SPRINGFIELD — A group of doctors at Holyoke Medical Center is suing insurer Health New England for more than $2.5 million in reimbursements that the company failed to pay for ER treatments, according to a recently filed lawsuit in the state. Hampden Superior Court.
The lawsuit says the Springfield-based insurance provider hasn’t issued reimbursements since July 2021 — in the midst of a pandemic — for emergency room treatments they are legally required to provide.
The claim says the company stopped reimbursing doctors, even partially, for the treatments they provided to hundreds of Health New England members whom the medical center sees “virtually every day.”
The plaintiffs are Lakes National Emergency Physicians Inc., a California-based company and physician group that operates the emergency department at Holyoke Medical Center.
The medical center’s website says the emergency department sees more than 42,500 patients a year. They are unable to turn down a patient in one of the poorest communities in the state.
“The National Lakes Emergency Physicians provide essential and lifesaving services to people with acute medical conditions or those who have suffered trauma or injury. Lakes National Emergency Physicians treats all patients who seek care in an emergency department, regardless of patient’s ability to pay or insurance status, as required by federal and state law,” reads the trial.
The group of doctors is considered “out of network” for Health New England customers because the doctors do not have a contract with the insurance company, according to the claim. The company “froze” its payments after conducting what the lawsuit claimed was a vague audit, followed by demands from the insurance company to turn over complete medical records in order to obtain reimbursement.
Insurance company officials disagreed strongly with the plaintiffs’ claims in the lawsuit and said the audit was prompted by a complaint from one of their members.
“In March 2021, Health New England received and investigated a member complaint about excessive charges for emergency services from Lakes, a group of providers with whom Health New England does not have a contract. Health New England’s investigation, including a third-party audit, raised concerns about possible overcharging by Lakes, as well as insufficient documentation from Lakes to substantiate the submitted claims,” said Susan O’ Connor, vice president and general counsel for health. New England, said in response to a request for comment.
“Health New England is committed to helping our members manage the cost of health care and would have preferred to work with Lakes to reach agreement on an appropriate reimbursement amount and how to ensure accuracy of claims at the coming. We vigorously dispute the allegations in the complaint and will defend against litigation,” O’Connor said.
The medical center treats more than 2,800 Health New England subscribers each year, the lawsuit adds.
“Health insurance companies like (Health New England) are required by law to pay out-of-network providers, such as Lakes National Emergency Physicians, the reasonable value of the services provided, even when the parties have not no direct contract,” the complaint reads.
“The emergency care provided by Lakes National Emergency Physicians makes the difference between life and death for countless Massachusetts residents and is the most important element of the Massachusetts health care safety net. ‘State,’ he adds.
Under state law, an insurance company is required to reimburse claimants within 45 days of receiving a complete claim, according to the plaintiffs.
The lawsuit says that prior to July 2021, Health New England routinely reimbursed Holyoke providers approximately 95% of the fees charged. They argue that the doctors were not given the opportunity to respond to the audit.
In March this year, the insurance company sent the group of doctors a letter demanding more than $1 million in overpayments, according to the plaintiffs. The insurance company also required complete medical records for each emergency claim, the lawsuit says. The two sides attempted to mediate the impasse, but that effort was halted when insurance company officials grew cold on the idea, according to the plaintiffs.
“Rather than pay, deny, or request additional information or documentation, as (Health New England) is required to do, (Health New England) has instead ‘frozen’ the claims, without explanation,” the lawsuit states. .
It is unclear whether these debts were passed on to consumer patients. A plaintiffs attorney did not return a request for comment. But, the insurance company said the lawsuit will have no impact on patient care from a consumer perspective.
“This litigation does not affect the ability of any member of Health New England to request emergency room coverage at any facility. Health New England remains committed to advancing care and improving lives in support of our mission to improve the health and lives of people in our communities,” O’Connor said.