Credit: VectorMine/Adobe Stock
Health insurers and health plan administrators say they're fighting to protect employer-sponsored health plans against "upcoding," or systematic efforts by doctors and hospitals to pad their bills by making patients look sicker than they were and treatments look more dramatic than they were.
The health care providers say that they have a side, that the conflicts over medical billing strategies are complicated, and that they face problems such as health plan administrators using artificial intelligence systems to deny requests for coverage and to deny claims in an unfair, arbitrary way.
They also argue that, in at least some cases, plan administrators may be presenting a misleading picture of what's happening by taking steps such as suddenly attacking well-established, openly discussed claim-coding strategies.
Providers are laying out some of those kinds of arguments in the U.S. District Court for the Eastern District of Tennessee, where three subsidiaries of UnitedHealth Group — UnitedHealthcare Services, UnitedHealthcare Insurance and UMR — are suing TeamHealth, a big emergency care services provider, over allegations that TeamHealth inflated bills by using higher-level CPT codes, or health care procedure codes, than the care delivered warranted.
Representatives for the UnitedHealth subsidiaries and TeamHealth could not immediately be reached for comment on the case.
But a memorandum that TeamHealth filed recently and a memorandum that TeamHealth filed the same day show how some of the arguments are playing out there. TeamHealth's memorandum supported a motion for summary judgment against the UnitedHealth subsidiaries, and the UnitedHealth subsidiaries were seeking summary judgment against some of TeamHealth's arguments.
The UnitedHealth subsidiaries argue, for example, that they do have standing to sue in court on behalf of the employer plans that the subsidiaries help administer, even if some of the plans no longer use the subsidiaries' services, both because of agreements the subsidiaries have with the employers and because of provisions in the Employee Retirement Income Security Act.
The UnitedHealth subsidiaries denied that the court should rule against them based on precedents set in other cases involving the UnitedHealth subsidiaries and TeamHealth, arguing that those cases were different.
TeamHealth's views: TeamHealth says in its memorandum that the court should dismiss the UnitedHealth subsidiaries' suit because the subsidiaries knew about TeamHealth's claim coding philosophy since at least 2015, the subsidiaries waited until October 2021 to file their suit, and the statute of limitations for actions involving allegations of claim coding rule violations was six years.
"The undisputed facts tell a story much different than the one portrayed in the complaint," TeamHealth says in its memorandum. "TeamHealth reached out to United in 2015 to discuss why United was denying so many of TeamHealth's claims — a problem many other providers were experiencing."
The companies held several meetings about coding interpretation differences, TeamHealth says.
"While the parties disagreed over those interpretations, United kept TeamHealth in its provider network," and it created a special code to speed up payment of some types of TeamHealth claims, the company says.
"That changed in 2019, when the parties could not reach agreement on contractual in-network rates," TeamHealth says. "United forced TeamHealth out of United's network."
The UnitedHealth subsidiaries also reduced the rates they paid for TeamHealth claims and created a special rule to slow consideration of every claim the company submitted, TeamHealth says.
"TeamHealth's affiliated practice groups were forced to file lawsuits against United to recover the fair value of the out-of-network emergency care rendered to United's patients for which United underpaid," TeamHealth adds. "On the eve of jury selection in one of those lawsuits, United filed its complaint in this case."
The jury eventually found in favor of the TeamHealth medical practice groups and against the UnitedHealth affiliates, TeamHealth says.
While the litigation has been underway, the UnitedHealth subsidiaries have provided few examples of upcoded emergency services claims, TeamHealth says.
© Arc, All Rights Reserved. Request academic re-use from www.copyright.com. All other uses, submit a request to TMSalesOperations@arc-network.com. For more information visit Asset & Logo Licensing.