Ok so we have other lawsuits already in place so we add one more here.  United is saying they were tricked now into paying high claims costs, but what about their fraud prevention algorithms they sell to help hospitals and providers all across the US?  Don’t these somehow come along and kick in with finding patterns and potential fraud?  The old Ingenix, now Optum, fraud prevention services/software have been around for a long time, even to the point to where lawsuits have been brought about stating they are too stringent and create false positives, so what gives here?  I would think the company would certainly use their own software to find fraud patterns as early as they can, right?  Here’s a few back links on the Lap Bands below to get you up to date on the history here. 

1-800-GET-THIN and Lap-Band Lawsuit Having Trouble in Southern California With Insurer Covering Legal Expenses For False Advertising Case
United Healthcare Gets Sued Over Refusal To Pay For Lap Band Pre-Op Evaluations and Actual Surgical Procedures, “Algorithm Says”?
Lap-Band Surgery Gets the Attention of the FDA–Warnings on Billboard Ads For 1-800-GET-THIN and More
FDA Gives Approval for Lap-Band Use With Less Obese Patients
LAP-BAND(TM) is First Obesity Intervention Device in Europe for Treatment of “Diabesity”

One issue stated here is that United is claiming false medical records were submitted to support claims where the patient’s height was changed to bring the body mass to a level that would meet insurance coverage.  On the other hand too I have read where people on purpose gained weight to quality but that is kind of odd in itself but if that happened, then they met the guidelines.  The lawyers on the other side said now they have to find out why they paid such claims and United said they are overwhelmed with claims and can’t screen them before making payments.  That’s kind of odd as that’s part of their business when patients every day have to get an approval for some procedures and drugs too from them.   So maybe they are admitting they have problems with their business models here and fraud prevention doesn’t work as good as it should even though they sell this software/service like crazy.  Here’s an example of a company that’s using their fraud prevention algorithms below. 

SAS Adds Optum (UnitedHealthcare) Fraud Prevention Algorithms That Includes Social Network Data Mining Analytics To Their Fraud Prevention Framework Software

At this point maybe we might begin to wonder about how good the anti-fraud algorithms really are?  A few yeas ago a number of dermatologists in San Diego fought the Ingenix fraud algorithms and a couple went out of business as the company came back after the fact and took money back and notified all other insurers to not pay several practices, so over night all their reimbursements were stopped, a rude awakening as of course the doctors had already provided the services to patients.  Again this is kind of an interesting defense here being the company sells and prides itself on anti fraud processes and now is saying they don’t do so well after all, at least in this case.  There might be something to that as in New York the company had no problem kicking out $175,000 for a $15,000 hammer toe procedure and that’s pretty glaring as I would have thought the “normal and customary fees” data base would have set off an immediate alarm there with one that out of tolerance?

$175,098.80 To Fix A Hammer Toe Billed by New York Podiatrist And the Insurer Paid It, Well Sort Of As They Sent the Check to the Patient By Accident, A New Investigation For “Out of Network” Charges Has Resulted

Anyway, using such a defense in my opinion anyway might hurt the credibility of the products and software they sell, you think?  We know the pressure is on all insurers as CMS through an audit found a “risk fiddler algorithm” that worked for 5 years and allowed insurers to bill an additional $70 billion, or around $14 billion a year as an average.  That will be gone and CMS can’t really even file a fraud cause here as insurers would probably cut more services to Medicare Advantage Plans.  Why isn’t everyone honest about their numbers you could ask? 

CMS Discovers That Insurers Offering Medicare Part D “Really Know To Sharp Shoot A Model With Adjusting Risk For Profit”, A Common Everyday Occurrence in Financial Markets…

When you see Wall Street style quantitative math models that fiddle with risk become apparent?   We saw the same happen with the Ingenix lawsuit that the AMA filed and settled with paying doctors short for 15 years with United and the other insurers licensed it so they settled as well, or at least most of them anyway as I ran across this of late at the link below and now Aetna who agreed to settle is trying to get out of their portion of how long they too used the Ingenix models on out of network payments.

Ingenix (Optum-United Healthcare) Lawsuits Still Bouncing Around Out There–One Recently Settled in New Jersey With Horizon Blue Cross Blue Shield That Was Still Using the Flawed and Corrupt Data Base for Out of Network Payment Calculations

Anyway, it seems to be kind of an odd defense for a company that has sold and marketed anti-fraud software and systems for years.  Maybe the United models need some work on their anti fraud solutions?  Variables will cause models to be updated and re-written as we all know and in the financial world this happens all the time.  So this will be interesting to follow as again they seem to be putting the credibility of their own products and software on the line with the type of legal defense I’m reading in this article, you think?  This quote below kind of says it all and ask any provider or hospital about how “good faith” works with insurers as they are sometimes nickeled down on other small claims that cost them time and money to research.  There was a story in the LA Times not too long ago to where doctors in Los Angeles had taken a lot of time to document, send images, etc. on a medically needed breast reduction.  United wanted all kinds of documentation, etc. and then came back months later after all the work and effort on the part of the doctors and said “her policy would not cover that”, so whey didn’t they advise in the first place was the question with the doctors instead of taking their time sending groves of information for the claim? 

"By practical necessity, United must reasonably and in good faith rely on the veracity of the descriptions of the services rendered as stated on the claims form and the amount of the bill submitted by the provider for each service."

You can decide for yourself on this one, but again when the company has sold so much anti fraud software and services, this is a strange defense here to say “we can’t handle the claims” and were the victim here?   BD 

The nation's largest health insurance company has accused the brothers behind the 1-800-GET-THIN advertising campaign of defrauding the insurer of more than $40 million by operating a complex weight-loss surgery billing scheme.

UnitedHealth Group Inc. contended in a lawsuit that Michael and Julian Omidi operated a network of companies that tricked the insurer into paying claims for medical procedures that were unnecessary, ineligible for coverage or never even performed.

The companies advertised for several years on Southern California freeway billboards, radio and television with a catchy slogan: "Let your new life begin, call 1-800-GET-THIN."

An attorney who represents the surgery centers denied UnitedHealth's allegations and said he would seek to have the lawsuit dismissed.

"There was certainly no systematic attempt to defraud an insurance company," said Daron Tooch, who represents several surgery centers sued by UnitedHealth. "It's just a series of allegations designed to counteract the lawsuit we filed."

UnitedHealth declined to discuss the lawsuit, issuing a short statement instead: "UnitedHealthcare will continue to vigorously litigate the claims and counterclaims affiliated with the 1-800-GET-THIN litigation."

The lawsuit contends that UnitedHealth paid more than $43 million on "false and misleading" claims submitted by the Omidis' companies. Multiple claims were for pre-surgery procedures that were not performed, including ultrasound, psychological and nutritional consultations, the lawsuit said.

"United receives nearly 2 million healthcare claims per day and must comply with various laws and regulations mandating that such claims be paid within a short period of time," the company said in the lawsuit. "By practical necessity, United must reasonably and in good faith rely on the veracity of the descriptions of the services rendered as stated on the claims form and the amount of the bill submitted by the provider for each service."

UnitedHealth's allegations come two years after several law enforcement agencies opened an investigation of the Omidis for "potential violations of federal law, including conspiracy, healthcare fraud, wire fraud, mail fraud, tax violations, identity theft [and] money laundering," according to a statement by a U.S. Food and Drug Administration criminal agent in a court filing in an unrelated criminal case. No charges have been filed.



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