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United Healthcare Gets Sued Over Refusal To Pay For Lap Band Pre-Op Evaluations and Actual Surgical Procedures, “Algorithm

Posted Mar 24 2014 9:07pm

This is an odd one here and the entire press release reads below.  Did the risk and cost algorithms change in the middle of all of this?  In read the press release, United approved the evaluations with pre-operative tests to see if patients qualified and then refuses both the surgery and the tests?  Ok one thing to refuse the surgery but gee when you have tests going at least pay for that. 

Patients were obese and did qualify but you tell me, is is now more expensive to help slim folks down and rather just let stay fat instead?  We do all these studies about losing weight being beneficial and I know you can’t be just a “little” over weight to qualify by any means.  So with everything that company does, driven by analytics, I ask did something change here with the analytics?  Did a mortality risk assessment prove these folks will have shorter lives and thus cost the company less maybe? Nobody pulled this type of decision out of their head this day and age I think and we all know health insurers can make a stop over to the MIB and get a mortality assessment if they need one and probably all this data might end up there too and there might be some data to sell possibly to create some studies that might be used to substantiate decisions. 

California does not issue licenses to surgery centers and yet they want one.  That’s an old one for stalling claims, I can go back about 8 to 10 years in seeing that response.  It happens in other states too with denials and anyone who does billing will tell you the same thing.  The press release also says this division of their Optum subsidiary is in the Philippines.  In addition are we seeing “being fat” is pre-existing too.  No wonder they want all those Visa and MasterCard records to see what size clothes you could be buying.  Optum, let’s see don’t know which division but former HHS director Steve Larson works somewhere over there. 

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Now granted in Los Angeles we had one Lap Band clinic that had problems but that clinic is not referenced here.  That was a different deal with an unsafe clinic and false advertising and they all are not like that one, it was one case.  United is still making record profits by the way and at the same time firing doctors that take care of Medicare Advantage patients.  

Lap-Band Surgery Gets the Attention of the FDA–Warnings on Billboard Ads For 1-800-GET-THIN and More

Lap-Band surgery is FDA approved.

FDA Gives Approval for Lap-Band Use With Less Obese Patients

Just yesterday though they had no problem with some bad algorithms kicking out a check for over $175,000 to fix a hammer tow in New York.  A few months ago they bid and won a contract in Maryland and the county has to rescind it as they had no doctors in the area to see the patients, which was a retiree HMO plan. 

$175,098.80 To Fix A Hammer Toe Billed by New York Podiatrist And the Insurer Paid It, Well Sort Of As They Sent the Check to the Patient By Accident, A New Investigation For “Out of Network” Charges Has Resulted
Howard County School Board in Maryland Rescinds United Healthcare Contract As Retirees Didn’t Want the Medicare Advantage Plan, No Providers Available..

The company is getting so big with 15 pages of subsidiaries listed at the SEC as well so you seem to find one of their subsidiaries floating around somewhere in almost every area of healthcare.  Banks and insurance companies anymore are really just big software companies and software in the words of Bill Gates is nothing more than a bunch of algorithms that need to work together. 

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Ok so after coving all of this for about seven years now, where’s the study and the algorithmic formulas that lead to these decisions, and there were some around were they not? This is ground into all our heads now with years of experience with “algorithm says” and if you haven’t woken up to that fact yet, well you might start thinking about it.  So I guess this is the next legal battle here and I might guess there will be plenty of data probably to substantiate the decisions if in fact this is the case here.  When I think about the $175,098 that was so easily kicked out on a check to fix a couple hammer toes, well you know that could have bought a few lap band surgeries, maybe?  BD 

LOS ANGELES--( EON: Enhanced Online News )--United Healthcare, one of the nation's largest health insurance companies, along with hundreds of employer-funded health plans, was sued March 20, 2014 in U.S. Federal District Court in Los Angeles by Hooper, Lundy & Bookman, PC for alleged refusal to pay for Lap-Band surgeries which United Healthcare previously authorized for morbidly obese patients. The complaint alleges a "deliberate, willful and concerted effort" to deny health insurance coverage for lap-band surgery constituting discrimination against the morbidly obese. The plaintiffs in the case are Los Angeles-based surgical centers and physicians to whom the patients went for the Lap-Band surgeries.

“This is a classic case of an insurance company putting profits over people,” said Daron Tooch, of the Los Angeles law firm Hooper, Lundy & Bookman that filed the case on behalf of the surgical centers. Tooch stated, "almost everyone in America with health insurance knows exactly what this case is about -- a health insurance company whose employees and representatives are taught to 'just say no' or to delay, delay, delay rather than pay claims for Lap-Band surgery, which has long been recognized as a legitimate basis for dealing with morbidly obese individuals."

The complaint alleges that United authorized hundreds of patients to undergo pre-operative tests to determine whether the patients qualified for the Lap-Band surgery, but refuses to pay for the preoperative tests or the Lap-Band surgeries despite the fact that the patients qualify for the surgery.

The complaint alleges that United has created pre-textual excuses for refusing to process or to pay the claims. In many instances, United has refused to pay for post-surgery adjustments to the Lap-Bands. As a result, these patients are unable to receive the additional medically necessary care they need, and to which they are entitled, and are being held financially liable for the care they have already received. Many of these patients are foregoing receiving the necessary medical services because of the financial liability.

The complaint alleges that United:

  • Makes repeated and redundant requests for unspecified medical records, even where records had already been provided on multiple occasions, and when the surgical centers call to find out what specific records are missing, United cannot provide such information.
  • Forwards the surgical center claims for "further review" by United's wholly owned subsidiary, OptumInsight, which apparently is located in the Philippines, without forwarding the medical records along with the claims. United promises the OptumInsight will take 15-30 days, when in fact the so-called review takes years with no payment resulting from the "review."
  • Asserts that one or more of the surgical facilities was not listed in United's database of health providers as a reason for non-payment, even though claims had previously been paid to those same facilities and even though United sometimes paid the surgeon who performed the surgery.
  • Demands surgery center licenses, even though California does not issue licenses to surgery centers.
  • Denies claims because the patient supposedly did not have coverage, for instance, because of a pre-existing condition, when such coverage in fact existed.
  • The surgery centers and physicians seek a federal court order requiring United Healthcare and the ERISA plans to honor their obligations owed to the insured employees and to pay for the Lap-Band and related surgical claims in good faith and expeditiously.

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