Envision Healthcare, UnitedHealth spar in dueling lawsuits

UnitedHealthcare's war with physician staffing firms continues.

Envision Healthcare filed suit against the insurer, the physician firm announced Friday, over claims denied by the country's largest health plan. UnitedHealthcare axed Envision from its network in early 2021, saying that Envision's high costs did not reflect fair market rates.

Later on Friday, UnitedHealthcare countersued the physician firm, accusing it of fraudulently upcoding claims for services provided to UHC members.

Envision said in the announcement that prior to its removal from UHC's network, the insurer has denied about 18% of submitted commercial claims. In November 2021, after it was pulled from the network, that number spiked to 48% of all claims, according to Envision.

For the highest-acuity claims, UnitedHealthcare denied 60% of those submitted.

“After pushing Envision clinicians out-of-network in January 2021, United began a routine and systematic denial of commercial claims related to emergency room care for its members with the highest acuity—patients who sought care for life-threatening illnesses and complications,” said Jim Rechtin, Envision Healthcare CEO, in the announcement.

“United’s scheme to deny patient claims violates federal law. Improperly withholding payment from the very frontline clinicians who treated their members in their most acute time of need is, in my opinion, cold, callous and inhumane," Rechtin said.

A spokesperson for UnitedHealthcare said the insurer is reviewing Envision's filing. In the second lawsuit filed Friday in Tennessee federal court, the insurer said that it had approached Envision with evidence of upcoding that suggested UHC had overpaid Envision to the tune of millions.

UnitedHealth said in the countersuit that Envision "systematically misrepresented" services it rendered to UnitedHealth members across thousands of claims in order to bilk the insurer for higher payments. UHC said it then came to Envision with the evidence it had, including a draft of the complaint filed Friday, seeking a remedy.

"Rather than act in good faith, Envision took United’s confidential complaint, provided under Rule 408, and quickly and quietly drafted its own complaint based on United’s and filed it without warning in an effort to beat United to the courthouse," the insurer said in its lawsuit. "Despite engaging in fraud on United that has been independently verified by academic studies, whistleblowers and United’s own firsthand investigation, Envision has now attempted to recast United as the villain, claiming United has unreasonably denied or 'downcoded' its fraudulent claims. Envision’s bad-faith tactics have left United no choice but to seek recourse in this court."

"United brings this action to put a stop to Envision’s fraud, and to recoup the amounts Envision obtained through its scheme," the insurer said.

Envision's lawsuit includes several examples of claims that were denied, including in the case of a 31-year-old man who needed an emergency appendectomy. Claims for the man's care underwent a "pre-payment review" and were then denied, Envision said.

UHC has battled with Envision and its physician staffing rival TeamHealth over reimbursements. TeamHealth sued UnitedHealth in July over alleged downcoding for emergency care services.