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Practice Area: Employee Benefits


WellPoint/Ingenix Out-of-Network “Usual and Customary” Rates Health Litigation

Summary of the Lawsuit:

This lawsuit alleges that participants in health plans insured or administered by WellPoint and who utilized services provided by an “out-of-network” doctor or medical provider and for which Wellpoint allowed less than the medical provider’s billed charge.  The lawsuit alleges that Wellpoint paid out-of-network charges based on using a Ingenix database that collected the “usual and customary rates” (“UCR”) which were manipulated downward and as a result, the participants in the health plans were reimbursed far less than they should have been.

Summary of the Claims:

The lawsuit claims that the use of the Ingenix database by WellPoint and its subsidiaries to calculate the usual and customary rates violated Sherman Antitrust Act, the Employee Retirement Income Security Act (ERISA) and the Racketeer Influenced and Corrupt Organizations Act (RICO).  Among others, WellPoint insures or administers plans through Anthem Blue Cross and Blue Shield, Blue Cross and Blue Shield of Georgia, Inc., Blue Cross of California (Anthem Blue Cross) and Empire BlueCross BlueShield.

According to the New York Attorney General, WellPoint, other insurers and Ingenix have manipulated the data to skew the "usual and customary" rates downward.  In report entitled, "The New York Attorney General's Health Care Report: The Consumer Reimbursement System Is Code Blue," which can be found here, the New York Attorney General's office found the rate of underpayment by insurers ranged from 10 to 28 percent for various medical services across New York.  
Ingenix and its use by and contributions from health insurance companies was also the topic of a recent Senate Commerce, Science and Transportation Committee staff report entitled "Underpayments to Consumers by the Health Insurance Industry." The report can be found here. The report states: "in every region of the United States, large health insurance companies have been using two faulty database products owned by Ingenix, Inc., to under-pay millions of valid insurance claims. The companies have used these Ingenix database products without providing even the most basic information about them to consumers or health care providers." As a result, the lawsuit alleges that many subscribers were reimbursed far less than they should have been for out-of-network medical services.
Status of the Litigaton

The litigation is ongoing and currently in discovery.

Whom to Contact for More Information:

If you are a member of the proposed class or you have information which might assist us in the prosecution of these allegations, please contact one of the following persons:

Brent W. Johnson
Cohen Milstein Sellers & Toll PLLC
1100 New York Avenue, N.W., Suite 500
Washington, D.C. 20005
Telephone:  888-240-0775 (Toll Free) or 202-408-4600