UnitedHealth Group subsidiary UMR incorrectly denied emergency room and urinary drug screening claims for 'thousands," the U.S. Department of Labor alleges in a lawsuit filed July 31 in a Wisconsin federal court.
UMR is UnitedHealthcare's third-party administrator that provides benefits services to at least 2,136 self-funded employer health plans, according to the complaint.
By denying emergency claims "based solely on diagnosis codes and not applying a prudent layperson standard," the Labor Department said UMR has violated the Employee Retirement Income Security Act of 1974, which oversees self-funded plans. The department added that UMR's explanation to members for the denied emergency claims violated the ACA and the government's internal claims procedures regulations.
For urinary test denials, the Labor Department alleges that UMR denied all claims from August 2015 to August 2018 without determining whether a claim was medically necessary.
According to the complaint, UMR changed its claims review process in 2018 to cover some urine screenings that were provided in an emergency setting. In 2019, the subsidiary allegedly switched its urine screening claims denial codes from lack of medical necessity to a request for more medical records from the provider.
The lawsuit is seeking to require UMR to reform its emergency and urinary drug testing claims procedures to comply with ERISA and readjudicate all denied or partially denied claims from Jan. 1, 2015, to present.
"This complaint deals with practices that are no longer in effect. We will continue to work with the DOL to discuss any concerns it has related to this matter," a UnitedHealthcare spokesperson told Becker's.