Powers’s contract with United Healthcare of Florida, along with its affiliate, WellMed Medical Management, dated back to 2010.
United was reimbursing Powers regularly for Avastin — a drug that treats age-related macular degeneration, diabetic eye disease and retina problems — and processed his claims under CMS ASP Drug Pricing Files.
WellMed, however, had been reimbursing Powers a different way: using the default rate of a percentage of his billed charges. Because of this, for more than six years Powers was receiving a much higher reimbursement rate from WellMed than United.
In 2019, WellMed realized its error and ordered Powers to pay back $250,000, an amount WellMed claimed it was owed for its three-year Avastin overpayment.
Ron disputed this fiercely, pointing out that, per the 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.”
Interestingly, United and WellMed brought up the applicability of certain fee schedules, saying that “the fee schedule included in the contract is actually a sample and that the actual fees are derived from ‘market standard specifications’ which change regularly.”
The arbitrator dismissed this 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.”