case was at the Superior Court level, Judge Edward Burke wrote in his decision: “This court finds that [Canyon Surgery Center and El Dorado Surgery Center] have received the reasonable value of their services from SCF, if not more.”
Topics Workers' Compensation Oklahoma Arizona
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