UnitedHealthcare (UHC) claims that TeamHealth, which employs physicians in about one out of every six emergency rooms in the US, purposefully upcoded for potentially hundreds of thousands of medical claims. And given the size of the company, it can significantly drive up costs in all emergency departments. For instance, one claim totaling $1,712 was for a young man treated in the ER for indigestion after eating a chili dog. He was given Maalox and sent home.
According to UHC’s lawsuit, “TeamHealth's tactics have crossed the line from aggressive profit maximization to fraud…[and] steadily defrauded the UnitedHealthcare plaintiffs, their self-funded customers and their members out of millions of dollars through systematic upcoding." The insurer alleges fraud, unjust enrichment, negligent misrepresentation and violations of Tennessee's consumer protection laws.
TeamHealth countered by calling the lawsuit “frivolous” and a “calculated effort to divert attention away from the court case brought by TeamHealth affiliate Fremont Emergency Medicine against UHC for their gross underpayment of frontline clinicians.”
Murphy went on. UHC "continues to generate record profits by down-coding claims and refusing to consider the expertise of frontline clinicians who make a diagnosis…Even during a pandemic, UnitedHealthcare utilizes tactics like these to profit off the backs of emergency medicine providers who are on the frontline treating patients and risking their own lives. The bottom line is the less UnitedHealthcare reimburses, the more profits they make."
Previous TeamHealth vs. UnitedHealthcare Lawsuits
This isn’t the first time TeamHealth and UHC have clashed. Reuters reported that a Nevada state court jury on December 7, 2021 ordered the insurer to pay TeamHealth $60 million in punitive damages from a 2019 lawsuit after finding that it had underpaid TeamHealth affiliates for emergency care.
And in November the same jury ordered the same insurer to pay TeamHealth $2.65 million in compensatory damages. Murphy called the December award "a critical precedent that large health insurers can't underpay frontline doctors for lifesaving care."
The case is Fremont Emergency Services (Mandavia) v. UnitedHealth Group Inc, Nevada 8th Judicial District Court, No. A-19-792978-B.
TeamHealth won a previous lawsuit against UnitedHealthcare, which alleged the insurer's shared savings plan encouraged the underpayment or termination of physician contracts. According to the lawsuit, UHC underpaid on 11,000 claims, totaling about $10.5 million.
Upcoding occurs when a healthcare provider submits a claim to an insurer or claim administrator utilizing a Current Procedural Terminology (CPT) code that misrepresents the services provided: the code deceives the insurer into overpaying either by misrepresenting the type or the degree of services rendered. Because TeamHealth manages billing and coding for the physician groups it contracts with, it decides which codes to use, according to its policies.
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UnitedHealth alleges that TeamHealth ramped up its "aggressive pursuit of profit" in the wake of its $6.1 billion acquisition by private equity firm Blackstone in 2017 and consequently has “drawn the ire of patients, insurers, and the government”.
LawyersandSettlements will be keeping tabs on TeamHealth vs. UHC in 2022, stay tuned…