This class action, brought against entities in the UnitedHealthcare group of companies, concerns contracts for a Medicare Advantage (MA) insurance plan. The plaintiffs say they are being dropped as providers without being given any reason and that the process violates MA Regulations and the companies’ provider manual.
The class for this action is all those who, during the relevant period, were notified by a UHCG company that they will be removed from the plan when their contracts expire.
United Healthcare Group (UHCG), the complaint says, “is the largest healthcare company in the world…” It offers access to healthcare to around 50 million people.
It is an MA organization (MAO). This means it gets paid a “risk-adjusted” fixed monthly amount for each of the patients in an MA plan, rather than fees for individual services.
The plaintiffs claim to be primarily inner-city healthcare providers who treat Medicare and Medicaid patients. They claim that if they are dropped from the current contracts, they will suffer damage to their reputations and also that “thousands of their patients, most of whom are elderly and economically disadvantaged, will have their medical care interrupted and their long-term physician-patient relationships severed.”
Part of the complaint’s allegations is that the terminations were not done according to the rules in the companies’ own documents.
Also, the complaint says, in the case of a termination, “the process must conform to the MA Regulations” in the Code of Federal Regulations. These require the following:
- That a physician be told the reasons for termination and give notice of the right to appeal;
- That a majority of the hearing panel members are peers of the physician; and
- That written notice be given to licensing or disciplinary bodies if the reason for termination is a deficiency in the quality of care provided.
The complaint says that the terminations do not follow these rules either. For example, the complaint claims “none of the Providers were given an opportunity to appear before any appeal panel … and none knew what information may have been provided” to any such appeal panel.
According to the complaint, all the providers’ appeals were denied or no determinations were received.
The complaint alleges that patients who will no longer be able to get care from the terminated providers are being referred to Riverside Medical Group (RMG), a provider company that is owned by UHCG. In 2018, RMG tried to acquire two provider companies, but they refused. Those two are among those being terminated. The complaint claims that if UHCG controls the providers for the patients, it can report more severe conditions and get higher payments for them, whether or not they receive treatments for the reported conditions.
Article Type: LawsuitTopic: medical
Most Recent Case Event
United Healthcare Dropping Providers Without Explanation Complaint
September 19, 2019
This class action, brought against entities in the UnitedHealthcare group of companies, concerns contracts for a Medicare Advantage (MA) insurance plan. The plaintiffs say they are being dropped as providers without being given any reason and that the process violates MA Regulations and the companies’ provider manual.
united_healthcare_americare_medicare_provider_contracts.pdfCase Event History
United Healthcare Dropping Providers Without Explanation Complaint
September 19, 2019
This class action, brought against entities in the UnitedHealthcare group of companies, concerns contracts for a Medicare Advantage (MA) insurance plan. The plaintiffs say they are being dropped as providers without being given any reason and that the process violates MA Regulations and the companies’ provider manual.
united_healthcare_americare_medicare_provider_contracts.pdf