UnitedHealth Sued Over Failure to Cover Surgical Procedure

On Thursday a case was filed in the District of New Jersey by Advanced Surgery Center against United Healthcare Insurance Company. The case is regarding underpayment of an out of network provider by an Employee Retirement and Income Security Act (ERISA) plan.

The plaintiff, working on behalf of a patient with ERISA employer health plan, sought pre-authorization of surgical procedures prior to performing services. These hernia-related procedures were authorized individually prior to procedure being performed and the same procedure codes were properly billed after the treatment.

The complaint said that as an out of network provider, the bill was sent to Viant for repricing. The bill in the amount of $117,652.00. Payment was made in the total amount of $12,478.66 for CPT 49585 only, of which $5,794.90 was paid by Defendant, and $6,689.76 was applied towards Patient’s coinsurance and deductible liability. Contrary to the original authorization for all procedure codes, the repricer only paid on the main procedure code and considered all other procedure codes as lesser included charges which were not paid separately. Lesser included charges is a feature for contracted providers, of which the plaintiff is not.

Plaintiff is suing for failure to make payments according to the patient’s plan and breach of fiduciary duty. Plaintiff is represented by Halkovich Law LLC.