Opioid-Related Lawsuits Are on the Rise - Who's to Blame?

For more than a decade, the California insurance commissioner’s office has led a case against United Healthcare Group (UHC) for wrongly denying insurance coverage. The case included more than 900,000 violations, the largest number ever found in the state’s history.

In January, the California State Supreme Court ruled in favor of patients, ordering UHC to pay $91 million in fines. The court’s ruling will help the state of California better police insurers and protect patients.

UHC is not the only insurer to be accused of wrongfully denying claims in California. The insurance commissioner has also launched an investigation into Aetna based on a lawsuit brought by a college student. In deposition for that lawsuit, Aetna’s former medical director admitted that physicians were not reviewing medical records to determine medical necessity. They were only provided “pertinent information” from nurses. This process may have led many patients to be denied coverage for treatments they desperately needed.

Thanks to the UHC decision, the commissioner may have a stronger case against Aetna. While the state’s decision doesn’t affect insurers in other states, it may help patients in other states support their cases. It upholds the legal right of states to hold insurers accountable. And dozens of these cases are underway across the country.

One such case, a class action lawsuit against United Behavioral Health, focuses on its violation of mental health parity laws in Illinois, Connecticut, Rhode Island, and Texas. In a scathing decision against the company, the federal judge said the company was deceptive and put its bottom line ahead of the patient’s health. The case uncovered ways that the company crafted its own guidelines so it could find ways to deny coverage later.

Because this ruling was so large and was a federal ruling, it may have a huge impact on patients across the country. It will set a precedent for many other cases and, hopefully, lead to changes in how insurance companies conduct business.

The Cost of Denied Insurance Coverage

It is important to remember that denied coverage isn’t just a matter of money; it can mean the lives of patients who desperately need help. Denied coverage can keep patients from getting the care they need, increasing the rates of suicide or overdoses. Patients who receive lower level care than they need are still at great risk of poor outcomes.

Judges are taking the human cost of denied coverage into account, which explains the strength of their rulings and the steep financial punishments. Though the fight for parity is not over, each ruling makes it more likely that patients will be able to get the lifesaving care they need.

At Datapro billing, we can help you navigate in-network contracts as well as the ever-changing reimbursement trends. Contact us to discuss if moving in-network will benefit your facility and learn how we can help you negotiate better in-network contracts.