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Emergency Department Doctors Sue Insurer Over Out-of-Network Underpayment

A doctor working on a laptop.

Female doctor or practitioner using calculator and work on laptop computer with medical stethoscope and notebookon the desk at clinic or hospital. Medical healthcare costs ,fees and revenue concept.

Northeast Emergency Medicine Specialists LLC (NEMS) filed a lawsuit against Harvard Pilgrim Health Care of Connecticut Inc. and Point32Health Inc. (together Pilgrim) earlier this week, alleging violations of Connecticut’s “surprise billing laws.” The plaintiff, a company that staffs the emergency departments of various Connecticut hospitals, claimed that the insurance company failed to pay for amounts due under patients’ medical bills.

The District of Connecticut lawsuit explained that in view of the importance of emergency medical services and to protect patients from surprise bills, the state enacted a law that compels insurance companies to pay doctors specified amounts, the greatest of the in-network fee, the usual, customary, and reasonable rate as set forth in the FAIR Health database, or the Medicare rate. The plaintiff further reported that the law applies only to emergency department services, for which there are no contractually agreed upon service rates.

Pilgrim, the plaintiff alleged, accepted all claims listed in an exhibit to the complaint as properly coded emergency department claims and correctly listed the applied amount as the “allowable amount” on that portion of the patient’s explanation of benefits (EOB). However, NEMS alleged, the defendant failed to pay the difference between the in-network rate and the FAIR Health database rate for each of the claims, and instead shunted that cost to patients.

By shifting the payment obligation, Pilgrim in effect directed the plaintiff to ask patients for money, in violation of both the Surprise Billing Law and the Connecticut Unfair Trade Practices Act, which forbids such direct requests for payment, the complaint said. According to NEMS, Pilgrim also acted and continues to act in bad faith by shirking the obligations it knows it must comply with under the Surprise Billing Law. 

The complaint explained that the plaintiff’s billing company, Gottlieb LLC, appealed many of aforementioned EOBs, although there is no such requirement as an out of network provider. Pilgrim however, “either did not respond or, after repeated requests for a response, simply denied the appeal.”

The plaintiff seeks a declaratory judgment, damages plus interest, treble damages, and an award of its attorneys’ fees and costs. NEMS is represented by its own counsel.

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