United Healthcare, the largest insurer in the country, filed a lawsuit against American Renal Associates on July 1, charging that the country’s fifth largest provider convinced Medicaid patients to switch to more lucrative commercial insurance plans that paid the provider thousands of dollars more.
In the 39-page complaint, filed in the United States District Court in the Southern District of Florida, United said ARA launched a “fraudulent and illegal scheme … to unlawfully obtain benefit payments from United for dialysis services rendered to vulnerable patients suffering from chronic kidney disease.”
The complaint identifies 27 dialysis patients treated at 12 ARA clinics that United said joined the insurer’s Gold Compass 1500 plan in Florida and its Compass and Navigate Plan in Ohio. United said some of the patients would have qualified for Medicare. “…Many of the patients ARA counseled into dropping Medicaid coverage and switching to a United commercial plan … were also eligible for Medicare coverage at the time they were enrolled in the United plans by ARA employees.”
In addition, it charges in the suit that ARA told patients it would pick up any charges for co-pays or deductibles once they agreed to sign onto the commercial plans.
In a statement, ARA defended its practices.
“At all times, we are dedicated to putting patients first, and we structure all of our relationships within that framework and with the intent to provide patients with the best possible service and quality of care,” said Michael Costa, vice president and general counsel of American Renal Associates Holdings Inc. “We believe this lawsuit is without merit. We intend to vigorously defend this legal action for American Renal and on behalf of all patients who choose and trust us with their care.”
ARA, which went public in April, serves about 13,400 patients at 194 dialysis clinics in 25 states and the District of Columbia. Thirty-nine of those clinics are in Florida.
United: AKF’s premium payment program aided ARA’s efforts
United’s suit claims that ARA’s efforts to move patients to commercial plans were aided by the American Kidney Fund’s Health Insurance Premium Payment program, which helps needy patients cover their premiums. The AKF was not named as a defendant in the suit, but United said the AKF “…knew or should have known that the terms of the United commercial plans to which ARA endeavored to steer ESRD patients did not permit AKF or ARA to make premium payments for United plan members, or to contribute to or reimburse those members for their premium payments.”
Dialysis providers helped to create HIPP back in 1997 as a way to cover insurance premiums for dialysis patients. It was approved by the Office of Inspector General and allows the AKF to provide grant assistance by making premium payments on behalf of financially needy dialysis patients. The OIG did not limit the program to Medicare and Medicaid plans, allowing HIPP to cover premiums for Marketplace plans, COBRA, or an employer group health plan. The program currently benefits approximately 79,000 patients nationwide, the AKF says; nearly two-thirds of those individuals are getting help with their Medicare Part B and Medigap premiums.
“We help patients who are in financial need to pay for the coverage they have chosen. It doesn’t matter what kind of insurance they have or where they choose to get their care. Our job is to make sure they get the care they need despite their financial circumstances,” the AKF said in a statement.
In an interview with NN&I, AKF president and CEO Lavarne Burton said the OIG ruling requires the organization to maintain a pool for the funds given by providers, but checks are written to an insurer to cover a patient’s premium without being tied to a specific provider. The AKF also verifies that the patient meets criteria set by the HIPP for financial assistance.
“The companies who contribute to AKF will not be assured that the amount of HIPP assistance their patients receive bears any relationship to the amount of their donations,” the OIG ruling reads. “Indeed, the companies are not guaranteed that beneficiaries they refer to HIPP will receive any assistance at all. HIPP will not be advertised to the public by the companies; this should reduce the probability that a beneficiary would select a company based on its participation in HIPP.”