The Employee Retirement Income Security Act (ERISA) also governs some health plans provided to employees or union members. In this case, two union self-funded health funds have sued Elevance, Inc., Anthem Health Plans, Inc., Anthem Blue Cross, Empire Blue Cross Blue Shield, and Empire Blue Cross (collectively called “Anthem” in the complaint), alleging that the companies have refused to let them see claims data, so that they can perform their fiduciary duties under ERISA to the plans.
The class for this action is all ERISA self-funded health plans that entered into administrative service agreements Anthem for claims administration or network access since December 2016.
ERISA requires that health plans oversee the performance of service providers that help with the administration of plans, the complaint says, and also requires that plans be permitted access to claims data in order to do this. However, the complaint alleges that Anthem refuses to give the plans in this case access to this data.
Anthem insures and administers self-funded health plans like the ones in this case. “When administering self-funded health plans,” the complaint alleges, “covered healthcare expenses of plan participants are paid from the Plan’s own assets, which are composed of contributions from plan sponsors and plan members, and Anthem is paid fees for providing administrative services under an Administrative Service Only Agreement (‘ASO’).”
Anthem also “establishes a network of doctors, hospitals, pharmacies, and other health care providers to provide services and supplies to plan members at a supposedly discounted price. ERISA also considers Anthem to be a fiduciary of the self-funded plans because it has some discretionary authority or control over the plans’ relationships with the network of providers.
However, the complaint says that Anthem refuses to provide access to participant claims data, even though, according to the complaint, it is required to share this data with the unions by various rules and laws.
The complaint suggests that the reason Anthem will not provide the information is that “it is not uniformly applying its negotiated discount to the claims it processes” and that “instead, Anthem is either unlawfully retaining the improperly discounted amounts for itself, or it is imprudently overpaying providers” thus breaching its obligations to the plans and participants.
The unions have recently had difficulty paying for health fund benefits, the complaint alleges, with one required to divert money from its annuity fund to the health plan and the other forced to institute deductibles for the first time. The trustees of one of the funds, the complaint alleges, “have learned that some Local 40 Fund participants are avoiding going to the doctor and others are rationing or have stopped taking prescribed medications.”
Article Type: LawsuitTopic: Insurance
Most Recent Case Event
Anthem, Empire Union Health Funds Hiding Claims Data, Says ERISA Complaint
December 5, 2022
The Employee Retirement Income Security Act (ERISA) also governs some health plans provided to employees or union members. In this case, two union self-funded health funds have sued Elevance, Inc., Anthem Health Plans, Inc., Anthem Blue Cross, Empire Blue Cross Blue Shield, and Empire Blue Cross (collectively called “Anthem” in the complaint), alleging that the companies have refused to let them see claims data, so that they can perform their fiduciary duties under ERISA to the plans.
Anthem, Empire Union Health Funds Hiding Claims Data, Says ERISA ComplaintCase Event History
Anthem, Empire Union Health Funds Hiding Claims Data, Says ERISA Complaint
December 5, 2022
The Employee Retirement Income Security Act (ERISA) also governs some health plans provided to employees or union members. In this case, two union self-funded health funds have sued Elevance, Inc., Anthem Health Plans, Inc., Anthem Blue Cross, Empire Blue Cross Blue Shield, and Empire Blue Cross (collectively called “Anthem” in the complaint), alleging that the companies have refused to let them see claims data, so that they can perform their fiduciary duties under ERISA to the plans.
Anthem, Empire Union Health Funds Hiding Claims Data, Says ERISA Complaint