HOUSTON – A small Houston-area hospital scored a significant win against an insurance company in a reimbursement dispute when a state district judge issued a summary judgment in favor of the hospital.
Apollo Hospital, located in The Woodlands and now called Texienne Hospital Systems, alleged that Universal American Insurance Corp. improperly denied millions of dollars in claims submitted for services Apollo provided to members of Universal American’s insurance plans.
The insurer contended that it could deny claims based on a flat-rate arrangement called “capitation” between Universal American and an affiliate of Apollo Hospital. Harris County District Judge Mike Engelhart agreed with Apollo, ruling that the insurance company could not deny claims on that basis.
“This is an indisputable victory for our client,” said Apollo Hospital’s lawyer, Ashish Mahendru of the Houston commercial litigation firm Mahendru P.C. “Insurance companies, in their never-ending effort to save money, cannot put patient care at risk by throwing medical providers under the bus when it comes to reimbursement.”
Also representing Apollo Hospital was Mahendru P.C. lawyer Darren Braun. Apollo filed suit after Universal American refused to reimburse the hospital at the agreed-upon rate of 100 percent of the “Medicare allowable payment.” Instead, the insurance company denied over $10 million in claims, based on a years-old capitation arrangement that Universal American had with a primary care practice loosely affiliated with Apollo.
Mr. Mahendru and Mr. Braun successfully argued that the contract had no bearing on Apollo Hospital, which was governed by a completely new and separate contract containing specific reimbursement provisions. Judge Engelhart agreed, issuing the summary judgment on Nov. 17, 2017.
The lawsuit is Texienne Hospital Systems, L.P., v. Universal American Corp., et al., Case No. 2017-08003 in Harris County’s 151st District Court.
Mahendru P.C. is a boutique commercial litigation firm whose attorneys are known for their tenacity, intelligence and experience. Founded in 2001, the firm has a simple philosophy: Your problem is our problem. We adopt it, understand it and solve it. Our objective is to resolve every case in the best, fastest and most cost-efficient manner possible. To learn more, visit https://thelitigationgroup.com/.