UHC is among the largest claim administrators of employer-provided health plans. According to the Complaint, TeamHealth is one of the largest emergency room staffing, billing, and collections companies in the United States. It controls as much as 17 percent of the emergency medical services market and operates as many as 3,400 emergency medical facilities in 47 states, employing roughly 18,000 healthcare professionals. TeamHealth, which reportedly employs the doctors in roughly one out of every six emergency rooms in the country, is owned by the private equity giant, Blackstone.In the battle of the behemoths, the interests of patients seem forgotten. Nonetheless, patients can take steps to watch their wallets and guard their healthcare.
What is upcoding?
Upcoding is a practice through which health care providers submit claims to an insurer or administrator utilizing a Current Procedural Terminology (CPT) code that exaggerates or misrepresents the type or degree of services provided. That falsehood misleads the insurer or claims administrator into overpaying. The practice appears to be common and increasing. Claims administrators may not catch the lie because of the huge numbers of claims they process.
To be clear, in UHC’s lawsuit, the hospitals and doctors are not accused of pocketing the profits. According to the Complaint, “[N]o emergency room physician ever saw a dime of this extra revenue. TeamHealth pays physicians a flat hourly rate, and retains all of the revenue above costs generated by TeamHealth-affiliated medical groups. TeamHealth’s inequitable conduct served only to line the pockets of TeamHealth executives and their private equity backers.”
The Complaint cites the case of a young man suffering from indigestion after eating a chili dog He sought treatment in an ER staffed by a TeamHealth physician. The doctor gave him Maalox and sent him home. TeamHealth then allegedly submitted a claim for a particularly complex and severe condition, resulting in a $1,712 charge.
UHC was reportedly billed $1,428 on the claim of a woman who was diagnosed with an ear infection at another TeamHealth ER. TeamHealth submitted another $1,421 claim for a strep throat.
TeamHealth manages all billing and coding for its physician groups. It further restricts communication between claims administrators and the doctors and hospitals that provide services to patients. As set out in the Complaint, “TeamHealth blocks attempts by insurers and claims administrators to contract directly with its affiliated medical-groups, and demands independence from the hospitals within which it operates in its dealings with insurers and claims administrators. It thus intentionally interposes itself between insurers, claims administrators and medical providers.”
What about the patients?
UHC and TeamHealth both have financial incentives to win this battle. But neither upcoding, the charge UHC has leveled against TeamHealth in this lawsuit, nor underpayment for services, with which TeamHealth has previously charged UHC, makes for better patient care. As far as patients are concerned, the rewards of either outcome in the war between giants is beside the point.
In addition, claims administration is a profit-driven business. Premiums and other healthcare costs will ultimately reflect claims experience, which can be easily be distorted by the profit-driven push and pull. Upcoded, expensive claims will eventually cost everyone in the insured group.
On a more immediate level, upcoding can have a negative impact on patients’ credit score. An unpaid medical bill can ruin a credit. To top it off, the false information recorded in a medical record may later affect the quality and amount of protection a patient can get.
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Watch your wallet!
Patients can take six important steps to avoid becoming collateral damage in big money lawsuits:
- Do not pay your medical bill without reviewing your statement. Errors are very common, and you need to let your insurer know;
- Insist on an itemized statement;
- Ask your doctor to review your statement;
- on’t be shy about asking the hospital billing department to make adjustments with the services that you did not receive;
- contact your insurer or claims administrator with questions;
- Know your states rules for hospital charges – these vary from state to state;