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Life Health > Health Insurance > Life Insurance Strategies

Hospital Sues Carrier Over Utilization Review

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A New York hospital is clashing with a health insurer over the standards used to decide whether the care provided to patients was medically necessary.

Lawyers for Brookdale University Hospital & Medical Center Inc., New York, have filed a suit in the U.S. District Court in New York against Health Insurance Plan of New York, New York, the hospital’s subsidiaries, and a utilization review consulting firm.

In the complaint, Brookdale University Hospital alleges that the defendants engaged in a “pattern of racketeering activity” by applying unreasonable standards for managing HIP patients’ access to care at Brookdale University Hospital.

The consulting firm began reviewing care at Brookdale University Hospital for HIP in 2001.

In one case, Brookdale University Hospital alleges, the consulting firm said care provided for a woman dying of cancer was medically unnecessary because care violated standards dealing with the treatment of “infectious diseases,” even though the woman was not suffering from an infectious disease.

HIP has responded by calling the Brookdale University Hospital accusations “profoundly dishonest and defamatory.”

Brookdale University Hospital entered the HIP provider contract that required use of the utilization review consulting firm voluntarily, and it could have terminated the contract at any time, HIP says in a statement.

The hospital started the current suit “without any warning,” and it has repeatedly canceled meetings with HIP that were supposed to give the plan and the hospital a chance to improve coordination of care, HIP says.

If there were any systemic problems with the quality of the HIP utilization review program, Brookdale University Hospital should have taken action to work with HIP to correct the problems, HIP says.


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