The class action lawsuit alleges a conspiracy among health insurers, including Anthem Blue Cross, Blue Cross and Blue Shield of California, and Wellpoint to reduce reimbursements for out-of-network services.
Some health insurance plans permit members to seek medical care from out-of-network providers. For consumers who have contracted to obtain out-of-network benefits and agreed to pay the higher premiums, health insurers generally reimburse members for out-of-network services either at the actual amount of their medical bills or the “usual and customary rate” of doctors in the same or similar geographic area for substantially the same service.
The class action alleges health insurers used an electronic database owned and controlled by the health insurance companies to artificially set and cap the “usual and customary rate” of doctors in order to lower their reimbursement costs to members.
Defendants’ misconduct has allegedly harmed millions of consumers who have had to pay higher-than-normal rates for out-of-network services. Click here to download a report by New York’s Attorney General concerning systemic conflicts of interest and self-dealing by health insurers for out-of-network reimbursements to consumers.
This Report lays out our central finding: the out-of-network system is broken. Insurers mislead and obfuscate in their policy language. They promise to reimburse based on usual and customary rates — a form of market rate — but then reimburse based on schedules compiled by one of their own, the nation’s second largest health insurer, which has an interest in depressing reimbursement rates. They hide this conflict of interest from their members. They pretend an independent database underlies these rates — it does not. Our investigation found that the Ingenix schedules themselves, created in a well of conflicts, are unreliable, inadequate, and wrong — usually at the expense of the consumer.
- New York Attorney General, Report Concerning Out-Of-Network Reimbursements
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