The U.S. Department of Labor is alleging UnitedHealth Group denied thousands of patients' payments for emergency room services and urinary drug screenings.
The lawsuit states that UMR, a third-party administrator and UnitedHealth subsidiary, denied claims based on diagnosis codes and failed to abide by requirements of the Affordable Care Act (ACA) and Labor Department’s claims procedures regulation.
UMR denied all urinary drug screenings from August 2015 to August 2018, when it should have determined whether a claim was medically necessary, which violated the Employee Retirement Income Security Act (ERISA), the lawsuit further alleges. From August 2018 to the present, UMR allowed some urinary screenings if it was done in an emergency setting but changed its denial code again in October 2019. Explanation of benefits did not comply with the ACA.
UnitedHealth Group had not responded to a request for comment at press time.
The lawsuit says that UMR changed its urinary drug screening process in August 2018 because 98% of those claims were overturned upon appeal.
Medical plans through UMR are required to directly define a “prudent layperson standard” through the ACA. A prudent layperson standard requires insurance companies to provide coverage for emergency care based on symptoms.
After denying a patient ER claim, UMR sends an explanation of benefits that has “very limited information,” the Department of Labor claims. Denied claims do not point to specific plan provisions or rules, the prudent layperson standard, state whether there was a lack of proper documentation or provide a description of additional information to further explain the decision. UMR, allegedly, does not inform claimants of the informal appeal process, according to the lawsuit.
Only limited information was given to patients who had urinary drug screenings payments denied as well, as UMR did not reference plan provisions or provide a description and explanation of the failed claim, the lawsuit claims.
The complaint was filed in the U.S. District Court for the Western District of Wisconsin. UMR is believed to handle at least 2,136 ERISA-covered health welfare benefit plans in this location.
UMR is considered the nation’s largest third-party administrator, according to UnitedHealth.