Rockland plastic surgeon seeks $159,000 from Anthem for costs of mastectomies
A Rockland County plastic surgeon is suing Anthem Inc. health insurance for nearly $159,000 for not fully paying for the costs of breast reconstructions for two breast cancer patients.
Dr. Hakan Usal of Tappan accused Anthem of violating the Women”™s Health and Cancer Rights Act of 1998, in a complaint filed June 18 in U.S. District Court in White Plains.
Anthem “hardly provided any coverage for those procedures,” the complaint states, paying 6% of the costs.
Usal, according to court exhibits, also is holding the patients responsible for his charges.
Anthem did not respond to an email asking for its side of the story.
Usal was not in Anthem”™s Empire Blue Cross Blue Shield network, according to the complaint, but both patients received in-network exceptions before they were treated.
In May 2018, Usal performed a mastectomy on a 48-year-old woman at Good Samaritan Hospital in Suffern. Twelve days later he performed emergency surgery to stop bleeding from one of her breasts.
He billed $112,702 for the procedures. Anthem paid $7,965, leaving $104,737 as the patient”™s responsibility.
In July 2019, Usal performed a double mastectomy on a 49-year-old woman at Good Samaritan. He billed $56,350 for the procedure. Anthem paid $2,231, leaving $54,119 as the patient”™s responsibility.
The women appealed to Anthem, asking that their out-of-pocket costs be limited to the customary charges that applied to in-network doctors.
Anthem made no additional reimbursements, according to the complaint.
The women assigned their health care rights and benefits to Usal, authorizing Anthem to make payments directly to the surgeon.
According to similar language in their assignments, they remain responsible for the bills.
“I understand that I am financially responsible for all services rendered,” one of the assignments states, “and I agree to pay all charges denied or not covered by my insurance carrier. This assignment and authorization in no way releases me from this responsibility.”
If the account is turned over to a collection agency or attorney, the assignment states, “I am responsible for all costs of collection and interest as allowed by law.”
Usal”™s attorney, Michael Gottlieb, appealed to Anthem. He claimed that the payments ”“ totaling about 6% of the total amount billed ”“ violated Empire”™s policy for in-network exceptions and violated the Women”™s Health and Cancer Rights Act.
The federal law requires coverage of all stages of breast reconstruction for a mastectomy, according to the complaint, at a rate negotiated by the insurer and doctor.
“Failure to remit additional payments will result in my client initiating legal action,” Gottlieb”™s appeal letter states.
With no agreed upon reimbursement rate, Gottlieb argues in the complaint, Anthem should pay 100% of the remaining charges: $158,857.