DOL sues UnitedHealth third-party administrator for improperly denying ED claims

The Department of Labor July 31 sued a third-party administrator owned by UnitedHealth Group in the U.S. District Court for the Western District of Wisconsin, alleging it improperly denied claims for emergency services and urinary drug screening since 2015. The department asks the court to require the third-party administrator (UMR Inc.) to reform its claims processing procedures for such claims, readjudicate the affected claims in compliance with the Employee Retirement Income Security Act, and enjoin it from committing future violations. 

The AHA in June 2021 sent a letter to UnitedHealthcare’s CEO responding to the insurer’s decision to allow retroactive denial of coverage for emergency-level care in facilities. “Patients are not medical experts and should not be expected to self-diagnose during what they believe is a medical emergency,” the letter stated. “Threatening patients with a financial penalty for making the wrong decision could have a chilling effect on seeking emergency care.” 

In addition, the AHA letter said, “this is exactly why federal law requires insurers to adhere to the prudent layperson standard, which prohibits insurers from putting up coverage roadblocks to emergency services, such as by determining retroactively whether a service will be covered based on the patient’s final diagnosis.”