Under California law, insurers must pay reasonable fees to medical providers for emergency services performed on one of their insureds, even if the medical providers are not part of their own networks. California laws also require prompt payment to medical providers. The complaint for this class action claims that Anthem Blue Cross complies with neither of these laws.
The class for this action is all licensed medical providers (including provider groups) who have sent claims for reimbursement to Anthem for services to a patient who has Anthem health coverage, where the provider did not have a contract with Anthem and Anthem (a) did not pay a claim for emergency services, (b) did not meet the prompt payment deadlines and did not pay the appropriate interest or penalty, or (c) paid the patient instead of the provider.
Under California’s Health and Safety Code, a health care plan “shall reimburse providers for emergency services and care provided to its enrollees, until the care results in stabilization of the enrollee…” Under regulations, the insurer must pay “the reasonable and customary value for the health care services rendered” and then goes on to enumerate the factors that should be taken into consideration when the value is determined.
The plaintiff in this case if Wun-Ling Chang, MD, Inc. Dr. Chang is a specialist in infectious diseases. She does not have a contract with Anthem but says she has often provided emergency treatment to patients insured by Anthem. The complaint says that Anthem has at times either refused to pay for the treatments or delayed in paying them.
California’s Health and Safety Code also specifies that insurers must pay medical bills promptly. It says that they must reimburse any claim, or, if a claim is contested, any uncontested portion of the claim as soon as practicable, but no later than thirty working days after the claim is received. The deadline stretches to 45 working days if the plan is a health maintenance organization. Alternatively, it must provide written notice that the claim is contested and the reasons it is contested during the same period of time.
The complaint says, “For any claim not timely reimbursed, interest accrues at a rate of 15% per annum, and such interest must be automatically included with the reimbursement payment, or the plan is subject to additional penalties.
The Insurance Code sets forth similar requirements.
The complaint alleges violation of unfair competition laws, breach of contract, and quantum meruit laws, which refers to the payment earned for services.