NYC Health + Hospitals seeks an additional $28.6M from UnitedHealthcare in wrongful claim denials

Four months after taking UnitedHealthcare to arbitration over $11.5 million in denied claims, NYC Health + Hospitals says it has uncovered an additional $28.6 million in wrongful denials.

The additional denials were discovered following a review of nearly 4,000 claims between July 2014 and December 2017. All told, the nation’s largest public hospital said it is owed $40.1 million.

“Our clinicians have no incentive to admit patients needlessly, while UnitedHealthcare has an obvious conflict of interest: They want the premiums from their beneficiaries and don’t want to pay for their care,” Mitchell Katz, M.D., president and CEO of NYC Health + Hospitals said in a statement. “Rather than provide appropriate reimbursement for services rendered, they prefer to give more money to their shareholders and reap big bonuses for themselves.”

UnitedHealth reported $8.3 billion in profits during the first half of 2018. The company’s two CEOs pulled in more than $110 million in compensation last year.

“The priorities are skewed,” Katz added. “It’s our responsibility to stand up and challenge wrongful denials, as all health systems should.”

On average, UnitedHealthcare denied reimbursement for three newly hospitalized patients every day over a three-and-a-half-year period, according to the health system. The “vast majority” of the denied claims involved emergency services, NYC Health + Hospitals spokesperson Bob de Luna told FierceHealthcare.

RELATED: NYC Health + Hospitals looks to claw back $11.5M in wrongful denials from UnitedHealthcare

The denied claims included a pregnant woman with a history of miscarriages admitted for medical treatment at 22 weeks because an ultrasound showed she was at high risk for losing her baby. Another denied claim involved a 62-year-old woman who showed up at the emergency department with multiple signs of a stroke or heart attack, just three days after she was discharged from a previous stroke.

Another claim involved a one-year-old girl that required a surgical consultation and IV antibiotics.

Matthew Siegler, senior vice president for managed care and patient growth at NYC Health + Hospitals said he was “appalled” by some of the denied claims and UnitedHealthcare’s decision not to provide coverage.

The health system has been reviewing all its managed care contracts as it modernizes its financial operations and indicated it may pursue arbitration against other insurers. An arbitration hearing is scheduled for this fall, although no date has been set.

“As we continue to negotiate fair rates and terms with private insurance companies, we see that some want to be good partners for the benefit of their beneficiaries, and some care more about profits,” Siegler said. “Some are especially egregious. And then, there’s UnitedHealthcare.”

RELATED: Emergency physicians sue Anthem over ER policy change

“We have offered to meet with NYC Health + Hospitals to review their concerns, but they have declined our invitation," UnitedHealthcare spokesperson Maria Gordon Shydlo said in a statement to FierceHealthcare. "We remain willing to meet with them as soon as they are ready to address this issue with us directly.”

Other insurers have come under fire for emergency department policies seeking to limited unnecessary visits. Earlier this year, UnitedHealth said it would begin rejecting complex ED claims. In July, the American College of Emergency Physicians (ACEP) took Anthem to court to prevent Anthem from implementing a policy to restrict coverage for ED visits.

ACEP said the insurer has been retrospectively denying claims for what it deems “non-emergent” services since it announced the new policy last year.

Editor's Note: This story has been updated to include a statement from UnitedHealthcare.