A group of plastic surgeons hit UnitedHealthcare with a proposed class action on Monday, alleging the nation's largest insurer "routinely and consistently" denied claims for a type of breast augmentation surgery requested by cancer survivors despite a federal law that requires them to do so.
The complaint, filed in a New Jersey federal court, said the health giant's failure to cover deep inferior epigastric perforator surgery violates Employee Retirement Income Security Act guidelines. Those federal guidelines state that, once an ERISA plan provides coverage for a mastectomy, insurers are required to cover breast reconstruction.
Surgeons are challenging United's claim that having more than one clinician perform DIEP procedures is not medically necessary, and seek repayment for the expense of filing the lawsuit, along with the remainder of their patients' bills, with interest, and any other relief the court determines appropriate.
"Thousands if not tens of thousands of claims have been denied by United at the expense of highly skilled surgeons and their patients," the lawsuit said.
DIEP is a type of surgery that uses fat and skin from a patient's abdomen to create a new breast. The surgery can take up to 12 hours with multiple surgeons to complete, the lawsuit said, but ultimately offers patients "significantly better cosmetic results, has fewer donor site complications, is muscle sparing" and a better psychological experience than other types of breast reconstruction.
Insurers have previously been reluctant to cover the procedure since it often requires more than one surgeon, which can make it more expensive than similar treatment. A November 2020 analysis from Bloomberg Law found at last seven instances of insurers—including Minnetonka, Minn.-based UnitedHealthcare—fighting DIEP claims in court in 2020, saying that these disputes were indicative of payers becoming increasingly aggressive about lowering costs and reducing provider reimbursements. One expert said the litigation signaled that providers were attempting to overcharge insurers. Most of these disputes were resolved through undisclosed settlements, including UnitedHealthcare's.
This most recent case comes on behalf of two plastic surgeons, whose patients' employers contracted with UnitedHealthcare for benefits administration. In one instance, Dr. Joseph Tamborino submitted a bill for $50,000 which UnitedHealthcare refused to cover, saying it was the patient's responsibility since the use of an assistant surgeon for the procedure was not "medically necessary," according to the complaint. In another instance, the lawsuit alleged that Dr. Taylor Theunissen submitted a bill for $60,000 that UnitedHealthcare denied, despite offering prior authorization for the service to be performed by two surgeons. UnitedHealthcare likewise said the patient should foot the $60,000 bill.
The complaint traces UnitedHealthcare's blanket denials to a policy change in 2017, although "nothing has changed in the medical literature since then that would justify United being the only major claims administrator to adopt this new uniform reimbursement policy." The company's claims adjudication engines are programmed to automatically deny any DIEP surgery when an assistant surgeon or co-surgeon is used, the lawsuit said, which directly contradicts with industry practice and the "overwhelming balance of medical literature."
By denying claims, the lawsuit said UnitedHealthcare avoided paying benefits it owed individuals, and lowered costs for its corporate customers, "allowing United to retain current customers and expand its business to new customers," the lawsuit said. The company also gained fees by processing multiple denials on behalf of its self-insured customers.
UnitedHealthcare declined to comment on the suit. The complaint represents just one of a number of flare ups the insurer has suffered over the past month.
Earlier in June, UnitedHealthcare unveiled a policy to retroactively deny emergency department claims. After complaints from the American Hospital Association, American College of Emergency Physicians and other providers, the insurer quietly announced it was pausing the policy through a customer service tweet.
In June, the company was also hit with a suit from a laboratory in New Jersey, which alleged the insurer systematically denied paying the claims for 51,000 COVID-19 tests administered to its beneficiaries. Two days later, UnitedHealthcare announced it would increase what it pays pediatricians and family medicine clinicians to match Medicare rates.
