Five New York emergency room physician groups on Monday filed a federal lawsuit alleging that UnitedHealth Group and Multiplan conspired to underpay out-of-network providers.
The group of staffing firms, all of which are out of network for UnitedHealthcare, claim that the insurer and Multiplan worked together using Multiplan’s Data iSight platform to set their own “reasonable” rates for out-of-network claims, which undercut payments to the doctors. The physicians added that they were undercut affected the COVID-19 pandemic, when they were putting their lives at risk to treat patients. A number of the instances cited in the lawsuit occurred in 2020.
“Receiving payment for a reasonable amount or usual and customary amount is essential because, unlike other situations involving out-of-network providers, when a commercially insured patient receives emergency medical services in New York, the emergency health-care provider is prohibited from balance-billing the patient,” the doctors said in the lawsuit.
UnitedHealth disagreed.
“A small number of providers, and especially private equity-backed physician staffing companies like TeamHealth, are driving up the cost of care for the people and customers we serve,” the company said. “Some of the TeamHealth provider groups that are not part of our network today charge 700 to 900% of Medicare rates for the care they provide.
“This sort of excessive pricing from out-of-network providers contributes to skyrocketing health-care costs for everyone,” the company added. “TeamHealth has filed a lawsuit in an attempt to challenge our efforts to address the unreasonable and anticompetitive rates its providers charge. We believe the lawsuit is meritless and plan to aggressively defend ourselves against TeamHealth’s baseless claims.”
The allegations in the case are similar to those brought in September by two hospital-based physician groups. Emergency Care Services of Pennsylvania and Emergency Physician Associates of Pennsylvania alleged that UnitedHealth hired a data analysis firm to develop market-based reimbursement rates. However, the plaintiffs alleged that the tool used to determine the rates, Data iSight, doesn’t use information about services or rates in local markets.
UnitedHealth, the largest insurer in the country, has clashed with physician staffing firms including TeamHealth and Envision as part of an industrywide back-and-forth on how to address surprise medical billing. These firms provide a large number of physicians to hospital emergency departments, an arrangement that is a common source of surprise bills when a patient is treated at an in-network hospital by an out-of-network physician. TeamHealth also sued UnitedHealth after it cut certain out-of-network reimbursements by 50 percent.
The physicians’ lawsuit asserts claims under the federal Racketeer Influenced and Corrupt Organizations Act and New York state law. The physicians are seeking monetary, injunctive and declaratory relief.
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Photo courtesy of: Benefits Pro
Originally Published On: Benefits Pro
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