Close Close

Practice Management > Building Your Business

Supreme Court declines to review provider reimbursement case

Your article was successfully shared with the contacts you provided.

The U.S. Supreme Court is skipping over an appeal from physicians who want to be able to sue Anthem Inc. (NYSE:ANTM) over how Anthem units calculate “usual, customary and reasonable” rates for out-of-network services.

Many of the physicians in the case, Medical Association of Georgia et al. vs. WellPoint Inc. (Case Number 14-554), were involved in efforts to get Anthem, which was previously known was WellPoint, to agree to a 2005 settlement in connection with reimbursement practices. The plaintiffs involved in that class action agreed to release the company from claims “in any way related” to the facts in exchange for $450 million in cash payments and investments in changes in business practices.

Anthem has argued that the settlement agreement should keep the class members from taking further action.

The physicians say that they should be able to proceed with claims involving reimbursement decisions and other antitrust-related actions that took place after 2005, and that letting the 2005 settlement agreement block suits over post-2005 problems would be wrong.

The 11th U.S. Circuit Court of Appeals sided with Anthem.

The physicians say four other circuits have issued conflicting rules. Anthem contends that the physicians are applying the old circuit court rulings incorrectly, ignoring a conflicting 1985 Supreme Court ruling, and going after Anthem for practices that the company had been using before the negotiations that led to the 2005 settlement agreement had started.

Earlier this week, the Supreme Court included the case in a list of cases that it has decided not to take up.

See also: Providers Sue Over Rates


© 2023 ALM Global, LLC, All Rights Reserved. Request academic re-use from All other uses, submit a request to [email protected]. For more information visit Asset & Logo Licensing.