A recent class action settlement with UnitedHealth Group (United) secures rights under the Employee Retirement Income Security Act of 1974 (ERISA) for out-of-network (OON) physicians that received Repayment Requests from United. This could impact allergists who have received Repayment Requests from United because they are OON to the patient’s ERISA plan between Jan. 2005 and June 2021.
ERISA requires a plan administrator, such as United, to provide an enrolled patient with “notification of any adverse benefit determination” that includes, among other things:
- The specific reason or reasons for the adverse determination.
- Reference to the specific plan provisions on which the determination is based.
- A description of the plan’s review procedures.
- The time limits applicable to such procedures, including a statement of the patient’s right to bring a civil action under ERISA.
ERISA also requires plan administrators to establish “a procedure by which a [patient] shall have a reasonable opportunity to appeal an adverse benefit determination.” Under ERISA, a patient may designate the physician as the patient’s Authorized Representative to exercise the patient’s legal rights.
Who is part of the Class entitled to relief?
Generally, after United pays a claim to an OON provider and later determines that it has overpaid that claim, United will send the provider a Repayment Request. A group of OON physicians and suppliers filed a class action lawsuit against United alleging that United failed to give OON providers the notice and appeal rights required by ERISA in connection with those Repayment Requests.
The physicians and suppliers involved in the lawsuit (the Class):
- Provided health care services or supplies to patients with an ERISA plan that is insured or administered by United.
- Received payments from United for those services or supplies and subsequently received one or more Repayment Requests after January 24, 2005.
- Had an unresolved Demand as of June 2, 2021.
What was the outcome of the lawsuit?
The Class and United ultimately settled the lawsuit subject to the following conditions:
- For Class members that received Repayment Requests within the 12 months prior to June 2, 2021, United must: (1) provide a spreadsheet listing and an explanation for all overpayment claim redeterminations; (2) treat all Class members as “Authorized Representatives” for the claim redetermination; and (3) provide information on how the Class member can appeal the redetermination or file a civil action under ERISA.
- For all OON providers in receipt of new Repayment Requests issued by United, United must recognize the OON provider as an “Authorized Representative” with corresponding ERISA rights if the provider gives United an executed Authorized Representative Designation form, which is available on United’s website; or an executed Assignment of Benefits form that assigns/conveys/transfers to the provider any right/claim/cause of action/chose in action with respect to the plan or insurance policy.
This lawsuit is Integrated Orthopedics, Inc. v. UnitedHealth Group, No. 2:11-cv-00425 (D.N.J). For more information about the settlement, please visit the United Class Action website.
The information contained in this article is not intended to constitute legal advice.