Case Result: Ophthalmologist Awarded $510K After Medicare Tries to Backtrack Its Error

Professional:
Ophthalmologist

Primary issue:
Medicare plan administrator sought $250,000 from ophthalmology practice after three years of reimbursing at an incorrect rate.

Argument:
Our client, a Port Richey, Florida-based ophthalmologist, had a contract with United Healthcare of Florida, along with its affiliate, WellMed Medical Management, dating back to 2010.

United had been reimbursing the ophthalmologist regularly for Avastin (for diabetic eye disease, retina problems and age-related macular degeneration), processing the claims using CMS ASP Drug Pricing Files; WellMed was reimbursing by the default rate of a percentage of the billed charges. This meant the ophthalmologist got a higher reimbursement rate from WellMed than United. WellMed, upon discovering its error, ordered the ophthalmologist to pay back $250,000, which WellMed contended it was owed because of the overpayment.

United and WellMed pointed to the fee schedule in the contract, saying it “is actually a sample and that the actual fees are derived from ‘market standard specifications’ which change regularly.”

Benefit of Using Chapman Law Group:
Our client was denied an appeal and a request for reconsideration, so we filed multiple briefs, a counter-claim and a counter motion for summary judgment. At arbitration, we maintained that, per the Medicare plan administrator contract, “reimbursement is governed by the ‘Default Percentage of Eligible Charges,’ which would equal 50% of [Powers’s] usual and customary charge for the drug. In other words, … WellMed had been correctly reimbursing him under the terms of the Contract, and that it has no basis to claim any overpayment.”

Result:
At arbitration, the arbitrator rejected United and WellMed’s fee schedule argument, calling it “an incomprehensible way of trying to determine rates. Indeed, it is apparently so confusing that WellMed itself arrived for more than six years at a rate it now claims is excessive.” Our client was awarded $510,706 in damages.

Area of Law:
Medicare Reimbursement, Denial, and Partial Payment of Claims 

Disclaimer:
This information is a sample of our past results. Prospective clients may not obtain the same or similar results. Every case is different and each case must be evaluated and handled on its own merits. The circumstances of your case may differ from the results provided. The information provided has not been reviewed or approved by the State Bar.