A White Plains company is demanding $1.1 million from Fidelis Care for allegedly mishandling health insurance claims.
Premier Home Health Care Services accused Fidelis of fraud in a complaint filed on May 13 in Westchester Supreme Court.
“Fidelis’ instructions to Premier to submit claims manually or via paper,” the complaint states, for instance, “were rooted in fraud and were aimed at stalling payment or expiring the contractual limitations period.”
Fidelis bills itself as an affordable health care insurer serving about 2.5 million people in New York. It is a subsidiary of Centene Corp., a publicly-traded healthcare enterprise worth $42 billion by market capitalization, based in St. Louis.
Premier is based in White Plains and serves about 15,000 clients weekly, according to the complaint, for services such as nursing, personal care and escorting patients to appointments.
In 2022, Fidelis agreed to reimburse Premier for services provided to Fidelis’ members. Premier submitted claims and received payments through an electronic exchange chosen by Fidelis.
Premier alleges three “buckets” of mishandled reimbursement claims.
One bucket is for claims submitted for Premier clients who were eligible for services under both Medicare and Medicaid. Fidelis allegedly processed the dual eligibility claims incorrectly.
Premier says it alerted Fidelis to the problem in February 2023 and was advised to rebill claims on paper, instead of electronically. Claims were still denied, according to the complaint, in some instances because Fidelis said they had not been received in time.
Another bucket refers to claims where the electronic clearinghouse allegedly doubled the amount of time to be reimbursed. Fidelis denied the claims because they exceeded the maximum level of eligible services.
Premier and Fidelis officials met biweekly for ten months to resolve $1.3 million in disputed claims in the clearinghouse dispute, the complaint states. Fidelis paid about $712,000, leaving about $622,000 unpaid.
The third bucket includes claims denied for miscellaneous reasons such as purported invalid data, duplication, lack of authorization and late submissions.
Premier is demanding $500,000 for alleged fraud and $622,000 for alleged breach of contract and violation of the New York Prompt Pay Law.
Fidelis’ media relations office did not reply to an email asking for responses to the allegations.
