There’s big news in the world of healthcare lawsuits. Last month, the United States Department of Labor (DOL) announced that it would be suing United Health Group for wrongfully denying emergency department claims.
This isn’t the first time UnitedHealth has been sued for wrongfully denying claims. In fact, it’s not even the first time a lawsuit is being brought against them this year. Last month also saw the announcement that a federal appeals court would be partially reviving a class action against the insurer, with the class accusing UnitedHealth of wrongly denying claims for mental health coverage.
The Wisconsin case, however, deals with another aspect of claim denial: emergency room visits.
For context, federal law mandates a Prudent Layperson Standard (PLS), that a patient must have their emergency care covered as an insurance plan benefit if they reasonably assumed that they were at risk for an emergency at the time they presented to the ED. For example, if one believes that they’re having a fatal medical emergency, but it later turns out that they were having a non-deadly panic attack, they can contest an insurer’s refusal to pay for the bill by citing the PLS.
Crucially, the PLS is determined by symptoms, not diagnoses. This issue is at the root of the Department of Labor’s case against UMR, a division of UnitedHealth Group based in Wausau, Wisconsin.
Essentially, the Department of Labor is alleging that United used diagnosis codes on claims to determine if they would pay the claim or deny it, rather than using the PLS. The DOL claims that UMR used a policy called “True Emergency” for 371 of its employer plans, whereby if the assigned diagnosis on a patient’s claim was not on a predetermined UMR diagnosis list, then the claim was denied. UMR, the DOL alleges, did not analyze the claims any further to assess if the PLS was met.
While typical commercial insurance plans are governed by state law and regulation, employer plans are governed at the federal level. This is how the DOL, rather than a local authority, ended up involved in this case, with the agency saying that they suspect the number of people affected by these denials was in the thousands.
There is an additional allegation in the lawsuit that UMR denied urinary drug screening tests. Medical professionals sometimes request patients undergo drug screenings for several, medically-necessary reasons, including verifying the progress of a patient’s substance abuse treatment as well as ensuring a patient doesn’t have an adverse reaction to medication due to a substance in their body.
The DOL’s lawsuit seeks for those whose claims were wrongfully denied to be reimbursed. The DOL has also asked the court to prevent UMR from continuing the alleged practice. For their part, UMR said in a statement that the lawsuit is based on an administrative process that’s no longer in place, adding that they “will continue to defend our position vigorously.”
This lawsuit could have broad and significant repercussions for emergency physicians. First and foremost, the federal government’s involvement in this lawsuit validates the advocacy efforts by emergency physicians to remove barriers to emergency care that insurers such as United have been utilizing for years. As many industry professionals have noted, over half of insured people are unsure whether they have the right to contest refusals from healthcare providers — and according to the American College of Emergency Physicians, nearly 70% of adults are concerned that their insurance won’t cover their care.
If the DOL’s allegations are true, it’s unlikely that United would be alone in this specific behavior — and United would certainly not be the first insurance company to be called out for dubious refusals of claims. To that end, Anthem Blue Cross Blue Shield was recently added to the list of insurance company defendants for unpaid and underpaid claims, including ED claims.
Depending on the outcome in the Wisconsin court, UMR may have to review the relevant claims, which could lead to an unknown number of previously denied claims being paid. The lawsuit specifically asks that UMR readjudicate all denied or partially denied claims from the beginning of January, 2015 to today, but whether they must actually do this, or the specific dates that must be looked at, will be determined along with the outcome of the lawsuit.
If you or someone you know has an insurance claim that they feel was falsely refused, the Wisconsin Department of Health Services website has a page dedicated to informing patients of their rights and what they can do to contest a refusal.