AMA Sues WellPoint Over Out-of-Network Payments

The American Medical Association and four other medical groups filed suit Wednesday, March 26, against WellPoint, accusing the Indianapolis-based health insurer of underpaying providers for out-of-network services.

The lawsuit, filed in federal court in Los Angeles, where several of the co-plaintiffs are based, follows similar actions last month by the AMA against Aetna and Cigna.

All three AMA suits allege that the insurers conspired with Ingenix, a unit of UnitedHealth Group, to set artificially low reimbursement rates for out-of-network care.

A yearlong investigation by the New York attorney general into insurers’ use of the Ingenix database resulted in January and February settlements in which several insurers agreed to cease using the Ingenix database and to contribute to the cost of developing a replacement database operated by an independent third party.

Despite the agreements, the Chicago-based AMA filed suit to recoup payments that should have been made to doctors while the Ingenix database was still in use, AMA president Dr. Nancy Nielsen said in a statement.

“Now that the underlying scheme has been exposed, health insurers are doing the right thing by cutting their ties with the flawed Ingenix database. However, serious damages resulting from prior use of the Ingenix database still need to be addressed,” Nielsen said.

Other plaintiffs in the litigation are the California Medical Association, the Connecticut State Medical Society, the Medical Association of Georgia and the North Carolina Medical Society.

In response to the suit, WellPoint said in a statement that it “is committed to providing appropriate reimbursement for out-of-network services. We are in the process of reviewing the complaint and are unable to comment further at this time.”

The lawsuits are available at the AMA’s Web site at www.ama-assn.org/ama/pub/physician-resources/legal-topics/litigation-center.shtml.

Filed by Joanne Wojcik of Business Insurance, a sister publication of Workforce Management. To comment, e-mail editors@workforce.com.