UnitedHealthcare Underpaying Out-of-Network Emergency Medical Providers


Mid-Atlantic Surgical Associates PC (Mid-Atlantic), a cardiac surgery group, filed a class action lawsuit against UnitedHealthcare, alleging that UnitedHealthcare underpaid out-of-network providers for emergency medical services and advised its patients, both verbally and in writing, to ignore bills for services from these providers. Mid-Atlantic asserted that UnitedHealthcare violated state and federal regulations in order to pressure out-of-network providers, including Mid-Atlantic, to become in-network providers with UnitedHealthcare. It is alleged that UnitedHealthcare has offered to defend its members, by paying for their lawyers, if out-of-network providers sue members to collect outstanding balance bills, i.e., the difference between what UnitedHealthcare decides to pay Mid-Atlantic, and its member’s copayment, coinsurance, or deductible. It is believed that the class members in this action, out-of-network providers that have been subject to UnitedHealthcare’s underpayments, number into the hundreds.

UnitedHealthcare argued that providers must accept payment that UnitedHealthcare deems to be sufficient under FAIR Health usual and customary charge data regardless of Mid-Atlantic and other providers’ actual billed charges. Alternatively, Mid-Atlantic contended that there is no agreement between them and UnitedHealthcare, and Mid-Atlantic
never agreed to accept payments based on FAIR Health.

Mid-Atlantic is seeking, among other damages including compensatory damages, injunctive relief, and counsel fees, (1) that UnitedHealthcare pay out-of-network emergency medical services in amounts that ensure balance bills are not sent to the patients, and (2) confirmation that out-of-network providers are permitted to bill a UnitedHealthcare member the difference between the payment made by UnitedHealthcare and such member’s copayment, coinsurance, or deductible.

Related Practices:   Healthcare Law

Related Attorney:   Carol Grelecki, John D. Fanburg