UnitedHealthcare, one of the largest health insurers in the country, filed suit this week against TeamHealth, claiming the staffing company deliberately upcoded commercial insurance claims for emergency room services, which led to overpayments of more than $100 million
The lawsuit, filed Wednesday in U.S. District Court for the Eastern District of Tennessee, claims that for the past five years TeamHealth “covertly and methodically engaged” in upcoding to deceive UnitedHealthcare into overpaying for emergency room (ER) services. The insurer claims that the emergency room staffing and billing company “deliberately upcoded tens, if not hundreds, of thousands of claims,” resulting in United overpaying TeamHealth by more than one hundred million dollars.
United said it reviewed tens of thousands of commercial health benefits claims submitted by TeamHealth and determined that well over half of the claims TeamHealth submitted to United used the two highest level CPT codes for ER visits—roughly 60 percent—when they should have used lower-level CPT codes. The lawsuit alleges that the upcoded claims falsely stated that TeamHealth’s physicians had rendered extensive treatment under urgent circumstances when they had treated routine health problems, such as sore throats, ear infections, dizziness, and back pain. In other words, United claims, TeamHealth systematically misrepresented the services provided to UnitedHealthcare members across many thousands of individual commercial health benefits claims to obtain higher payments.
According to the lawsuit, after the insurer learned of recent allegations that TeamHealth engaged in abusive billing practices, United decided to conduct a pre-pay review on claims TeamHealth billed for ER services using higher rated 99284-99285 CPT codes. The review determined that in 2020 TeamHealth coded more than half (51 percent) of its claims to United as 99285. This is a far higher rate than other providers use the code, which is reserved to particularly severe medical issues requiring urgent treatment.
Based on the high error rate uncovered with the 2020 per-pay review, United expanded the review at the beginning of 2021 to include all claims for ER services billed by TeamHealth using the 99284 and 99285 CPT codes. Combined, the insurer said it reviewed more than 47,000 claims billed by Telehealth to its commercial insurance plans and found that nearly 75 percent of the claims reviewed that were billed using the 99285 CPT code were not supported by medical records and were improperly upcoded. United said the claims should have used lower CPT codes that would have paid at lower rates.
In a statement to Axios, TeamHealth CEO Leif Murphy called the lawsuit “frivolous” and a calculated effort to divert attention away from an upcoming court case in Las Vegas, brought by TeamHealth affiliate Fremont Emergency Medicine against UnitedHealthcare for gross underpayment of frontline clinicians. In addition, he said that the District Court in Nevada dismissed a similar claim by United in the lead up to the trial. Murphy said United continues to generate record profits by down coding claims and refusing to consider the expertise of frontline clinicians who make a diagnosis.