TMA Successes Mount in HRI Lawsuit
Court Invalidates HRI/Metro Teachers “Recovery Action;” HRI Counterclaim Dismissed
The Tennessee Medical Association has scored another win in its ongoing legal case against Health Research Insights, Inc. (HRI) and Nashville’s Metropolitan Board of Public Education (MBPE), arising out of a challenged “recovery audit.”
A ruling by Circuit Court Judge Thomas Brothers agreed with the TMA position that HRI’s demands for refunds from physicians based on accusations of alleged “upcoding,” made on behalf of MBPE, were barred by the 18-month statute of limitations on recoupments by insurance entities in Tennessee. The partial summary judgment, requested by the TMA and two of its members, clarifies that the demand letters and threatening calls made in 2009 were based on stale claims not subject to reopening, and thus the demands are time-barred.
“This decision upholds the statutory 18-month limit on raising claim overpayments, which had been ignored in these demands,” said TMA President B W. Ruffner, Jr., MD. “The TMA fought hard to pass this statute to protect its members, their practices and their patients from insurers seeking to reach back too far to challenge claims on which the books have been closed.”
This is the second in recent favorable developments. In June, HRI dropped its countersuit against the TMA shortly after filing it. (Under State procedure rules, however, HRI could refile the cases within one year.)
“The TMA is pleased but not surprised by these victories,” added Dr. Ruffner. “These developments underscore the importance and effectiveness of TMA’s work on behalf of Tennessee’s physicians.”
Background
The TMA filed suit against HRI in June 2009 challenging the legality of payment demand letters the private recovery contractor sent to many physicians contracted through BlueCross BlueShield of Tennessee to care for employees of MBPE.
The heavy-handed letters demanded payments from physicians based on claims data, made without a prior review of medical records to determine if the services documented in the records justified the physicians’ CPT coding. Although BlueCross adjudicated and paid the claims and did not contend there had been overpayments or upcoding, HRI’s letters demanded an amount it contended physicians owed based on what HRI described as an “algorithm.” Despite the fact that the claims were beyond statutory and contractual time limits for reopening, HRI demanded records if the physicians disputed the demands.
In a deposition taken by the TMA, HRI’s “independent coding expert,” who reviewed the plaintiff’s records, agreed that the claims of the two physician plaintiffs were properly billed.
Despite this testimony, HRI filed a countersuit against the TMA in April 2010 alleging, among other things, that the TMA had used its “market share” and conspired with BlueCross to drive up the costs of physician reimbursement in Nashville. That claim in the lawsuit was withdrawn within days, followed by the dismissal of the rest of the counterclaim soon thereafter.
Dr. Ruffner said this is just one example of the advocacy benefits members receive from the TMA and urged physicians to give additional support for this ongoing case and future legal advocacy for members and their patients by contributing to the TMA Legal Fund, www.tnmed.org/legalfund.