UnitedHealth targeted in new lawsuit alleging underpayment of out-of-network ER doctors

The Healthcare Justice Coalition filed a lawsuit in Union County Superior Court against UnitedHealth Group alleging that a group of physicians was either unpaid or significantly underpaid for emergency services.

This complaint was first surfaced by Law.com Radar.

The Healthcare Justice Coalition is an organization that works with emergency medicine practice groups and attempts to ensure that physicians are not underpaid or unpaid by health insurance companies. Two of the emergency practice groups the coalition works with are NES Health and NES Georgia whose physicians provide emergency services at St. Michael’s Medical Center and Trinitas Regional Medical Center in New Jersey, among other hospitals. The complaint alleged that the physicians were unpaid or underpaid for their services and assigned their accounts and the right to sue to the coalition, according to the complaint.

In addition to naming UnitedHealth Group, the complaint named UnitedHealthcare Insurance and Oxford Health plans, as well as fictitious defendants. It was filed on behalf of the coalition by Dante B. Parenti of Lauletta Birnbaum in Sewell and Eric D. Chan and Avi W. Rutschman of Athene Law in Los Angeles, California.

“Systemic underpayments by health plans of the kind that physicians have experienced threaten the stability of America’s health care system by forcing emergency physician groups into bankruptcy and shuttering emergency departments,” the complaint said. “Even when physician groups are not forced to shut down, inadequate reimbursement may nonetheless force a reduction in physician coverage, negatively impacting patient care.”

The claims alleged that the physicians provided emergency services on an out-of-network basis and that the defendants must pay the coalition for emergency services based on the reasonable value of those services, which may be as much as the full billed charges, according to the complaint.

The two-count complaint included claims for quantum meruit/unjust enrichment and violation of the New Jersey Health Claims Authorization, Processing, and Payment Act. Under the Emergency Medical Treatment and Labor Act, the complaint alleged, federal law requires physicians to render emergency services to all patients at an emergency department regardless of insurance coverage or ability to pay.

Related: UnitedHealthcare uses AI that wrongfully denies ’90%’ of claims, says lawsuit

“Defendants were obliged to provide emergency care to their members,” the complaint said. “When those members presented to the emergency room, physicians fulfilled that obligation on defendants’ behalf. This, in turn, triggered defendants’ duty to pay the reasonable value for those services. This is true even if defendants did not become aware of physicians’ actions until after the emergency services were rendered.”

The coalition asked the court to enter a judgment in its favor and against the United defendants in excess of $2.5 million, plus interest, the costs of this action, and all other appropriate relief.

Counsel have not yet appeared for the defendants.