By Shelby Livingston
Modern Healthcare, April 6, 2020
Several behavioral health providers and patients sued UnitedHealth Group and Cigna subsidiaries for allegedly underpaying the providers for out-of-network claims, leaving patients with massive medical bills.
The lawsuits, filed last week in the U.S. District Court for the Northern District of California, claim that United Behavioral Health and Cigna Behavioral Health violated federal and state laws by systematically reimbursing the out-of-network providers for mental health and substance abuse treatment at unreasonably low rates in violation of the terms of their patients’ insurance plans.
Patients were left with big balance bills that often amounted to 90% of the cost of their care, the complaints allege.
The providers, which provide intensive outpatient program services, claim that they confirmed with UnitedHealth and Cigna that their patients had active coverage for out-of-network behavioral health services before providing treatment, and that the insurers assured the providers they would be paid at “usual, customary and reasonable” rates.
Instead, the insurers enlisted and paid financial incentives to Viant, a vendor that is also named as a defendant in the four cases, to reprice each out-of-network claim in a way that was not based on that reasonable rate and not varied based on geography, according to the complaints. Viant is owned by MultiPlan, which describes itself as healthcare cost-management company.
The patients, meanwhile, were enrolled in UnitedHealth or Cigna employer health plans offering out-of-network coverage for mental health and substance use disorder treatment. They argue that because the insurers underpaid their providers, they were left on the hook for bills averaging $30,000 each.
By Don McCanne, M.D.
With the COVID-19 pandemic, our health care system, our economy, and our personal lives are in turmoil. One of the lessons is that it is now more clear than ever that we are not receiving adequate value for the $4 trillion that we are spending on health care. Clearly we need comprehensive reform of our health care financing system, but it is crucial that in the confusion we not lose sight of the problems that need to be rectified. Those problems that are resulting in fragmentation and dysfunction in financing care are typified by the business model of the private insurers (as opposed to the patient service model that would typify a public insurer).
Today’s message reminds us of what is wrong with placing control of our health care dollars in the hands of private insurers. Two of the nation’s largest private, for-profit insurers have promised patients behavioral health services yet pay as little as 10 percent of the costs, leaving patients with bills averaging $30,000 each. To add insult, they step away from the transaction and hire a “cost-management” vendor to “reprice” the out-of-network claims, reneging on their assurance that they would pay “usual, customary and reasonable” rates.
Of the various reform proposals under consideration, sadly most would leave this inimical industry in control. The leading proposal – single payer Medicare for All – would remove the insurers and replace them with our own universal, equitable, public financing program which would ensure affordable comprehensive health care for all of us forevermore, amen. (It seems a generic “amen” is appropriate in these difficult times.)
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