Case Number: No. 3:22-cv-01541
Practice Area: Healthcare Litigation
Case Status: Pending
On December 5th, 2022, Berger Montague announced that a class action complaint has been filed alleging that network access provider Anthem, recently rebranded as Elevance, unlawfully refuses to allow self-funded health plans with which it contracts to access their own plan claims data in violation of federal laws. Anthem allegedly does this as part of its efforts to conceal its improper repricing of health provider claims and its failure to pass on the full value of the discounts it has negotiated with providers to the self-funded plans that purchase access to the Anthem network at Anthem’s negotiated rates.
Berger Montague’s clients, Bricklayers and Allied Craftworkers Local 1 Fund (BAC Local 1) and Sheet Metal Workers Local 40 Fund (SMW Local 40) operate self-funded health plans and contracted with Anthem for many years to have access to the Anthem network at Anthem’s negotiated discounts when members receive medical care or services from an Anthem network provider. BAC Local 1 and SMW Local 40 separately negotiated with Anthem for months to attempt to gain access to their own health plan claims data which they are required to periodically review to fulfill their monitoring function imposed by the Employee Retirement Income Security Act of 1974 (“ERISA”). Their complaint alleges that Anthem acted unreasonably, engaging in protracted negotiations with both funds despite having no intention to provide access to the data being requested. The complaint further alleges that Anthem hid behind unlawful gag clauses in its administrative services agreements with BAC Local 1 and SMW Local 40 to deny the funds access to their own claims data, including the negotiated discounted rates with providers.
Despite Anthem’s refusal to give BAC Local 1 and SMW Local 40 access to their own health plan claims data, the Trustees of both funds obtained limited network claims data and compared the prices paid for services to health plan members to the Anthem negotiated rates posted on certain hospital websites. The Trustees found that the hospital’s negotiated rates with Anthem posted on the hospital websites in machine-readable files did not match the amounts that Anthem caused BAC Local 1 and SMW Local 40 to pay for covered network services. The complaint alleges that Anthem failed to apply the promised discounts found in each health plan’s administrative service agreement and failed to pass on the entire discount to which each plan was entitled based on the negotiated rates between Anthem and the providers in the Anthem network.
In recent years, both health plans, like other employers and self-funded plans in America, have had to make difficult decisions in paying for their continuously rising health care costs. For example, the complaint alleges that in 2022, BAC Local 1 was forced to divert $2 per-employee-per-hour of employer contributions earmarked for its pension fund to its health fund to cover expected health fund shortfalls. In 2019, the Local 40 Fund was forced to switch from a zero deductible plan to a high deductible plan to keep the Local 40 Fund solvent. The complaint alleges that as a result, some Local 40 Fund participants have reported that they are avoiding going to the doctor and others are rationing or have stopped taking prescribed medications.
BAC Local 1 and SMW Local 40 are represented by Shanon J. Carson, Julie S. Selesnick, Karen L. Handorf, and Abigail G. Gertner of Berger Montague PC. They are joined by Gregg D. Adler of Livingston, Adler, Pulda, Meiklejohn & Kelly.
Read an Article Highlighting the Litigation:
- Health Insurers Don’t Want You to Know Where Your Money Is Going
- Berger Montague Clients File Class Action Against Anthem
- Self-funded plans sue Anthem, alleging overcharging and other ERISA violations
- Unions suing Elevance Health for allegedly restricting access to claims data
- Union Suit Against Insurer May Be ‘Tip of the Iceberg’ Amid Plan Sponsor Discontent