Surgical Centers Sue UnitedHealth
A group of California outpatient surgical centers has sued UnitedHealth Group, claiming the Minnesota-based insurance giant has systematically blocked claims they have submitted for performing lapband weight-loss surgery on hundreds of patients.
UnitedHealth countered that the surgery centers were all affiliated with the controversial 1-800-Get-Thin billboard marketing campaign to bring in patients.
The Food and Drug Administration ordered the campaign halted in 2011, asserting that it did not properly disclose the dangers of the surgery, which involved placing an adjustable gastric constriction in a patient's abdomen. As many as five patients who were referred as a result of the campaign wound up dying from complications related to their surgeries.
“This same law firm (representing the surgical centers) attempted to take similar legal action against us on behalf of several patients who received services from 1-800 GET THIN affiliated providers and those suits were all dismissed by the court,” said UnitedHealth spokesperson Cheryl Randolph in an email last week. “It has been reported that 1-800-Get-Thin affiliated providers are under federal investigation for healthcare fraud.”
Randolph added that the lawsuits are currently being reviewed.
In court papers UnitedHealth filed in a separate case, it said that it had been notified by the California Department of Insurance that several of the surgery centers were being investigated for insurance fraud. And in yet another unrelated action, an FDA investigator claimed in an affidavit that the surgery centers were being investigated by several agencies for potential federal violations, according to the Los Angeles Times.
But attorneys for the outpatient surgical clinics say UnitedHealth left as many as 1,000 patients in the lurch for thousands of dollars in unpaid bills in some cases, either for pre-surgical testing or the surgery itself, and threatened the health of patients who have already undergone the procedure.
“United’s failure to pay for follow up lap-band adjustments is impacting the patients’ medical care. The patients are worried that if they go in for follow-up appointments, they won’t be able to afford them. United is putting whatever allegations it is making ahead of patient care and safety,”
said Eric D. Chan, an associate with the Los Angeles law firm of Hooper, Lundy & Bookman, which represents the surgery centers.
The surgery center plaintiffs include the Almont Ambulatory Surgery Center; Bakersfield Surgery Institute; Ciro Surgery Center; Independent Medical Services Inc.; Modern Institute of Plastic Surgery & Antiaging Inc.; New Life Surgery Center; East Bay Ambulatory Surgery Center; Orange Grove Surgery Center; San Diego Ambulatory Surgery Center; Skin Cancer & Reconstructive Surgery Specialists of Beverly Hills; Valencia Ambulatory Surgery Center; West Hills Surgery Center and Palmdale Surgery Center.
Chan also confirmed that the firm represents some of the UnitedHealth enrollees in separate legal actions.
According to Chan, UnitedHealth has created “pretextual” reasons for not paying the claims. They include demands to see the licenses of the surgery centers, even though such licenses are not requried under California law; mutiple requests for patient medical records, and assertions that the patient's coverage did not extend to a lapband procedure when that was not the case.
Moreover, the suits claim many coverage determinations are forwarded to the Philippines offices of UnitedHealth affiliate firm OptumInsight for reviews that sometimes take years to complete and still led to payment denials.
Chan could not say how much money the surgery centers are owed by UnitedHealth, but did say it is was well into the millions of dollars.
"Almost everyone in America with health insurance knows exactly what this case is about -- a health insurance company whose employees and representatives are taught to 'just say no' or to delay, delay, delay rather than pay claims for lapband surgery, which has long been recognized as a legitimate basis for dealing with morbidly obese individuals," said Daron Tooch, another Hooper Lundy attorney.
The suits were filed last month: one in federal court for employer group claims under the Employment Retirement Income Security Act, and one in Los Angeles County Superior Court for patients who had individual coverage. The suits primarily allege breach of contract.
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