UnitedHealthcare sues TeamHealth, alleges fraud

UnitedHealthcare is suing emergency care provider TeamHealth, alleging the company deliberately and systematically tricked the health insurer into paying more than $100 million in fraudulent claims.

The lawsuit, filed in the U.S. District Court for the Eastern District of Tennessee on Wednesday, accuses private-equity-owned TeamHealth of violating state and federal laws governing fraud, insurance regulation and consumer protection by upcoding hundreds of thousands of emergency department bills.

In one instance, UnitedHealth Group’s insurance subsidiary alleges TeamHealth clinicians treated a 23-year-old man suffering from indigestion after eating a chili dog by giving him an antacid and sending him home, the complaint says. But TeamHealth subsequently billed the insurer for $1,712 on the grounds that the patient required “emergency medical care of particularly high complexity under exigent circumstances,” the lawsuit alleges.

UnitedHealthcare reviewed some 46,000 TeamHealth claims and found that roughly 60% should have been categorized by lower-level Current Procedural Terminology codes, the complaint says.

TeamHealth CEO Leif Murphy called the lawsuit is retaliation for a legal action his company took against the insurer earlier this week, and an example of what he described as UnitedHealthgroup’s practice of shortchanging providers.

In addition to misrepresenting the complexity of services provided, United Healthcare says TeamHealth collected inappropriately high fees by submitting bills for services supposedly performed by doctors that actually were administered by physician assistants or nurse practitioners. TeamHealth also hid the list of medical groups it operates, making it hard for UnitedHealthcare to recognize a pattern of overbilling, according to the complaint.

“Because TeamHealth engaged in a subtle form of fraud involving deliberate exaggeration rather than outright fabrication, its fraud was difficult to detect, investigate and confirm,” the lawsuit claims.

The private equity firm Blackstone acquired TeamHealth for $6.1 billion in 2017.

Since then, TeamHealth has bought medical practices and kept them outside of insurers’ provider networks. The company currently operates 3,400 emergency medical facilities that employ 18,000 providers, which accounts for 17% of the market, according to the lawsuit.

Because TeamHealth pays its clinicians a flat, hourly rate, providers did not receive any the extra revenue, which Blackstone retains, according to the insurer. TeamHealth’s centralized billing centers are also in charge of assigning CPT codes, leaving physicians in the dark about the high rate of inflated claims, UnitedHealthcare alleges.

“The specific fraudulent behavior at issue in this case is just one piece of this larger culture of profit maximization at any cost, which demonstrates the extreme lengths to which TeamHealth will go in order to pad its bottom line,” the complaint says.

UnitedHealthcare seeks an injunction to stop TeamHealth from upcoding patients, and demands reimbursement for compensatory and treble damages, equitable and declaratory relief, pre- and post-judgment interest, attorneys and court fees, and any other relief the court deems just and proper. UnitedHealthcare is seeking a jury trial.

UnitedHealth Group and TeamHealth have a history of suing each other.

Courts have repeatedly dismissed similar claims in other jurisdictions, Murphy wrote in an email. UnitedHealthcare’s lawsuit is an attempt to distract from a case a TeamHealth facility brought against the healthcare giant Monday, he said.

“United continues to generate record profits by downcoding claims and refusing to consider the expertise of frontline clinicians who make a diagnosis,” Murphy wrote. “Even during a pandemic, United 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 UnitedHealth reimburses, the more profits they make.”

Source: modernhealthcare.com