United Healthcare Sued by TX Surgery Center for Refusing to Pay Claims

United Healthcare Sued by TX Surgery Center for Refusing to Pay Claims

A Texas surgery center has sued UnitedHealthcare Services Inc. in state court, alleging the insurer is refusing to reimburse costs for additional medical help during a difficult weight-loss procedure after previously approving the use of assistant surgeons.

Texas Center for Obesity Surgery PLLC, based in Plano, alleges UnitedHealthcare of Texas Inc. owes it more than $900,000 for the use of assistant surgeons during 57 laparoscopic sleeve gastrectomy surgeries, which reduce the size of a patient’s stomach.  According to the surgery center, UnitedHealthcare had preapproved using assistant surgeons, then refused to pay, and alleges this constitutes fraud and a deceptive trade practice.

“UHC arbitrarily, fraudulently and with no disregard to the health of the patient refused to compensate TCOS for the use of the medically necessary assistant surgeon,” the suit said.

According to the suit, UnitedHealthcare did pay for assistant surgeons for four sleeve gastrectomies and made partial payment for six others, which the obesity center said is evidence the extra help was necessary for the health of the patients. The suit says the surgery is “extremely complex” and would be “inappropriate and impossible” to perform without an assistant surgeon present.

“If the use of the assistant [surgeon] was medically necessary in one of the 57 surgeries, there is no justification to claim the use of an assistant surgeon on the other 56 surgeries would not be medically necessary,” the suit says.

The obesity center said before 2011, all major insurers, including UnitedHealthcare, reimbursed it for using assistant surgeons, and that UnitedHealthcare was the only insurer to refuse payment for the extra help.

But the center said it sought and received approval to use the assistant surgeons before lifting a scalpel, and that UnitedHealthcare promised to reimburse the cost. The suit alleges UnitedHealthcare knew it would not pay and intentionally or negligently misrepresented that it would, constituting fraud.

The surgery center also claims UnitedHealthcare’s “despicable conduct” and “conscious disregard” for the surgery center’s rights was a deceptive trade practice in violation of the Texas Insurance Code, and a breach of its duty of good faith and fair dealing.

Case Information: (Texas Center for Obesity Surgery PLLC v. United Healthcare of Texas Inc. et all)

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