After nearly 15 years of litigation between UnitedHealth Group Inc. and a group of physicians, the health insurance giant agreed to pay $11.5 million to resolve allegations that it incorrectly paid and managed doctors’ billing claims.
UnitedHealth Group and its subsidiaries agreed to spend at least $9 million in enhancements to its provider self-service website to increase efficiency and reduce delays in managing of claims. The additional funds will go toward educational programs for medical society members pertaining to ICD-10-CM coding, CPT coding, medical review audits, appeals, and claims submission and processing. The settlement stems from lawsuits filed in 2001 by the Medical Society of the State of New York, the Connecticut State Medical Society, the North Carolina Medical Society, the Tennessee Medical Association, and several individual physicians.
Daryl Richard, UnitedHealth Group spokesman, said that the insurer was pleased to finally be ending the litigation, and that the company looks forward to new ways of collaborating with doctors.
“Physicians will have simpler and more comprehensive access to claims management information through enhancements we are making to our physician website,” Mr. Richard said in a statement.
Dr. Joseph Maldonado, president of the New York medical society, said the settlement was a significant victory for physicians.
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“This settlement will improve access to information and the ability to adjust claims for all in-network physicians contracting with United and submitting claims, while providing certain benefits to member physicians,” he said in a statement.
The case was part of a series of lawsuits filed in the early 2000s alleging illegal business practices and corruption by Aetna, Cigna, UnitedHealthcare, Healthnet, Humana, PacifiCare, Prudential, and WellPoint. The suits alleged that the defendants engaged in a conspiracy to wrongfully and fraudulently pay doctors less than the amounts to which they were entitled. Several of the cases were consolidated into what is referred to in court documents as “the lead case.”
The medical societies’ litigation was halted pending the outcome of the lead case, according to the UnitedHealth Group settlement documents. Following a 2007 ruling for defendants in the lead case, plaintiffs in the medical societies’ case attempted to revive their litigation, and a lengthy court battle ensued. The parties tried unsuccessfully to negotiate a settlement for years.
Meanwhile, settlements were eventually reached in the lead case with insurers agreeing to change their business practices and reimburse the plaintiff physicians for hundreds of million dollars, according to a summary by the American Medical Association, a plaintiff in one of the original cases. In addition, the settlements required the insurers to disclose their coding edits, adopt certain CPT conventions, and clarify the criteria under which medical procedures will be deemed medically necessary.
In its settlement with the medical societies, UnitedHealth Group denied all allegations in the suit and admitted no wrongdoing. For their part, the medical societies stated the claims have merit, but that they will dismiss the suit following payment of the settlement, according to court documents.
The settlement will offer significant relief in the areas of claims management and claims resolution, said Edith Kallas, a New York–based attorney and legal counsel for plaintiffs.
“We applaud the medical societies and individual physicians for their commitment to obtaining a meaningful resolution of these issues,” she said in a statement.
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