A Dobbs Ferry medical practice that provides behavioral and addiction services to Medicaid patients says a claims processing company refuses to pay for its work.
Symphony Medical P.C. accused Carelon Behavioral Health Inc. of denying nearly 10,000 claims totaling $2.9 million, in a  complaint filed on July 3 in U.S. District Court, White Plains.
By failing to reimburse Symphony, the complaint states, “Carelon undermines the aims and integrity of the Medicaid system and the public health care system as a whole.”
A Carelon spokesperson was unavailable to respond to a request for its side of the story.
Carelon is based in Boston and has contracts with Medicaid insurers to administer claims for behavioral health services. It is an affiliate of Elevance Health Inc., of Indianapolis.
Symphony has a contract with St. John’s Riverside Hospital, Yonkers, to provide behavioral health services.
Many health care providers refuse to treat Medicaid patients, according to the complaint, because reimbursements are lower than private insurance rates.
“By contrast, Symphony specializes in treating these underserved patients and provides them with the services they desperately need, knowing it is entitled only to Medicaid reimbursement at a rate lower than the actual market value of the services provided.”
Carelon approved Symphony’s claims sporadically from September 2018 though this past January, the complaint states, but denied 9,896 claims for $2,873,595, to which Symphony was entitled to $350.141 under the Medicaid reimbursement rate.
Carelon allegedly asserted that it did not have to pay because Symphony’s claims were bundled with claims submitted by St. John’s.
That assertion is false, Symphony says. Under its contract with St. John’s, it bills and collects fees for medical services and the hospital bills separately for services such as nursing, food, and medicine.
Carelon, Symphony and St. John’s officials agreed to discuss the dispute on April 18, the complaint states. But about 15 minutes before the meeting was to begin, Carelon messaged that it was rescheduling to re-evaluate and reprocess Symphony’s claims.
Instead, according to the complaint. Carelon denied the claims on May 29.
Symphony is demanding unspecified monetary damages under the New York Prompt Pay Law and for deceptive business practices, breaches of contract, and unjust enrichment.
Symphony is represented by White Plains attorneys Russell M. Yankwitt, Jonathan Ohring and Philip J. Tullo.
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