North Carolina doctors sue UnitedHealthcare

For the second time this year, the state medical society targets an insurer.

By Robert Kazel, amednews staff. June 7, 2004. - Correction

The North Carolina Medical Society has filed suit against UnitedHealthcare of North Carolina.

The lawsuit, filed May 14 in Wake County Superior Court, accuses United of some of the same improper business practices alleged in an earlier suit by the medical society against BlueCross BlueShield of North Carolina.

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The medical society requests the judge's assistance in curbing practices the society says are "designed to delay, deny, impede and reduce lawful reimbursement."

Medical society leaders met in January with United executives to present their grievances, but the talks haven't produced results. "We were discussing things, but we were not resolving things," Robert Seligson, executive vice president and CEO of the NCMS.

Neither the suit against United nor the one against the Blues plan asks the court for monetary damages for doctors. "This isn't about money; it's about trying to solve problems," Seligson said.

The complaint accuses the plan of bundling and downcoding claims, failing to recognize modifiers on CPT codes and systematically denying payments to doctors for medically necessary claims. The society also says United continues to maintain an "all products" policy requiring that doctors participate in all or none of its product lines; that doctors are no longer able to get a coverage decision from the plan before performing a medical service; and that confidentiality clauses in contracts ban physicians from discussing payment for disputed claims with other doctors. (See correction.)

A spokesman for UnitedHealth Group, the health plan's Minnesota-based parent, expressed disappointment. "We have worked extensively with the medical society to resolve the issues they've raised, and we believe for just about every issue they've raised concerns we've taken substantial efforts to address all the concerns," said spokesman Mark Lindsay.

Correction

This story incorrectly stated that a North Carolina Medical Society lawsuit against UnitedHealthcare accused the payer of prohibiting doctors from discussing payments for disputed claims among themselves. The society made that allegation against BlueCross BlueShield of North Carolina, not United, in a separate suit this year. Also, this article said that doctors “no longer” can get pre-treatment coverage decisions from United. Officials of the society say United contracts have never given them the ability to obtain advance decisions on reimbursement.