SPRINGFIELD — A group of Holyoke Medical Center doctors is taking insurer Health New England more than $2.5 million in damages they allege the company failed to pay for emergency room treatments, according to a recent lawsuit in Hampden Superior Court.
The lawsuit says the Springfield-based insurer has failed to pay refunds since July 2021 — in the midst of a pandemic — for emergency room treatments it is legally required to provide.
Prosecutors say the company has stopped reimbursing doctors, at least in part, for the treatment they provided to hundreds of Health New England members whom the medical center sees “nearly every day”.
The plaintiffs are Lakes National Emergency Physicians Inc. , a California corporation and physician group that staffs the emergency department at Holyoke Medical Center.
The medical center’s website says the emergency department sees more than 42,500 patients annually. They are unable to turn away any patient in one of the state’s poorest communities.
“National Lakes Emergency Physicians provide essential life-saving services to people with acute medical conditions or those who have experienced trauma or injury. Lakes National Emergency Physicians treat every patient seeking emergency department care, regardless of a patient’s ability to pay. or insurance status, as required by federal and state law,” the lawsuit reads.
The group of doctors is considered “out of network” for Health New England clients because the doctors do not have a contract with the insurance company, according to the prosecution. The company “frozen” its payments after conducting what the lawsuit says was a shadowy audit, followed by demands from the insurance company to turn over full medical records in order to receive compensation.
Officials at the insurance company disagreed entirely with the plaintiffs’ assertions in the lawsuit, and said the scrutiny stemmed from a complaint from one of their members.
“In March 2021, Health New England received and investigated a member complaint about excessive emergency department fees from Lakes, a group of providers that do not have a contract with Health New England. The Health New England investigation, including a third-party scrutiny, sparked Concerns about potential over-billing by Lakes, as well as insufficient Lakes documentation to support the claims made,” Susan O’Connor, Vice President and General Counsel of Health New England, said in response to a request for comment.
“Health New England is committed to helping our members manage the cost of healthcare and would have preferred to work with Lakes to reach an agreement on the appropriate amount of reimbursement and how to ensure the accuracy of future claims. We strongly oppose the allegations in the complaint and will defend against litigation,” O’Connor said.
The lawsuit adds that the medical center treats more than 2,800 Health New England subscribers each year.
“Health insurers such as (Health New England) are required by law to pay out-of-network providers, such as the Lakes National Emergency Doctors, a reasonable value for services rendered, even in the absence of a direct contract between the parties,” the complaint reads.
“The emergency care provided by the Lakes National Emergency Physicians is the difference between life and death for countless Massachusetts residents, and is the most important component of the state’s health care safety net,” he adds.
Under state law, the insurance company must reimburse providers within 45 days of receiving a full claim, according to the plaintiffs.
The lawsuit says that prior to July 2021, Health New England routinely paid Holyoke’s providers nearly 95% of billing fees. They argue that doctors were not given an opportunity to respond to the review.
In March of this year, the insurance company sent the group of doctors a letter demanding overpayments of more than $1 million, according to prosecutors. The suit says the insurance company also requested complete medical records for each emergency claim. The two sides tried to mediate the standoff, but that effort stalled when officials at the insurance company watered down the idea, according to prosecutors.
“Instead of paying, refusing or requesting additional information or documentation, as required by (Health New England), (Health New England) has instead ‘frozen’ the claims without explanation,” the suit says.
It is unclear whether this debt has been passed on to sick consumers. The plaintiffs’ attorney did not respond to a request for comment. But the insurer said the lawsuit would have no impact on patient care from a consumer’s point of view.
“This litigation does not affect the ability of any Health New England member 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.