UnitedHealthcare: Out-of-network ASCs file class action over low payments

Ambulatory surgery centers (ASCs), led by the California centers Downey Surgical Clinic and Tarzana Surgery Center, are following in the footsteps of physicians to battle Minnetonka, Minn.-based UnitedHealth Group Inc., over low out-of-network payments, reports Outpatient Surgery. The Los Angeles-based law firm Hooper, Lundy and Bookman Inc., (HLB) has filed an amended class-action complaint on behalf of ASCs nationwide charging that UnitedHealth "systematically failed to properly price the claims according to UCR [usual, customary and reasonable rates], and has systematically concealed this failure, through misrepresentations and concealments about its pricing and payment methods."

HLB originally filed a class-action lawsuit in 2009 alleging that UnitedHealth underpriced payments to out-of-network ASCs and did not follow its stated intent of calculating UCR rates by using its Ingenix subsidiary's database to compare the charges of ASCs in the applicable geographic region. On May 7, HLB amended the lawsuit to add employee health plans that used UnitedHealth to price claims as an additional class of defendants. In addition, HLB expanded its allegations, saying that the discovery process revealed that UnitedHealth rarely used the Ingenix database for setting out-of-network ASC rates.

"Instead, for many if not most claims, United simply used its in-network or Medicare rates as a baseline, coupled with what appears to be an arbitrary multiplier, when paying out-of-network claims to ASCs. Thus, United's representations to non-contracted ASCs about how it actually priced these claims appear false," says the law firm. "Moreover, whatever method United used--in-network rates, Medicare rates, or the Ingenix database--we feel it to be even more clear now that United did not appropriately calculate UCR rates. The amended complaint accounts for the expanded scope of the misconduct that has come to light."

In January 2009, UnitedHealth reached a $350 million agreement to settle a class-action lawsuit involving allegations of low payments for out-of-network physician services filed on behalf of the American Medical Association, state medical societies and other groups.  That lawsuit alleged that UnitedHealth routinely manipulated a database at its Ingenix subsidiary to cut out-of-network physician reimbursements, reports the American Medical News.  The settlement is slated to be finalized on Sept. 13, and physicians and patients can file for payment until Oct. 5. Under that agreement, UnitedHealth admitted no wrongdoing.

To learn more:
- read this Outpatient Surgery article
- read the Hooper, Lundy and Bookman press release
- read the amended class-action lawsuit
- read this American Medical News article