UnitedHealth Housekeeping Spurs Settlement Trend for Providers

Law,Business,Health This summer brought about insurer merger acquisitions of Cigna by Anthem and Humana by Aetna, which leaves UnitedHealth as the only remaining major insurer not to make such an announcement. However, the UnitedHealth Group Inc. very recent settlement of a suit over 15 years old and another settlement of a suit that was over 6 years ago is a typical business effort to clean up their books in preparation for a huge transaction of this sort. Here’s the backstory: In May 2015, UnitedHealth Group agreed to pay $11.5 million to settle lawsuits brought by the state medical societies and individual doctors. The dispute arose over how UnitedHealth pays and codes claims. Specifically, the lawsuit claimed that UnitedHealth was systematically denying payments to doctors for medically necessary claims solely to meet internal financial goals. It was alleged that UnitedHealth programmed its software to automatically downcode claims and penalize doctors whose charges weren’t within a certain range of treatment costs. When the lawsuit was originally filed over fifteen years ago, it represented medical societies in 19 states. At the time of settlement, only four states remained and included Connecticut, New York, North Carolina, and Tennessee. As part of the settlement, UnitedHealth agreed to spend at least $9 million to enhance the insurer’s website where providers file claims. The settlement also required money to be paid by the insurer to the Connecticut State Medical Society Physician’s Health and Education Fund and will be spent on educational programs for members regarding: medical coding, medical review audits, appeals, submitting and processing electronic claims. Physician Advisory Councils will be created in Connecticut, New York and Tennessee that will help doctors and providers resolve issue or problems with UnitedHealth. While settling with the above class of plaintiffs in May 2015, UnitedHealth then settled with another class of plaintiffs that were comprised of ambulatory surgery centers (ASC’s) according to the press release on September 10, 2015. The class action was filed over six years ago by a group of out of network California Ambulatory Surgery Centers. The complaint alleged that UnitedHealth improperly calculated the reasonable and customary amounts for out of network ASC’s resulting in overpayments. According to the press release, UnitedHealth has agreed to pay $9.5 million and the parties estimate that there are approximately 250 ASC’s that could qualify to participate in the settlement. The allegations outlined in each of these suits (suddenly settled within 4 months of each other) run in parallel to the developing trends in southern markets. Both out of network and in network providers in Florida are increasingly faced with denials and overpayment demands from Cigna (currently involved in a major merger with Anthem). Providers who haven’t already started documenting all of their payer communication (i.e. email, fax, in person meetings and phone calls), compiling claims that have been impacted and calculating an aggregate of the financial impact will be inadequately equipped to combat the expanding payer powder keg. Submit your questions to Attorney Valerie Shahriari