A Federal Court in Tennessee orders United Healthcare of Tennessee, Inc (United) to pay $99,000 in ERISA penalties for failing to provide a patient with treatment guidelines for 900 days. The $99,000 ERISA penalty is almost 3 times the amount of the medical claim benefits owed of $35,724.80
The US District Court Eastern District of Tennessee fined United Healthcare of Tennessee, Inc (United) $99,000 in ERISA penalties for failing to provide a patient plaintiff with United’s Treatment Guidelines (Medical Policy) for 900 days. The order came after the court had ordered United to pay $35,724.80 plus pre-judgment interest for United’s medical necessity denials. The court also ordered United to pay Plaintiff attorney fees.
The court’s ERISA United decision provides very powerful protection for all patients and providers with a possible $110 per-day statutory penalty for all medical necessity denials. PPACA has adopted ERISA claim regulations for both ERISA plans and non-ERISA plans. http://www.dol.gov/ebsa/healthreform/#internalclaimsandappeals
As a result of this court decision, both participating and non-participating hospitals, ASC’s and all providers should seek ERISA compliance and medical necessity appeals training in order to properly appeal all medical necessity denials using this court guidance in compliance with ERISA and PPACA regulations.
The court case info: Butler v. United Healthcare of Tennessee, United States District Court Eastern District Of Tennessee At Knoxville, No. 3:07-CV-465, Filed 09/30/13.
Ms. Butler’s (Plaintiff) insurer, United Healthcare, denied the claim on the basis that the service was not medically necessary. United had relied upon a physician reviewer opinion provided by a third-party service, Medical Review Institute of America. The case was remanded twice and dragged into its fifth year of litigation before the courts made their final ruling.
According to the court, “United’s careless handling of Ms. Butler’s claim, and its repeated denials, is confounding.” “[The] court believes that United’s handling of Ms. Butler’s claim was a result of a bureaucratic, perfunctory, and scattered process that was a product of United’s underlying conflict of interest”
The court goes on to say, “ERISA authorizes the court to impose statutory penalties in certain circumstances. Here, an administrator who fails to furnish, upon a participant’s request, any internal rule, guideline, or similar criterion that was relied upon to make the adverse determination may be liable for up to $110 per violation (i.e. per day). 29 U.S.C. § 1132(c)(1)(B); 29 C.F.R. § 2575.502c-1 (2013). The calculation of the penalty begins thirty days after the participant’s request for such information.”
The court ordered: “United was required to provide a copy of the Guidelines upon request. Mr. Butler requested those Guidelines on February 10, 2006 (see AR 164), but he did not receive those Guidelines until July 30, 2008, when United filed the administrative record. That filing came 900 days after Mr. Butler formally requested the Guidelines. Given the length of time during which the Guidelines were not disclosed, and the negative effect such non-disclosure had on Mr. Butler to present his appeal, the court awards the maximum penalty for each day of delay, which amounts to $99,000.00.” according to the court document.