Issue link: https://beckershealthcare.uberflip.com/i/1293457
14 ASC MANAGEMENT Cigna loses motion to dismiss ASC suit over 'systematic,' 'indiscriminate' claim denials By Angie Stewart C igna's motion to dismiss a lawsuit brought by South Amboy, N.J.-based Metropolitan Surgical Institute was partially denied, according to a document filed July 31 in the New Jersey District Court. e ASC sued Cigna for its "systematic denial of legitimate and proper claims" and failure to make payment upon those claims, court documents show. Cigna was accused of "automatic, indiscriminate" denial and underpayment of claims for medical services provided beginning in 2015. Metropolitan Surgical Center alleged that Cigna's actions violated the Employee Retire- ment Income Security Act of 1974, New Jersey state law, and contractual, fiduciary and other obligations owed. As a result of the allegedly illegal actions, the ASC said it incurred more than $2.04 million in losses. In a motion to dismiss, Cigna countered on seven points, including that the ASC did not exhaust internal claims procedures in the ERISA plans before filing the suit; is not en- titled to compensatory damages; and failed to identify the plans at issue. U.S. District Judge Michael Shipp ruled in favor of Metropolitan Surgical Institute on six points, opening "the door for the facility to sue for payment of the denied claims for which Cigna had been avoiding payment for years," said Keith Roberts, healthcare lawyer and co-chair of litigation at Brach Eichler, who filed the lawsuit on the ASC's behalf. "e ASC successfully defeated Cigna's motion to dismiss the case asserting that the out-of-networks claims could not be prosecuted against the carrier because the assignment of benefits was invalid," Mr. Rob- erts said in a prepared statement. "e court specifically upheld the assignment." n HCA Healthcare names new operations VP for 10 ASCs By Angie Stewart N ashville, Tenn.-based HCA Healthcare selected a new ambulatory surgery vice president of operations for its Gulf Coast Division. Four things to know: 1. Michael Nelson assumed the role Aug. 17. He oversees operations, business development and physician partnerships for 10 surgery centers in the Houston and South Texas markets. 2. Mr. Nelson joined the company from DaVita, where he spent two years as regional operations director for 18 Houston-area facilities providing dialysis treatment and physician services. 3. Prior to DaVita, Mr. Nelson held a four-year tenure in a variety of roles at Houston-based Nobilis Health Corp., which has a portfolio of 13 ASCs and four hospitals in Texas and Arizona. 4. Evan Ray, chief administrative officer of HCA Healthcare Gulf Coast Division, said in a pre- pared statement that Mr. Nelson's "extensive experience working with a variety of outpatient care facilities and provider groups will be a tre- mendous asset in his new role" and will allow for a smooth leadership transition. n Former pain clinic exec sentenced to prison in $4M kickback scheme: 5 details By Laura Dyrda F ormer CEO of Gallatin, Tenn.-based Comprehensive Pain Specialists John Davis was sentenced to prison for his role in a $4 million Medicare kickback scheme. Five things to know: 1. Mr. Davis was sentenced to 42 months in prison and one year of supervised release for participating in the scheme. He is also required to forfeit $770,036. 2. In 2019, Mr. Davis was convicted of one count of conspiracy to defraud the U.S. and violate the Anti-Kickback Statute and seven counts of violating the Anti-Kickback Statute. 3. While Mr. Davis was CEO of the pain group, he arranged for durable medical equipment referrals to co-conspirator Brenda Montgomery and her company CCC Medical in exchange for kickbacks. He received $770,000 in kickback payments disguised as payments to a company he had registered in his wife's name. 4. Mr. Davis and Ms. Montgomery received $2.9 million in im- proper payment from Medicare. Mr. Davis then used the funds to pay bonuses to CPS providers that ordered DME from CCC Medical. 5. Ms. Montgomery pleaded guilty to the scheme on Jan. 7, 2019 and is serving a 42-month prison sentence. n