UnitedHealthcare is suing emergency medical services company TeamHealth, alleging that the company deliberately and systematically tricked the insurer into paying more than $ 100 million in fraudulent claims.
In a lawsuit filed in the US District Court for the Eastern District of Tennessee on Wednesday, the privately owned TeamHealth company is accused of violating state and federal laws governing fraud, insurance regulation and consumer protection by transcoding hundreds of thousands of emergency department accounts.
In one case, insurance subsidiary UnitedHealth Group claims TeamHealth doctors cured a 23-year-old man suffering from indigestion after eating a chili dog by giving him an antacid and sending him home, the complaint said. But TeamHealth subsequently billed the insurer $ 1,712 on the grounds that the patient required “emergency medical care of particularly high complexity in urgent circumstances,” the lawsuit says.
UnitedHealthcare reviewed approximately 46,000 TeamHealth applications and found that approximately 60% should have been assigned to current lower-level procedural terminology codes, the complaint said.
TeamHealth CEO Leif Murphy called the lawsuit revenge for the lawsuit his company took against the insurer earlier this week and an example of what he called UnitedHealthgroup’s practice of cutting suppliers.
United Healthcare says TeamHealth not only distorts the complexity of the services provided, but also collects unreasonably high fees by invoicing services believed to be provided by physicians that were actually provided by paramedics or nurse practitioners. TeamHealth also withheld the list of medical groups it manages, making it difficult for UnitedHealthcare to recognize the inflated billing pattern, according to the complaint.
“Because TeamHealth used a sophisticated form of fraud involving deliberate exaggeration rather than outright fabrication, its fraud was difficult to detect, investigate and confirm,” the lawsuit said.
Private equity firm Blackstone acquired TeamHealth for $ 6.1 billion in 2017.
Since then, TeamHealth has purchased medical practices and kept them outside of the insurer’s provider networks. According to the lawsuit, the company currently operates 3,400 emergency rooms with 18,000 health care providers, representing 17% of the market.
Because TeamHealth pays its clinicians a flat hourly rate, service providers did not receive the additional income that Blackstone retains, according to the insurer. TeamHealth’s centralized billing centers are also responsible for assigning CPT codes, leaving physicians in the dark about the relatively high level of exaggerated requirements, UnitedHealthcare said.
“The particular fraudulent behavior in question is just part of this broader culture of maximizing profits at all costs, which demonstrates the extreme measures TeamHealth will take to maximize their profits,” the complaint said.
UnitedHealthcare seeks an injunction prohibiting TeamHealth from coding patients and seeking compensation and triple damages, fair and declarative defenses, pre- and post-adjudication interest, legal fees and costs, and any other remedy the court deems to be fair and proper. UnitedHealthcare is seeking jury trial.
UnitedHealth Group and TeamHealth have sued each other more than once.
Courts have repeatedly dismissed similar claims in other jurisdictions, Murphy wrote in an email. The UnitedHealthcare lawsuit is an attempt to distract from the case TeamHealth filed against the healthcare giant on Monday, he said.
“United continues to generate record profits by coding claims and refusing to take into account the expertise of frontline doctors who make a diagnosis,” Murphy wrote. “Even during the pandemic, UnitedHealth is using similar tactics to profit from emergency care providers who are at the forefront of patient care and risk their lives. The bottom line is that the less UnitedHealth reimburses, the more profit they get. “