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 * Employee Benefits Security Administration
 * US Department of Labor sues Wisconsin-based third-party claims administrator
   for denying medical claims for thousands of participants




News Release


US DEPARTMENT OF LABOR SUES WISCONSIN-BASED THIRD-PARTY CLAIMS ADMINISTRATOR FOR
DENYING MEDICAL CLAIMS FOR THOUSANDS OF PARTICIPANTS

Investigation finds UMR Inc. violates ACA, ERISA

MADISON, WI – The U.S. Department of Labor has filed suit against the nation’s
largest third-party medical claims administrator for routinely denying
healthcare claims for emergency room services and urinary drug screening for at
least 2,136 self-funded employee welfare benefit plans.

On July 31, 2023, the department filed a complaint against Wausau-based UMR
Inc., a subsidiary of UnitedHealth Group Inc. of Minneapolis, in the U.S.
District Court for the Western District of Wisconsin, which seeks reimbursement
to plan participants whose claims were denied improperly by UMR from January
2015 to present, and an injunction to prevent the company from improperly
denying claims across the country.

UMR provides third-party administrative services for self-funded plans
nationwide and serves more than five million participants with custom health
plan designs, claim and claims-related services.

An investigation by the department’s Employee Benefits Security Administration
alleges UMR’s procedures for adjudicating emergency room claims relied solely on
diagnosis codes and did not comply with the “prudent layperson” standard in the
Affordable Care Act(link is external) and the Employee Retirement Income
Security Act. The investigation also found that UMR denied nearly all urinary
drug screening claims without reviewing the claims for medical necessity.

“UMR’s actions denied thousands of participants payment of medically necessary
claims and claims where the participants sought treatment in what they believe
to be an emergency,” explained Regional Director for the Employee Benefits
Security Administration Ruben R. Chapa in Chicago. “The Department of Labor is
committed to ensuring that participants in employee benefit plans receive the
services that they have contracted for to meet their and their families’ medical
needs.”

UMR is a named fiduciary to the self-funded employee welfare benefit plans for
the purpose of deciding claim determinations. The plans’ healthcare benefits are
funded directly from the plan’s assets or the sponsoring employer and are not
funded through insurance policies. The self-funded employee welfare benefit
plans contracted directly with UMR for administrative service arrangements. UMR
provides network access, management, and administration; claim recovery services
and subrogation; fraud and abuse management; processing of initial benefit
determinations; processing first and second level internal appeals; and pays
claims.

“The Department of Labor will take all necessary legal action to ensure
fiduciaries and service providers comply with the standards of the Affordable
Care Act and the Employee Retirement Income Security Act,” said Regional
Solicitor of Labor Christine Heri in Chicago. “UMR’s alleged decision to deny
claims violated its obligation as a fiduciary under its administrative service
plan documents and the law.”

Su v. UMR Inc.

U.S. District Court, Western District of Wisconsin

Civil Action No: 23-CV-513

Agency
Employee Benefits Security Administration
Date
August 4, 2023
Release Number
23-1721-CHI
Media Contact: Scott Allen
Phone Number
312-353-4727
Email
allen.scott@dol.gov
Media Contact: Rhonda Burke
Phone Number
312-353-4807
Email
burke.rhonda@dol.gov
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