Cigna Behavioral Health, Inc. and Viant, Inc. face a proposed class action lawsuit in which a pseudonymous health insurance plan participant claims the companies have “colluded to illegally withhold and systematically underpay” out-of-network behavioral health benefits.
The lawsuit alleges that while Cigna, as a health insurance plan underwriter and administrator, was contractually obligated to reimburse out-of-network providers at “usual, customary, and reasonable” (UCR) rates, the company instead sent the claims to Viant for repricing. Viant, for its part, then “negotiated” with healthcare providers by making a reimbursement “offer,” contrived through “deeply flawed methodologies,” that fell well below UCR rates, forcing health plan participants to foot the rest of the bill for behavioral therapy, according to the case.
Through this so-called “dishonest and self-serving reimbursement scheme,” Cigna and Viant have systematically underpaid out-of-network benefits for which health plan participants paid through monthly insurance premiums, the lawsuit alleges.
The plaintiff says she and her son were members of a health insurance plan provided through her employer, non-party Intuit, Inc. According to the lawsuit, the plaintiff’s son sought treatment for mental health and substance abuse disorders through an intensive outpatient treatment program (IOP). Through the plaintiff’s preferred provider organization (PPO) plan, Cigna was contractually obligated to reimburse the son’s out-of-network treatment cost at the UCR rate, defined as “the amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service,” the lawsuit alleges.
According to the case, however, Cigna failed to follow its methodologies for calculating UCR rates, and instead relied on Viant to “reprice” the reimbursement cost and ultimately pay the plaintiff’s son’s IOP provider well below what was contractually agreed upon in the plaintiff’s plan. The case claims that although Cigna does not have Viant reprice all insurance claims, there is a “disturbing nationwide increase” in the frequency of Cigna’s use of the company to pay back out-of-network IOP providers at “a fraction” of the rate Cigna had been previously paying for such services. Through its contracts with Cigna, Viant receives a kick-back for the money it “saves” Cigna by repricing reimbursement claims, the lawsuit alleges.
“Every dollar ‘saved’ is a dollar that should have been paid by Cigna and instead was paid by Plaintiff,” the complaint claims, arguing that Cigna’s conduct amounts essentially to a scheme to shift the costs of IOP treatment to the plaintiff and other health plan participants.
According to the case, after Cigna reimbursed IOP providers at “unreasonably low” rates, the providers had no choice but to send the rest of the bill to the plaintiff and proposed class members. The case claims the defendants’ conduct has damaged both behavioral health patients and their providers, ultimately blocking patients from receiving much-needed treatment.
“While the exact number of patients who have relapsed and providers who have been forced out of business as a result of these practices is unknown, a substantial number of lives and livelihoods have been lost in furtherance of corporate profits and executive bonuses,” the complaint states, adding that Cigna and Viant have likely retained tens of millions of dollars unjustly.
The lawsuit looks to cover all members of health plans administered or insured by Cigna whose claims for out-of-network behavioral health treatment were underpaid or repriced by the defendants.