US Labor Department sues UnitedHealth Group

The U.S. Department of Labor has brought a lawsuit against UnitedHealth Group subsidiary UMR, claiming it incorrectly denied emergency room and urinary drug screening claims for thousands of patients, thereby failing to comply with the requirements of the Affordable Care Act and the DOL’s claims procedures regulation.

According to a complaint filed July 1 in a Wisconsin federal court, UMR is UHG’s third-party administrator, providing benefits services to more than 2,000 self-funded employer health plans.

What’s the impact
The lawsuit claims that in violation of the Employee Retirement Income Security Act (ERISA), which oversees self-funded plans, UMR denied all urinary drug screenings from August 2015 to August 2018, when instead it should have determined whether each claim was medically necessary.

UMR changed its urinary drug screening process in August 2018 because 98% of those claims were overturned on appeal, the lawsuit contends.

Since that time the subsidiary has allowed some drug screenings in emergency settings, but the explanation of benefits was not in line with ACA requirements, the suit states. It also alleges that in 2019, UMR switched its urine screening claims denial codes from lack of medical necessity to a request to the provider for more medical records.

Upon denying a patient’s ER claim, UMR’s subsequent explanation of benefits lacked critical information, the DOL claimed, and did not point to specific plan provisions or the “prudent layperson standard,” which requires insurance companies to provide coverage for emergency care based on a patient’s symptoms.

Allegedly, UMR does not inform claimants of the informal appeal process, according to the lawsuit. And only limited information was given to those whose urinary drug screening payments were denied, with no reference plan provisions or an explanation of the failed claim.

The lawsuit seeks to compel UMR to reform its emergency and urinary drug testing claims procedures to be in line with ERISA, and adjudicate denied and partially denied claims from January 1, 2015 to the present.

The suit was filed in the U.S. District Court for the Western District of Wisconsin. Healthcare Finance News