(By Joe Schulz, Wisconsin Public Radio) The U.S. Department of Labor is suing a third-party health insurance administrator based in Wausau for wrongfully denying thousands of emergency room and urinary drug screening claims.
Federal officials say UMR Inc., a subsidiary of the Minnesota-based UnitedHealth Group, improperly denied insurance claims for more than 2,000 people since January 2015. The labor department filed a lawsuit in federal court last Monday, after an investigation found the company’s process for evaluating emergency room claims allegedly did not comply with the law, relying solely on diagnosis codes and not the “prudent layperson” standard.
Ruben Chapa is regional director for the U.S. Department of Labor’s Employee Benefits Security Administration. He said the prudent layperson standard requires insurers to look at whether someone seeking emergency treatment believed they required immediate care.
“For example, you’d have an instance where an individual goes in with heartburn but doesn’t believe that it’s heartburn; he or she believes it’s a heart attack,” Chapa said. “If the individual really believed that it was a heart attack, then most insurance plans would cover that.” UMR also allegedly denied nearly all urinary drug screening claims without reviewing them for medical necessity.
Chapa said drug screenings can be medically necessary for multiple reasons, ranging from ensuring a patient’s substance abuse treatment program is moving in the right direction to ensuring a medication doesn’t have a negative reaction with another substance in someone’s system.
He said UMR’s claim denials have had major health and financial consequences for those affected. “There’s a significant impact to an individual’s health and welfare,” he said. “Individuals, in some instances, have gone bankrupt because there’s large expenses that are sometimes associated with the treatment they received.”
The lawsuit seeks reimbursement for those with wrongfully denied claims, and asks the court to prevent the company from continuing that practice. In a statement, UMR said the lawsuit is based on an administrative process that’s no longer in place.
“We have been in ongoing conversations with the (Department of Labor) regarding this matter and will continue to defend our position vigorously,” the statement read.
Comments