United, Data iSight “Arbitrary” Payments to Surgical Assists Texas Class Action

This Texas class action brings suit against United Healthcare Insurance Company and Multiplan, Inc., which does business as Data iSight (DIS), concerning the rates it pays for surgical assist services under plans governed by the Employee Retirement Income Security Act (ERISA). The complaint alleges that the companies make arbitrary and sometimes inadequate payments to surgical assists (SAs) for their services.

The class for this action is surgical assists who performed procedures in Texas for patients insured by United Healthcare under plans governed by ERISA, where United processed a claim for surgical assist services under taxonomy codes 246ZC0007X, 363L00000X, 364S00000X, 363A00000X, 163WR0006X, or 246ZC0007X and determined that benefits were owed under the plans but did not pay reasonable or customary rates for the services.

The SAs in this case did not have contracts with the companies and were not considered participants in their networks. They are therefore out-of-network providers and have not agreed to specific rates for specific services. They provide services to patients who are members of health insurance plans which United administers and which are believed to be governed by ERISA.

At the time the services were provided, the patients assigned their benefits under their insurance plans to the healthcare providers. This allows the healthcare providers to make claims for payment directly to the insurers. The complaint alleges, “On information and belief, United paid and continues to pay claims submitted by Plaintiffs using an arbitrary methodology.”

As an example, it presents two procedures and the payments United made for SA services for them:

• Shoulder surgery; performed on 11/18/2019 and paid on 09/14/2020; CPT codes 29827, 29824, 29826, and 29823. United and DIS paid $11,705.18.
• Shoulder surgery; performed on 12/28/2020 and paid on 09/15/2021; same CPT codes. United and DIS offered only $2,396.87.

The complaint alleges, “United and DIS engage in a uniform practice of reducing and offering to pay unreasonable amounts for surgical assist services.”

According to the complaint, both United and DIS are fiduciaries for the plans at issue in this case. The complaint alleges, “It is an abuse of their discretion and fiduciary duties for [United and DIS] to calculate out-of-network benefit payments in the manner that United and its vendor Data iSight have done.” Also, it says that the companies’ use of “arbitrary and inappropriate methodologies to price and pay” the bills, the companies “have systematically and drastically underpriced and underpaid [SAs] for their services.”

The counts include violations of ERISA, including violating the terms of its insurance policies, breaching its fiduciary duties, and failing to pay benefits.

Article Type: Lawsuit
Topic: Insurance
Tags: Health Insurance, Incomplete payment of benefits due, Insurance, Medical Providers