UnitedHealthcare presses EBCT center for $100K in back claims

Sep 5, 2007

Another imaging facility is reporting friction with insurance giant UnitedHealthcare of Minneapolis. In the latest episode, a Southern California imaging center is contesting UnitedHealthcare's claim that it is owed nearly $100,000 in back payments for electron beam CT (EBCT) scans that the insurer says shouldn't have been paid -- because EBCT allegedly doesn't use x-ray beams.

This newest dispute is between UnitedHealthcare and Advanced Body Scan of Newport (ABSN), a single-modality (EBCT) independent imaging facility in Newport Beach, CA, that performs diagnostic CT studies based on referrals from physicians in its community. The center also offers screening tests that it markets directly to the public.

In June, UnitedHealthcare informed ABSN that the payor had conducted an audit of payments made to the center and had identified an overpayment of $98,568.87, according to a letter provided to AuntMinnie.com by ABSN.

The payments were for claims made on patients who received services between November 2004 and December 2005. The billed charges were inappropriate because the services billed were not the services performed, the letter said:

The codes which were used to represent the imaging services that were billed for indicate that the services were performed utilizing x-ray beams. However, it was discovered that the services were performed by using an EBCT (electron beam computed tomography). In addition to the services not being rendered as billed, EBCT scans are not a covered benefit.

Dr. Alan Boyar, who owns ABSN along with Dr. Greg Robertson, said he was baffled by the letter, because EBCT does indeed use x-ray beams, which are created when the scanner's electron beam hits a tungsten target.

A second letter, dated July 16, 2007, claimed that ABSN had billed for screening services for asymptomatic patients, and tacked on another $15,627.43 to the total demanded for repayment for clients billed through PacifiCare of California, an insurance provider that UnitedHealthcare bought in December 2005.

Boyar said he was confused by this letter as well, as it seems to claim that since ABSN also performs screening studies, all studies done on UnitedHealthcare subscribers must have been screening exams.

The letter went on to state that "performing a set of 'regular' CT scans and billing them separately in order to have a total body scan covered is not appropriate, nor reimbursable."

"They're accusing us of fraud for reconverting physician-ordered tests for body scans for insurance," Boyar said. "But we just do what physicians order. If they order tests for multiple areas, we do that."

Although ABSN is a Medicare contractor, it has not contracted with any of the available discount preferred provider organization (PPO) plans until recently, Boyar said. For several years, ABSN has billed UnitedHealthcare as an out-of-network provider for diagnostic studies initiated by a physician order.

"Insurance is only billed when patients are sent in from outside physicians with an order for the exam that must include diagnosis," Boyar said. "We do our own billing by paper and all claims include a copy of the physician's order and our radiologist's report."

ABSN is not the first imaging center to report trouble with UnitedHealthcare. On May 17, Radiological Associates of Sacramento (RAS) in California filed a lawsuit charging the insurer with breach of contract for cutting reimbursement for multiple scans of contiguous body parts.

UnitedHealthcare representatives did not respond to AuntMinnie.com's request for comment. But the dispute does beg the question of whether other EBCT facilities will receive letters from UnitedHealthcare requesting repayment for services. Whatever happens, UnitedHealthcare's actions show just how tangled health insurance can be in the U.S.

"Say your house catches fire and you get an insurance settlement and pay a contractor for repairs," Boyar said. "Then, a year later, your insurance company determines that the claim was outside their coverage. They are going to go after the beneficiary to recover their money, not the contractor. Why is healthcare different? United Healthcare appears to be going after the contractor instead of the beneficiary for alleged payments outside of coverage."

By Kate Madden Yee
AuntMinnie.com staff writer
September 6, 2007