Judge Orders 67K UnitedHealthcare Claims Reprocessed

(Photo: Shutterstock)

What does a federal magistrate judge do on Election Day?

Well, if you’re U.S. Chief Magistrate Judge Joseph Spero in San Francisco, you put the finishing touches on a 99-page order hitting UnitedHealthcare, the nation’s largest health insurer, with an injunction requiring the company to revisit about 67,000 denials of claims for mental health and substance abuse coverage.

Spero on Tuesday reaffirmed a finding from last year where he found the guidelines that UnitedHealthcare used when making coverage decisions didn’t provide for generally accepted standards of care outlined in the plaintiffs’ health insurance policies.

In his prior ruling, Spero found that United Behavioral Health (UBH), which manages behavioral health services for UnitedHealthcare, breached its fiduciary duty to policyholders by following guidelines that emphasized cost-savings and addressing acute problems rather than treating underlying issues.

“UBH engaged in this course of conduct deliberately, to protect its bottom line,” Spero wrote Tuesday.

Spero’s latest order grants a request from the plaintiffs’ team at Zuckerman Spaeder and Psych Appeal for an injunction designed to prevent UBH from harming class members in the same way going forward—an injunction that could be in place for up to 10 years.

UBH is required to reprocess all of the claims that were denied based on the flawed internal guidelines under the watchful eye of a special master, who will also be tasked with making sure that UBH provides proper training for its claim reviewers.

The parties have been asked to jointly put together a slate of three possible special masters in the coming weeks, or alternatively, pitch their own independent lists of candidates if they can’t come to an agreement.

Zuckerman Spaeder health care practice head D. Brian Hufford said in a phone interview Tuesday that the ruling “reflects the court’s appreciation for the extent of the problem here and the fact that he found that United had not been upfront about their conduct.”

“United was putting its financial interest over the people that it actually owed fiduciary duties to,” he added.

Eric Hausman, a spokesman for UnitedHealthcare said via email that the company has taken steps over the past several years “to improve access to quality care by enhancing coverage through clinician-developed, evidence-based guidelines, expanding our network of providers, and providing new ways for people to quickly access care through telehealth and other digital platforms.”