Class Action Lawsuit Victory For Pathologists in Florida for Payment of PC-CP

[KeratinPearls]

From: Patrick Montoya
Trial Attorney at Colson Hicks Eidson


I’m pleased to announce that the final tranche of settlement payments totaling over $12 million dollars to Florida hospital-based pathologists were sent out on October 18. I was appointed lead class counsel by Broward County Chief Judge Jack Tuter in March 2021. The class-action settlement we secured compensates pathologists for professional component clinical pathology billing that went unpaid since 2016 by Ambetter. Future payments required under the Settlement Agreement are anticipated to benefit the class of Florida hospital-based pathologists an additional $11 million to $39 million, making the total value of the settlement $23 million to $51 million.

Pathologists are medical doctors who examine bodies and body tissues, perform lab tests, and diagnose diseases. I’m proud to represent pathologists to see that they are properly paid for the valuable work they do on the frontlines of medicine. Especially in this time of Covid-19, it is pathologists who designed the testing, process the testing, and produce the results so that we can all live in a safer environment. This is a historic settlement for Florida based pathologists. We believe it is the first of its kind settlement for an Affordable Care Act plan (“Obamacare”) for laboratory services in the nation.

The specific service that Ambetter stopped paying for is known as the “professional component of clinical pathology” (PC-CP). PC-CP services include, among other things, the pathologists selecting test methods, overseeing quality assurance and quality control measures, supervising laboratory personnel, reviewing abnormal or unexpected results, and being available to discuss the medical significance of laboratory results with clinicians.

We filed a class-action lawsuit on behalf of Ruffolo Hooper & Associates, M.D., P.A. (RHA), who are pathologists. RHA’s primary locations are hospitals in the Tampa area. RHA served as the lead plaintiff and class representative in the lawsuit against Ambetter. I commend RHA for carrying the flag for pathologists and making sure that health insurance companies pay for this valuable and necessary medical service. I’m pleased that Ambetter stepped up and resolved this case to make pathologists whole for past and future payments.

I’ve been at this fight for PC-CP for pathologists since 2004 when we took on a similar case against Blue Cross Blue Shield when it refused to pay for PC-CP. We took that case against the Blues all the way to trial. The jury awarded us every dollar we asked for. We were affirmed by the Florida Supreme Court and that case made payment for PC-CP in Florida the law of the land.

I will continue fighting for PC-CP on behalf of pathologists. I currently have pending cases for pathologists against United, Oscar Health, Bright Health and Molina Health Care. We will continue to protect our pathologists’ rights in the Courts until the insurance companies get it right and recognize PC-CP as a valuable and necessary medical service.

Thanks Patrick and RHA for sticking up for pathologists and our field!!!!!

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[deleted314957]

Is the requirement for a specific (signed) contractual relationship between the pathologist and the patient still required in patient billing cases? Our specific judicial district in FL lost a pc billing case a couple decades ago because the patient did not have a contract with the pathologist. We had to have the admission paperwork changed.

The PC-CP billing has been a legal football for decades with differing decisions depending on the jurisdiction. Jack Bierig (probably dead now) used to do this for the CAP. He also represented groups. There was some huge union, Central States Truckers, that decided to stop paying us and the legal crap dragged out for years. The non paying unions and insurers sent letters to their beneficiaries telling them that they don’t have to pay that and the practice is double dipping. Ruffalo and Hooper have been at this for DECADES. I don’t believe I saw Aetna or the Blues or HCA mentioned in that article. Who cares if a couple small potatoes roll over. In any case, it will be interesting to see how much money ends up in the pockets of pathologists. It should easily exceed 100K/ pathologist/ yr I would think if the pathologists actually receive the compensation they are due. These people actually expect that we should run a hospital lab for free. Yada-yada-yada.

Shot the largest boar i’ve ever gotten today. Retirement is fun. That b.s. wasn’t.

 

[octopusprime]

"My name is Patrick Montoya. You killed my client's reimbursement. Prepare to die."

 

[WEBB PINKERTON]

Ambetter is a biggie in obamacare

 

[Med Director New England]

The Florida society of pathology ( who led this) is probably the best advocate we have for our field - better than the national path groups.

I follow the FSP even though I don’t practice there or otherwise have any connection.