LOS ANGELES (CN) – A home medical-services company says the nation’s largest health insurance company, United Healthcare Services, has cheated it out of $47 million through an elaborate scheme of fraud and delay.
In a federal lawsuit filed Wednesday, IV Solutions says United Healthcare authorized it to provide intravenous medication or other infusion therapy to insured patients in California and then repeatedly came up with excuses to not pay its agreed-upon fees.
It “engaged in a scheme involving third-party contracts, promised payments, partial payments, extensive delays, and bogus denials to create the illusion that IV Solutions would ‘eventually’ get paid, when all the while the defendant had no intention of paying,” the company declares in its 30-page complaint.
After years of problems, IV Solutions came to understand the depth of the scheme only after a patient who had worked in United Healthcare’s claims department explained the insurer “had a corporate practice of intentionally denying claims that [it] knew it should cover.”
The ex-employee said Minnesota-based United believed medical-services providers “would accept low or partial payments rather than fight an extended battle with the defendant’s claims department and legal team to get the contracted amount,” IV Solutions says in its complaint. “It was a practice she had witnessed many times while working for the defendant.”
Other United representatives “leaked information” that the insurer “had marked IV Solutions for underpayment in 2009,” the suit says.
A United Healthcare spokesman did not respond to requests for comment on Friday, nor did an attorney with Crowell & Moring who represents it in an unrelated lawsuit involving IV Solutions.
The plaintiff’s lead attorney, Todd C. Theodora of Theodora & Oringher, also could not be reached.
Based outside Los Angeles, IV Solutions describes itself as “a high-end, specialty pharmacy.” It was one of the early companies to provide home infusion treatment services in the wake of the AIDS epidemic, when doctors preferred to send patients with compromised immune systems home rather than keep them in infection-prone hospitals, according to the lawsuit.
It offered its services to doctors for patients needing all kinds of medicines throughout the state, even on a rush basis. It “specialized in being the provider of last resort,” called upon when other infusion therapy companies could not help, the lawsuit says.
Therefore, it is not an “in-network” provider for United Healthcare or other health insurers, and its fees are high. United would agree to pay those fees only when necessary to avoid being sued by its insureds, IV Solutions says.
But according to the lawsuit, United decided not to pay IV Solutions any more than the very low rates it had negotiated with its in-network infusion therapy companies. To accomplish that, it paid some claims in full, some at discounted rates and many not at all.
By paying a few bills in full, United kept IV Solutions hopeful. With most other bills, the insurer would delay, seek changes, ask the bills to be resubmitted and then deny them as untimely, according to the complaint.
On average, United Healthcare paid about 8 percent of what IV Solutions billed, the company says. That is equivalent to the rate United pays the in-network providers – “which is the rate that the defendant had wanted to pay IV Solutions all along, and which is the rate that IV Solutions explicitly rejected numerous times.”
The lawsuit lists the individual amounts IV Solutions claims it is owed for treating 121 insured patients, ranging from $1 to more than $6 million, between 2010 and 2015.
By 2015, enough other providers had entered the home infusion market that United Healthcare could meet its insureds’ needs with in-network providers, and it stopped using IV Solutions.
“The ‘string along’ was over, and IV Solutions was stuck with tens of millions in unpaid bills,” the lawsuit says.
In addition to unpaid bills of $47,301, 910, the company is seeking punitive damages for fraudulent misrepresentation, breach of contract, unjust enrichment and six other causes of action.