Taylor Theunissen, MD, and Metairie, La.-based Sadeghi Center for Plastic Surgery filed a lawsuit against UnitedHealthcare, alleging the insurer failed to pay preathorized claims in violation of the Employee Retirement Income Security Act, according to Law Street Media.
Five things to know:
1. Patient N.T., designated as a beneficiary under ERISA, was diagnosed with breast cancer and had a bilateral mastectomy and breast reconstruction surgery, according to the Aug. 23 complaint.
2. The surgery required subsequent revision involving deep inferior epigastric perforator flaps. DIEP procedures are covered by the plan, which outlines that benefits are "for reconstructive procedures [including] breast reconstruction following a mastectomy and reconstruction of the non-affected breast to achieve symmetry," according to court documents.
3. Dr. Theunissen said UnitedHealthcare granted preauthorization because the procedures were deemed medically necessary. After the first surgery, the plaintiffs submitted claims to the insurer, which partly rejected the claims because "during adjudication of out-of-network claims, our system refers to the FH Benchmark database and automatically applies the amount reported at the plan's selected percentile for your geographic area for eligible claims," according to the complaint.
4. UnitedHealthcare's reasoning allegedly left the patient with an outstanding balance of more than $100,000. Patient N.T. required more surgeries that were preauthorized by UnitedHealthcare, but the insurer failed to pay out on claims after they were filed by the plaintiffs, according to the lawsuit.
5. The ASC argues that UnitedHealthcare repeatedly denied claims and that "the minimal payments that were made are clearly insufficient and contrary to the plan," according to the complaint, which accuses the insurer of violating ERISA and cites a claim for benefits, breach of contract and detrimental reliance. The plaintiffs are seeking a declaration of UnitedHealthcare's alleged violations and a direction requiring the insurer fulfill its payment obligations.
UnitedHealthcare did not immediately respond to Becker's request for comment.