Healthcare Lawsuits: UnitedHealth Alleges Fraud and Anthem, Express Scripts Accused of Overcharging

UnitedHealth Group has filed a lawsuit against American Renal Associates Holdings for fraudulent behavior. Three affiliates of the health insurer are alleging that American Renal Associates convinced patients to sign up for coverage under one of United’s Affordable Care Act plans instead of Medicare or Medicaid plans that the patients were eligible for.

The Wall Street Journal reported that the dialysis centers run by American Renal Associates received larger reimbursement payments for treatments under UnitedHealth plans compared with Medicare or Medicaid.

In a statement with its SEC filing, American Renal Associates said that it plans to “vigorously defend itself” against a lawsuit it says “is without merit.”

The lawsuit stems from complaints filed by 3 UnitedHealth affiliates in Florida regarding 27 patients who received dialysis at 12 facilities run by American Renal Associates in Florida and Ohio.

Meanwhile, Anthem and Express Scripts, the insurer’s pharmacy benefits manager (PBM), are facing a lawsuit that alleges they overcharged patients for prescription drugs. The lawsuit could cover tens of thousands of Americans in a class action case.

The lawsuit claims that Express Scripts violated its fiduciary duties to act prudently and in the best interests of participants under the Employee Retirement Income Security Act when it charged for prescription at prices higher than competitive pricing levels.

“Furthermore, Anthem breached its fiduciary duties by entering into a contract with Express Scripts that allowed Express Scripts to overcharge for prescriptions, and by failing to adequately monitor Express Scripts’ activities to the detriment of Plaintiffs and the Class,” the lawsuit also alleged.

The plaintiffs believe that based on a market analysis from Health Strategy, a third-party consultant, that the prices being charged were higher than competitive benchmark prices.

“Based on Health Strategy’s analysis, [Express Scripts]’s pricing exceeded competitive benchmark pricing by more than $3 billion annually, which projected forward indicated additional overcharges of approximately $13 billion over the remaining term of the PBM Agreement,” according to the lawsuit.