Treatment Centers Sue UnitedHealth for Denied Claims

Dive Brief:

  • Three treatment centers are alleging they are owed more than $5 million after claims they submitted to United Behavioral Health, a unit of UnitedHealth Group, were denied. The treatment centers want the claims reprocessed, according to a lawsuit filed Thursday in the Northern District of California.
  • The action comes on the heels of a court ruling from early this year that found UBH’s guidelines for treatment were too restrictive, which led to care being denied for substance use disorder and other behavioral health needs.
  • The plaintiffs are seeking class action status and estimate there are thousands of providers affected, totaling more than $9.3 billion in denied claims.

Dive Insight:

As the country is in the grips of an opioid epidemic, the plaintiffs say they have treated a “deluge” of patients seeking care for substance use disorder and other mental health issues.

This lawsuit comes as the opioid crisis is making its way into the U.S. court system in various ways. Drug manufacturers are facing significant pressure around their role in contributing to the problem.

Purdue Pharma has filed for bankruptcy in an attempt to settle thousands of lawsuits across the country, according to the New York Times. And last month, in a landmark case out of Oklahoma, a judge ruled that Johnson & Johnson must pay $572 million for its role in marketing the prescription painkillers and the influence it had on the continuing epidemic.

Judge Joseph Spero’s ruling on UBH treatment guidelines from earlier this year likely invited challenges such as the current suit over claims denials, given the judge’s findings.

Spero found UBH’s guidelines for coverage determinations were based “on its own bottom line” and UBH did not adopt a widely recognized standard of care from the American Society of Addiction Medicine because the finance department didn’t sign off on the change.

Instead, the payer used guidelines that were more restrictive than the generally accepted standard of care.

The treatment centers are arguing in the new filing that, because of the earlier ruling, claims through January of this year should be reprocessed — and at UBH’s expense.

The centers also want a neutral third party to oversee the reprocessing of claims, alleging that “UBH has demonstrated that they cannot apply guidelines in a fair, impartial or clinically appropriate manner,” according to the lawsuit.


Scroll to Top