Once again, insurance practices on cost-sharing and reimbursement for out-of-network providers and PPOs are ending up in dispute, with backlash from providers and customers.
Three patients covered by Cigna-administered employer PPO plans are suing the Bloomfield, Connecticut-based insurer, and raising questions about how customers should be able to access out-of-network benefits.
The lawsuit alleges that Cigna retaliated against the patients for receiving total parenteral nutrition from an out-of-network provider, a long-term home-based IV nutrition company called Nutrishare. According to the lawsuit, the insurer has attempted to encourage members to use other providers and denied payments to Nutrishare on the grounds that the provider did not collect full patient cost-sharing requirements.
"At the same time that it is selling policies that allow out-of-network benefits, Cigna is retaliating against patients who use or attempt to use their out-of-network benefits, by making threatening telephone calls to those patients, by directing the patients' physicians to encourage the patients to switch from out-of-network providers to inferior, in-network providers, and by underpaying and/or failing to pay the patients' out-of-network providers," lawyers for the patients write in a lawsuit.
California-based Nutrishare does not have a contract with Cigna, but previously was reimbursed at out-of-network rates without any acrimony, before the insurer started requiring collection of coinsurance and copayment, according to the lawsuit, filed in U.S. District Court for the Eastern District of California.
Cigna, the suit alleges, has denied payments to Nutrishare while imposing a requirement that patients pay the provider full coinsurance and copayment amounts. "Cigna members who receive TPN services from Nutrishare now are being faced with personal liability for all of the charges due to Cigna's failure to pay," the lawyers write.
Nutrishare emphasizes that it is a long-term total parenteral nutrition (TPN) provider, with expertise in avoiding complications such as infections -- one of the reasons the patients who are suing initially chose the provider.
One of the patients, an Evington, Virginia resident covered by a Cigna-administered PPO, suffers from esophagus inflammation and a mitochondrial disorder and has received TPN therapy from Nutrishare since 2000, after a bad experience with one of the in-network providers.
The patient developed "multiple central line infections requiring hospitalization, received incorrect and incomplete orders of TPN products and supplies, and experienced substantial complications in attempting to fill her orders for TPN products and supplies." No other TPN providers in the area specialize in long-term therapy, and the patient fears there could be more complications, according to the lawsuit.
In January 2014, the patient's employer switched to a self-funded plan administered by Cigna, and "specifically selected a PPO plan so that they could continue to receive TPN services from Nutrishare." Since then, though, according to the suit, this Cigna customer and the others who used Nutrishare have faced large barriers and punitive actions.
Lawyers for Nutrishare are asking the court to force Cigna to pay back claims and restitution and change PPO out-of-network practices. The insurer has not yet responded to the allegations.
This is not the first time Cigna has been in court for out-of-network billing -- although previously it has been the one suing.
Lawyers for the insurer last year sued the La Peer Surgery Center in California, arguing that the center reduced and waived employee-member's co-pays as a way to garner higher, out-of-network reimbursements and circumvent goals of incentivizing members to use in-network providers.
In another suit in Houston, Cigna argued that North Cypress Medical Center's patient discounts "virtually eliminates patients' responsibility to pay for their medical care while still charging enormous and unjustified costs to the employers who fund the patients' plans, a practice known as 'fee-forgiving.'"
It's not clear whether similar reduced cost-sharing strategies have been used by Nutrishare, but the cases (all related to ERISA plans) represent the consumer confusion and discontent that can arise in complicated provider networks.