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UnitedHealthcare/UF Health court case offers lessons for local health businesses

 A case lost by an insurance provider related to unpaid claims has led to a payout to two local hospitals. 

Minnetonka, Minnesota-based UnitedHealthcare Insurance Co. paid $4.7 million to UF Health The Villages Hospital and UF Health Leesburg Hospital in December after it lost a case where it has denied more than 1,000 patient claims for insurance coverage for medical care. 

The arbitration process was initiated in October 2019 by the two hospitals with the American Arbitration Association. The hearing took place virtually from July 26 to Aug. 3 due to Covid-19, but was considered to be in Orange County for procedural reasons. The three-person panel made the award to the hospitals in November. 

Representatives with UnitedHealthcare were not available for comment. 

Miami-based law firm Wolfe Pincavage LLP represented the UF Health hospitals, with co-founders Doug Wolfe and Danya Pincavage working alongside associate attorney Liana De La Noval. 

“My takeaway from the arbitration is that whether it was close call or not that a procedure is medically necessary or not, the benefit of the doubt likely will go to the provider that treated the knowledge of the patient and has the firsthand knowledge of what the patient’s symptoms are,” Wolfe said. “Hopefully, that will be helpful for other hospitals in combatting that.” 

Here, Wolfe and Pincavage spoke with Orlando Business Journal on their takeaways from the case and how it might impact other health systems. 

How might this impact other Florida health systems? 

Wolfe: We represent a lot of hospitals throughout the state of Florida and we see these issues recurring with lots of clients. It’s lots of groups, not just UnitedHealthcare. I was on a call with one of our clients and they said they are seeing an upward trend of denials over the last year and a half, so it is a problem that’s increasing and has been more rapidly. 

How unique are these cases compared to other markets? 

Wolfe: We have other clients that are more physician-based outside of Florida and they experience similar problems. It seems like each state may have its own variety of denials. There are a lot of things that are common across states. There may be some unique issues if a state has laws or other regulations tied to coverage issues. 

What are some of your takeaways from the case? 

Wolfe: There’s two things I would say. First, when it comes to these disputes between hospitals and insurance companies, everyone should try to be more upfront in all these things so it doesn’t get to where this case did. It costs a lot of money to pay lawyers and arbitrators to hash out these disputes. In an ideal world, the business side folks will be able to hash this type of situation out without it getting this far. The other thing I would say is this happened during Covid-19 and a lot of the procedural was unique. 

How did Covid impact the proceedings? 

Pincavage: One of the challenges during Covid was finding ways to move cases along when you had little access to in-person jury trials or other types of in-person proceedings. Because all the parties and arbitrators agreed to conduct the final hearing over Zoom, it allowed us to keep the schedule we previously agreed upon and keep the case effectively as scheduled. The court system in Florida has done a good job in transitioning to hold a lot of hearings over Zoom and I think that will persist even after Covid is over. With that final hearing, it allowed the scheduling of witnesses. No one had to travel, people could testify with about 10 minute’s notice. 

How often do these types of cases go before an arbiter or jury? 

Pincavage: Statistically, very few proceedings go through a trial or final hearing, which is what happened here because it was an arbitration. I think it’s something like 95% of all cases settle nationwide before going to trial or mediation.