Holyoke Medical Center emergency docs sue Health New England over $2.5 million in unpaid claims [masslive.com]

MassLive.com

SPRINGFIELD — A group of Holyoke Medical Center doctors are suing insurer Health New England over $2.5 million in reimbursements they claim the company has failed to pay for emergency room treatments, according to a lawsuit recently in Hampden Superior Court.

The lawsuit says the Springfield-based insurance provider has failed to make the reimbursements since July 2021 — in the midst of a pandemic — for emergency room treatments they are legally bound to provide.

The claim says the company stopped reimbursing the doctors even partially for treatment they rendered for hundreds of Health New England members the medical center sees “virtually every day.”

The plaintiffs are Lakes National Emergency Physicians Inc., a California corporation and physician group that staffs Holyoke Medical Center’s Emergency Department.

The medical center’s website says the Emergency Department sees over 42,500 patients annually. They are unable to turn any patient away in one of the state’s poorest communities.

“Lakes National Emergency Physicians renders critical, life-saving services to people with acute medical conditions or those who have experienced trauma or injury. Lakes National Emergency Physicians treats every patient seeking care in an emergency department, regardless of the patient’s ability to pay or insurance status, as required by federal and state law,” the lawsuit reads.

The physician group is considered “out-of-network” for Health New England customers because the doctors do not have a contract with the insurance company, according to the claim. The company “froze” its payments after conducting what the lawsuit argues was a vague audit, followed by demands by the insurance company to turn over full medical records in order to obtain reimbursement.

Officials with the insurance company wholly disagreed with the plaintiffs’ assertions in the lawsuit, and said the audit was triggered by a complaint from one of their members.

“In March 2021, Health New England received and investigated a member complaint regarding excessive emergency department charges from Lakes, a group of providers with whom Health New England does not have a contract. Health New England’s investigation, including an audit conducted by a third-party, raised concerns about potential over-billing by Lakes, as well as insufficient Lakes documentation to support the claims submitted,” Susan O’Connor, vice president and general counsel for Health New England, said in response to a request for comment.

“Health New England is committed to helping our members manage the cost of health care and would have preferred to work with Lakes to come to an agreement about an appropriate reimbursement amount and how to ensure claims accuracy going forward. We vigorously contest the allegations in the complaint and will defend against the litigation,” O’Connor said.

The medical center treats more than 2,800 Health New England subscribers each year, the lawsuit adds.

“Health insurance carriers like (Health New England) are required by law to pay out-of-network providers, such as Lakes National Emergency Physicians, the reasonable value for the services provided, even where the parties do not have a direct contract,” the complaint reads.

“The emergency care provided by Lakes National Emergency Physicians is the difference between life and death for countless residents of Massachusetts and is the most important component of the state’s health care safety net,” it adds.

Under state law, an insurance carrier is required to reimburse providers within 45 days of receiving a complete claim, according to the plaintiffs.

The lawsuit says that prior to July 2021, Health New England routinely reimbursed the Holyoke providers at approximately 95% of billed charges. They argue the physicians were not given an opportunity to respond to the audit.

In March of this year, the insurance company sent the physician group a letter demanding over $1 million in overpayments, according to the plaintiffs. The insurance carrier also demanded full medical records for each emergency claim, the lawsuit says. The two sides attempted to mediate the standoff, but that effort stalled when officials with the insurance company cooled to the notion, according to the plaintiffs.

“Rather than paying, denying or requesting additional information or documentation, as (Health New England) is required to do, (Health New England) has instead been ‘freezing’ claims, without explanation,” the lawsuit says.

It is unclear whether those debts have been passed on to the patients consumers. A lawyer for the plaintiffs did not return a request for comment. But, the insurance company said the lawsuit will have no impact on patient care from a consumer standpoint.

“This litigation does not impact the ability of any Health New England member to seek emergency room coverage at any facility. Health New England remains committed to advancing care and enhancing lives in support of our mission to improve the health and lives of the people in our communities,” O’Connor said.