Example of Class Representative

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Example of Class Representative

Named Plaintiff and proposed class representative, Brad Heinz, suffered increased costs and damages by CalPERS’ and Anthem’s acts or omissions improperly reducing the “Allowable Amounts” in PPO coverage and inappropriately reducing reimbursements for “out-of-network” non-emergency medical expenses over the period of 2008 to 2014.[1]

As an illustration, Heinz enrolled in PPO health insurance from CalPERS/Anthem from 2006 to 2014. CalPERS and Anthem distributed standardized promotional material, form contracts, and Evidence of Coverage documents that indicated that the “Allowable Amount” would be calculated in an identical method and amount whether the services were “in plan” or “out of plan.” Exhibits 24-26, 28, 41-53, 55, 59, and 60.

Over this time of 2006 to 2014, Heinz saw a therapist for counseling. Initially, the doctor was “in network” and contracted with Anthem at an agreed rate of $299.57 per session. Exhibit 14, page 2. The services were coded as 90807 and 90837 and labelled “cognitive services.” Exhibits 3-23, 27, 29-32, 34, 36, 38, 54. In May 2008, the doctor went “out-of-network” and stopped contracting with Anthem, but still saw Heinz in the same location providing the same services. Exhibit 14, page 2 and Exhibit 23. When the doctor went out of plan, CalPERS and/or Anthem reduced the “Allowable Amount” to between $76.91 and $136.86 per session for the same services. Exhibit 24. Then CalPERS and Anthem reduced the reimbursement to 60% of the “Allowable Amount,” reimbursing Heinz between $46.15 and $82.12 per session. Exhibits 3-23, 27, 29-32, 34, 36, 38, 54.

Arising out of prior litigation about unfair reimbursement rates, FairHealth.org[2] and other similar databases were set up by court order to provide comparison data on appropriate out-of-network reimbursement rates, including for services according to standardized medical codes and by zip code. See infra at paragraphs 128 to 135. For example, Heinz’s claims were numerically coded as 90836 and 90837[3] and labelled as “cognitive services” in San Francisco. Exhibits 3-23, 27, 29-32, 34, 36, 38, 54. Under FairHealth.org, the estimated UCR charge for cognitive services (90837) in San Francisco was two hundred dollars ($200.00) per 45 to 55 minute session. Under FairHealth.org, the Medicare baseline reimbursement for cognitive service (90837) in San Francisco was two hundred dollars ($200.00) per session. Exhibit 61.

By its inappropriate policies and practices of greatly reducing the “Allowable Amounts,” Anthem and/or CalPERS greatly reduced the total money that it paid out in reimbursements to Heinz and the class. As a representative example of the inappropriate policies and practices of greatly reducing the “Allowable Amount” below industry standards, CalPERS and/or Anthem reimbursed Heinz $45.15 to $82.12 per session when CalPERS and/or Anthem should have reimbursed him at a rate of $120.00[4] or higher per session.

[1] It is understood that CalPERS and/or Anthem calculated the “Allowable Amount” for “out of network” emergency care at UCR rates; however, if they did not, then those who sought reimbursement for “out of network” emergency services are also in the class.

[2] For a brief history how the FairHealth.org database emanated from the Attorney General’s resolution of the Ingenix under-reimbursement litigation, see infra at p 31-32 and Exhibit 58.

[4]A $120.00 reimbursement is the $200 “Allowable Amount” multiplied by the PPO rate of 60%.