UnitedHealth Group filed a lawsuit against TeamHealth on Wednesday, alleging that a group of emergency room providers, owned by a private joint stock company, deliberately and systematically tricked the medical giant into paying more than $ 100 million in bogus patient claims.
The lawsuit, filed in the US District Court for the Eastern District of Tennessee, alleges that TeamHealth violated state and federal laws regarding fraud, insurance regulation and consumer protection against enrichment by coding hundreds of thousands of emergency bills.
In one case, TeamHealth doctors cured a 23-year-old patient suffering from indigestion after eating a dog with chili by giving him an antacid and sending him home, the complaint said. However, the bill submitted by UnitedHealthcare stated that the person required “emergency medical care of a particularly high degree of complexity in an emergency,” and charged $ 1,712 from the insurer. UnitedHealthcare said it reviewed approximately 46,000 commercial applications and found that approximately 60% should have used lower CPT codes.
The lawsuit says TeamHealth not only misrepresents the complexity of the services provided, but also falsely bills UnitedHealthcare for services provided by nurse practitioners or physician assistants. According to the complaint, the company also withheld the list of medical groups it managed, making it difficult for UnitedHealthcare to recognize its overbilling scheme.
“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 bought TeamHealth for $ 6.1 billion in 2017.
Since then, the company has focused on buying medical practices and ditching the network of insurers. The lawsuit says TeamHealth does not allow its medical practice to enter into direct contracts with payers and requires independence from in-network hospital insurance contracts. According to the lawsuit, the company currently operates 3,400 emergency rooms with 18,000 service providers nationwide, accounting for 17% of the total market.
Because TeamHealth pays its doctors a flat hourly rate, providers do not receive any additional revenue generated from the privately held group. The company’s centralized billing centers are also responsible for assigning CPT codes to patients, leaving doctors in the dark about the large number of inaccurate claims filed, the lawsuit 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 lawsuit says.
UnitedHealthcare seeks an injunction prohibiting TeamHealth from transforming patients, as well as 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, TeamHealth CEO Leif Murphy wrote in an email. Leif said the UnitedHealthcare lawsuit was an attempt to distract from the case TeamHealth has filed against the health care giant that began on Monday.
“United continues to make record profits by coding claims and refusing to take into account the expertise of frontline doctors who make a diagnosis,” Leif wrote in an email. “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. ”