Chiropractor says Health Plan of the Upper Ohio Valley refused to reimburse him

By Kyla Asbury | Feb 4, 2013

MOUNDSVILLE – A man is suing the Health Plan of the Upper Ohio Valley, Inc., claiming it owes him more than $450,000.

On Sept. 30, 2001, Emil R. Nardone II and the defendant entered into a provider agreement in which Nardone agreed to provide chiropractic and related healthcare services to members of the defendant’s health maintenance organization, according to a complaint filed Jan. 29 in Marshall Circuit Court.

Nardone claims in early 2011, the defendant began withholding payment for chiropractic services.

During this same time period, Nardone hired an independent consultant and medical auditor, Dr. Tom Necela, to audit his chiropractic business and medical practice, according to the suit.

Nardone claims in May 2011, Necela reported that his practices were all up to or above professional standards for the chiropractic industry.

In February 2012, in an effort to resolve ongoing disputes with the defendant, Nardone asked the defendant to visit his office to have a meeting to discuss the ongoing billing disputes and remedy whatever disagreements there were, according to the suit.

Nardone claims his request was denied and the defendant requested that he come to its office in St. Clairsville, Ohio, to which he agreed.

On Feb. 24, Nardone went to the defendant’s office for the meeting and, because he had doubts about the defendant’s good faith commitment, he asked his counsel to join him, according to the suit. He says upon arriving at the office, he was taken to a conference room where the defendant’s medical director, head nurse, fraud investigator, general counsel and various claims reviewers were convened.

Nardone claims when it became clear that the meeting was not to discuss a resolution of the billing disputes, but instead to interrogate him in the hopes of finding him in breach of the provider agreement or in violation of law, his counsel advised him to cease cooperating in the interrogation and they were then asked to leave the meeting.

Following the meeting, the defendant continued its pattern of ignoring, denying or frustrating Nardone’s attempts to pre-authorize and seek reimbursement for treatment provided to the defendant’s members, according to the suit.

Nardone claims on Oct. 16, the defendant issued a notice of denial of medical coverage to one of its members who had been referred to him.

On Nov. 25, the provider agreement was terminated, according to the suit, and in December, the defendant began actively advising its members not to pay Nardone for any amounts billed for services previously provided pursuant to the provider agreement.

Nardone claims the defendant was actively informing its members that he was under investigation by its fraud unit and instructing the members not to pay him for services he provided.

The defendant unfairly accused him of balance billing and demanded that he cease and desist from any such activities, according to the suit.

Nardone claims that, according to an audit performed by his third-party billing company on Oct. 4, 2012, the defendant owed $453,879.30 in combined outstanding payment obligations for services rendered.

As a result of the termination of the provider agreement, Nardone has lost between 25 and 30 percent of his client base, according to the suit.

Nardone is seeking compensatory damages and declaratory judgment pursuant to West Virginia code finding that the defendant cannot deny him reimbursement, engage in discriminatory reimbursement policies, employ or contract with non-licensed chiropractors and prevent him from attempting to collect from the defendant’s members for all non-covered benefit charges or co-payments or reasonable deductibles. He is being represented by Teresa C. Toriseva and Glenn F. Elliott Jr.

More News

The Record Network