Updated to include a statement from UnitedHealthcare.
Dive Brief:
- The Nemours Foundation has filed a lawsuit against UnitedHealthcare claiming the insurer has not fully paid Nemours for care to the state's Medicaid recipients. The suit, filed Monday, seeks $15 million in damages.
- Nemours says United's Medicaid contract with the state is inadequate and has left thousands of residents without access to the Delaware's only children's hospital, forcing them to travel out of state for care.
- Nemours and United Healthcare have been at a standstill on contract negotiations since 2014.
Dive Insight:
If precedent is any indication, Nemours' case is strong. The foundation—which owns pediatric physician practices in Pennsylvania, New Jersey and Delaware and the Alfred I. du Pont Hospital for Children in Delaware—has already won similar settlements with UnitedHealthcare of Pennsylvania, UnitedHealthcare of the Mid-Atlantic and United Healthcare Community Plan of New Jersey.
"Nemours is routinely caring for children for whom United is responsible, despite United's belief that they do not need Nemours in their network. We cared for those patients and were paid variably, if at all, for doing so," Dr. Roy Proujansky, CEO of Nemours Delaware Valley Operations, said in a prepared statement.
"This situation is simply unsustainable. We will continue working with the State to ensure Delaware children covered by Medicaid have access to necessary and appropriate pediatric care."
"Nemours has repeatedly asked to be paid up to 50% more than other comparable children's hospitals in the region for providing the same inpatient services, which would significantly raise costs for the Delaware Medicaid program and the taxpayers who help fund Medicaid," UnitedHealthcare told Healthcare Dive in a statement. "Nemours is now using litigation to respond to our refusal of their excessively high rates, but our focus remains on ensuring the Medicaid members we serve have continued access to the specialized care they need through the many other care providers who have committed to improving patient quality and outcomes."