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Earlier this year, Abril Law filed a Petition for Declaratory Relief on behalf of a physician group, which sought a declaration of its rights under a written agreement entered into with a Florida Health Plan.  Specifically, the physician group pursued a declaration wherein the Court establishes that, as a matter of law, the Health Plan erroneously interpreted the Compensation Schedule contained in an amendment to their written agreement. This resulted in significant underpayments for a multitude of claims properly billed by the physician group.

In 2012, the physician group entered into a contract with the HMO Health Plan, and agreed to provide gastroenterology and hepatology services to subscribers enrolled in the HMO Health Plan in exchange for certain and defined fixed sums based upon and established by contractual payment provisions contained within the contract.

The HMO was contracted to reimburse the physician group at a specific Medicare Allowable rate. Additionally, the HMO contracted to pay the physician group a “carve-out” rate for certain enumerated medical procedures, as well as a defined rate of compensation for another series of CPT codes that the physician group provided for the HMO members at an unaffiliated, third-party endoscopy center.

In 2016, the physician group began providing diagnostic endoscopy services at their affiliated locations, eliminating the need for a third-party endoscopy center. Because the HMO Health Plan no longer needed to reimburse a third-party center, the parties entered into an executed Amendment that modified the level of reimbursement payable to the physician group by the HMO Health Plan to a specific Medicare Allowable Rate for a series of CPT codes.

Notwithstanding the foregoing, the physician group contends that the HMO Health Plan has underpaid the claims pursuant to the Amendment, while the HMO Health Plan alleges that the Amendment did not modify the “carve-out” rates. The action is set for hearing in November.

Abril Law continues to advocate for this physician group and healthcare providers who have been improperly reimbursed.