On Monday, an amended claim was filed in the Northern District of Illinois by a patient against Shirley Ryan Ability Lab (SRALab). The case alleges negligence and breach of contract in provider medical billing practices.
The plaintiff was a patient insured by United Health Care (UHC), the filing said. As a beneficiary of that coverage, the patient was insured for medically necessary health treatment as approved by authorization codes from UHC.
According to the amended filing, the patient was originally admitted to Banner University Medical Center suffering from uncontrolled back pain after undergoing a protein-rich plasma/Fibrin injection. The patient then developed progressive upper and lower extremity weakness. Testing and examination revealed that the patient had diffuse cervical and thoracic edema with osteomyelitis and the patient underwent an emergent laminectomy and fusion of the spine. After spending some time in acute inpatient rehab, UHC denied further stay in the unit, stating that further treatment should occur on an outpatient basis.
The plaintiff disagreed and sought inpatient treatment with SRALab. SRALab sought authorization for an inpatient stay, but was denied by UHC. The patient then sought treatment with self pay instead, though the patient did confirm that the facility was in network with UHC. The defendants agreed to a self pay option, but did not inform the patient that the amount that would have been paid by UHC was less than the self pay charges.
The plaintiff also noted that appeals were still pending with UHC to provide coverage and that the defendant agreed to support these appeals and comply with any demands from UHC as a part of the appeals process. However, the plaintiff accuses SRALab of not following through on this procedure, so when UHC finally agreed to approve and pay for the first two weeks of treatment, the defendant did not follow the billing requirements and did not submit the charges to UHC for payment in a timely manner, resulting in a new denial of benefits.
The plaintiff is suing for breach of contract, stating that the defendant should not have billed for the dates beyond the first two weeks of treatment that UHC approved according to the contract between UHC and SRALab. The plaintiff is also suing for negligence, regarding the defendants failure to bill properly to receive payment for the portion of the stay that was approved. Plaintiff is represented by Schiffman Law Office PC and Sugar Felsenthal Grais & Helsinger, LLP. Defendant is represented by Freeborn & Peters.
