Envision suing UnitedHealthcare over denied claims; UHC countersuing
UHC has filed its own lawsuit accusing the physician firm of deliberately upcoding thousands of claims.
Photo: Blanchi Costela/Getty Images
Physician firm Envision Healthcare has filed a lawsuit against UnitedHealthcare over the insurer's denied claims, sparking a countersuit from UHC, which claimed Envision fraudulently upcoded claims for services provided to UHC members.
UHC removed Envision from its network last year, claiming the firm's costs did not reflect fair market rates. According to Envision's lawsuit, UHC denied about 18% of submitted commercial claims – a number that swelled to 48% of all claims after Envision's removal from UHC networks, the firm said.
And for the highest-acuity claims, Envision is accusing UHC of denying 60% of those claims.
In a statement, Evision alleged that UHC "puts profits above all else, including patients and the physicians and advanced practice providers who provide life-saving care in emergency rooms across the country."
"After pushing Envision clinicians out-of-network in January 2021, United began a routine and systematic denial of commercial claims related to emergency room care for its members with the highest acuity – patients who sought care for life-threatening illnesses and complications," said Envision Healthcare CEO Jim Rechtin. "United's scheme to deny patient claims violates federal law. Improperly withholding payment from the very frontline clinicians who treated their members in their most acute time of need is, in my opinion, cold, callous and inhumane."
The lawsuit highlights several instances, including a 31-year-old man requiring an emergency appendectomy and a 2-month-old baby with unexplained episodes of choking, vomiting and turning blue, in which UHC subjected claims to a "pre-payment review" and then ultimately denied the claims.
""No other health plan comes close to the level of denials we see from United," said Rechtin. "Only United, with its $17.3 billion in profits in 2021 and 1,000% stock price increase for its owners, would have the audacity to refuse reimbursement to the clinicians providing the life-saving care to its own members."
WHAT'S THE IMPACT
In response, UnitedHealthcare filed its own lawsuit against Envision, alleging the firm deliberately upcoded thousands of claims and deceived UHC into overpaying millions of dollars for emergency care.
UHC claimed it had approached Envision with evidence of upcoding, and accused the firm of hurriedly filing a lawsuit to beat UHC to the courthouse.
"Despite engaging in fraud on United that has been independently verified by academic studies, whistleblowers and United's own first-hand investigation, Envision has now attempted to recast United as the villain, claiming United has unreasonably denied or 'downcoded' its fraudulent claims," UHC said. "Envision's bad-faith tactics have left United no choice but to seek recourse in this court."
THE LARGER TREND
This isn't the only legal entanglement for UnitedHealthcare. Last fall, UHC sued another physician firm, TeamHealth Holdings, alleging fraud for over-inflating medical codes to get greater reimbursement.
UnitedHealthcare alleged that since 2016, TeamHealth has upcoded claims and committed fraud by misrepresenting the services provided.
TeamHealth, in response, filed suit against UHC alleging the insurer's shared savings plan encouraged the underpayment or termination of physician contracts. The suit claimed UHC underpaid on 11,000 claims for a total of about $10.5 million.
A Clark County, Nevada, jury agreed with TeamHealth that United engaged in unfair reimbursement practices by deliberately failing to pay frontline emergency room doctors adequately for care provided to patients. The jury assessed about $60 million in punitive damages against UnitedHealthcare, finding it was guilty of fraud and malice in its conduct.
Twitter: @JELagasse
Email the writer: jeff.lagasse@himssmedia.com
