The contemporary comedian Gallagher is perhaps best known for smashing watermelons with a sledgehammer, covering his audiences with bits & pieces of the delectable fruit. I’m reminded of the resulting mess by this article in the Dayton Daily News:
“When Premier's network contract with Anthem expired on Jan. 1, Anthem stopped paying Premier directly for services at Miami Valley and Good Samaritan hospitals. Anthem sent reimbursement checks of four and five figures to enrollees instead.”
As one might imagine, not everyone who received this windfall forwarded the cash to Premier. And that’s where this whole messy episode gets complicated:
“Now Premier wants its money, taking legal action on what Shaw called "the most egregious cases." He said most of the suits are for bills in the neighborhood of $5,000, but they range from $1,000 to a $99,000 reimbursement check, which the patient said her estranged husband left town with.”
As with an onion, there are multiple layers here (not to mention a distinct, if unpleasant, odor). On the one hand, there is no contract between Anthem and Premier, thus Anthem would seem to be within its rights when it sends checks to its insureds instead. On the other hand, Premier did provide the services, and is entitled to be compensated.
On the gripping hand, however, is this:
“Anthem executives also said the suits were unnecessary because Anthem had offered to pay Premier the money that patients had not passed on to Premier.”
So, Anthem reimburses their insureds for medical services provided by Premier facilities, then agrees that perhaps that was ill-advised and offers to re-pay the claim directly to Premier, and Premier sues Anthem for – what, exactly?
“Citing Ohio law and the terms of Anthem's agreements with enrollees, Premier also has complained to the Ohio Department of Insurance over Anthem's payment policy for emergency services.”
Well, as we know from this episode, “(A)n indemnity insurer licensed to do business under Title 39 of the Ohio Revised Code would not be prohibited under applicable Ohio law from implementing the practice described in Anthem's notification.” So, Premier’s not likely to get very far with the DOI.
Premier’s position is that, regardless of the fact that there is no contract between them and Anthem, they still should have been paid directly; their contention is that “(i)f they'd done that, the patients wouldn't have gotten this windfall and spent it.”
As the saying goes, “what’s your point?” There is no contract, thus Anthem is under no obligation to adhere to Premier’s SOP. My only question is whether Anthem intends to 1099 those folks who received checks, as seems appropriate.
This whole situation reminds me of 2nd graders fighting over who gets to use the monkey bars first. Both sides need to grow up.
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