Peterson ex rel. Patient E v. UnitedHealth Group Inc.

242 F. Supp. 3d 834
CourtDistrict Court, D. Minnesota
DecidedMarch 14, 2017
DocketCase No. 14-CV-2101 (PJS/BRT), Case No. 15-CV-3064 (PJS/BRT)
StatusPublished
Cited by4 cases

This text of 242 F. Supp. 3d 834 (Peterson ex rel. Patient E v. UnitedHealth Group Inc.) is published on Counsel Stack Legal Research, covering District Court, D. Minnesota primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Peterson ex rel. Patient E v. UnitedHealth Group Inc., 242 F. Supp. 3d 834 (mnd 2017).

Opinion

ORDER

Patrick J. Schütz, United States District Judge

Two health-care providers — Dr. Louis Peterson and Riverview Health Institute (“Riverview”) — bring these actions on behalf of certain of their patients against UnitedHealth Group Inc. and various of its affiliates (collectively “United”). United acts as the administrator for numerous health plans governed by the Employee Retirement Income Security Act (“ERISA”), 29 U.S.C. 1001 et seq. According to plaintiffs, United has wrongfully failed to pay them and other providers who have treated patients enrolled in United-administered plans. Instead of paying the providers what they are owed, plaintiffs allege, United withholds some or all of their payments in order to offset overpay-ments that United claims to have made to the providers in connection with their treatment of different patients enrolled in different plans. Plaintiffs allege that this practice — known as “cross-plan offsetting” — violates ERISA and the terms of the plans.

This matter is before the Court on the parties’ cross-motions for summary judgment on the issue of whether the relevant plans authorize cross-plan offsetting. For the reasons explained below, the Court holds that they do not. But because this order “involves a controlling question of law as to which there is substantial ground for difference of opinion” and because “an immediate appeal from the order may materially advance the ultimate termination of the litigation,” the Court certifies this order for immediate appeal pursuant to 28 U.S.C. § 1292(b).

I. BACKGROUND

A. Cross-Plan Offsetting

United is one of the largest health insurers in the world. It both administers and insures health-insurance plans. Some of the plans that United administers are fully insured, meaning that United uses its own funds to pay claims. Other plans that United administers are self-insured, meaning that United uses the funds of the plan sponsor to pay claims. Bishop-Heroux Dep. 26-27. United’s fully insured business accounts for 22 percent of all claim payments; the remainder come from self-insured plans. Bishop-Heroux Dep. 55-56.

Administering health-insurance plans is a complex business, and United inevitably makes mistakes. One type of mistake is to pay a provider more than the provider is owed under the patient’s health-insurance [837]*837plan. This litigation challenges a particular technique that United uses to recover such overpayments — a technique known as “cross-plan offsetting.” The technique takes a little explaining:

Suppose that a patient named Andy is insured under a health plan administered by United. Andy sees Dr. Peterson for treatment of a sore neck. Dr. Peterson submits his bill to United. United pays $350 to Dr. Peterson. Later, however, United discovers that it should have paid only $200 to Dr. Peterson. United contacts Dr. Peterson, brings the overpayment to his attention, and asks him to return $150.

If Dr. Peterson agrees that he was overpaid and returns the $150, the problem is solved. But if Dr. Peterson does not agree that he was overpaid and refuses to return the money, United has limited options for getting back its $150. In theory, United could initiate administrative or legal proceedings against Dr. Peterson. As a practical matter, however, United is unlikely to do so, as United would spend far more than $150 in pursuing the $150 overpayment.

Another option might be to engage' in same-plan offsetting. Under this approach, United would wait until Andy or anyone else covered by Andy’s health plan is treated by Dr. Peterson. When Dr. Peterson submits a bill to United on behalf of that patient, United would deduct $150 from the payment that it would otherwise make to Dr. Peterson. From United’s perspective, however, same-plan offsetting presents a big problem: Dr. Peterson may never again treat Andy or someone who is insured under Andy’s plan. Dr. Peterson practices in New York City, a giant metropolitan area. Andy may work for a small company in a distant suburb, and he may be insured under a company-sponsored plan that covers only Andy and 20 other employees. The chances may be slim that Dr. Peterson will ever again treat someone who is insured under Andy’s plan. And thus, United may never have the opportunity to use same-plan offsetting to recoup its $150 overpayment from Dr. Peterson.

To get around this problem, United adopted the practice of cross-plan offsetting. Under this approach, United merely has to wait until anyone covered by any of the thousands of plans that it administers sees Dr. Peterson. Suppose, for example, that two weeks after treating Andy, Dr. Peterson treats Betsy, who is injured while on vacation in New York City. Suppose further that Betsy is insured under a plan that is administered by United and that covers Betsy and 50 of her co-employees (all of whom live in San Diego). When Dr. Peterson submits a bill to United on behalf of Betsy, United would deduct $150 from the payment that Betsy’s plan would otherwise make to Dr. Peterson and thereby recoup the overpayment that Andy’s plan made to Dr. Peterson in connection with his treatment of Andy. It is this practice of cross-plan offsetting that Dr. Peterson and Riverview challenge in these lawsuits.

In their briefs, the parties refer to the allegedly overpaid claims (such as Dr. Peterson’s claim for treating Andy) as the “A claims,” and the plans that made these overpayments (such as the plan that covered Andy) as the “A Plans” or “Plan As.” The parties refer to the later claims that United purportedly paid through debt cancellation (such as Dr. Peterson’s claim for treating Betsy) as the “B claims,” and the corresponding plans (such as the plan that covered Betsy) as the “B Plans” or “Plan Bs.”1

[838]*838Dr. Peterson and Riverview are both out-of-network providers who provided services to an “Andy” — that is, to a patient who was insured under a Plan A administered by United, Both providers submitted claims to United. Both received payment for those claims from the Plan A. Both were later informed by United that they had been paid too much. Both disputed that they had been paid too much, and both refused to return the alleged overpayment. With respect to both, United responded by recouping the disputed overpayment through cross-plan offsetting. In other words, when United learned that Dr. Peterson or Riverview had submitted a subsequent claim regarding a “Betsy”— that is, a different patient who was insured under a different United-administered plan (a Plan B) — United did not pay for those claims by transferring money to Dr. Peterson or Riverview. Instead, United purported to pay for those claims by cancelling debt that Dr. Peterson or Riverview allegedly owed to the Plan A.

Cross-plan,offsetting advantages United and disadvantages providers. When United and a provider dispute whether a claim was overpaid, cross-plan offsetting allows United to act as judge, jury, and executioner. United treats the provider as being in debt to Plan A — -no matter how strongly the provider denies being in debt to Plan A — and United collects that disputed debt by offsetting money that Plan B owes to the provider. In theory, the provider could initiate administrative or legal proceedings against United to recover the offset.

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Cite This Page — Counsel Stack

Bluebook (online)
242 F. Supp. 3d 834, Counsel Stack Legal Research, https://law.counselstack.com/opinion/peterson-ex-rel-patient-e-v-unitedhealth-group-inc-mnd-2017.