Insurance plan participants urged a California federal court to certify a class of 8,000 members in their lawsuit against Cigna, claiming that class certification is the only efficient and cost-effective remedy. The plan participants claim that Cigna colluded with Multiplan, its third-party billing contractor, and Multiplan's subsidiary, Viant, to underpay out-of-network claims for substance use disorder treatments. The case is RJ v. Cigna Behavioral Health, Inc. et al., case number 5:20-cv-02255, U.S. District Court for the Northern District of California.
In their lawsuit, the plan participants claim that Cigna and its billing companies violated the Employee Retirement Income Security Act (ERISA) and the Racketeer Influenced and Corrupt Organizations Act (RICO). They allege that their benefits plans required Cigna to reimburse their out-of-network claims for mental health and substance abuse disorder treatments at the usual, customary, and reasonable (UCR) rate. The UCR rate is a composite rate based on similar providers in the same geographic area.
However, Multiplan priced the claims using a Viant-furnished methodology, which calculated reimbursements at a rate that was much lower than the UCR rate. As a result, plan participants were left with much higher out-of-pocket costs for these treatments.
Cigna and Multiplan argued against class certification. The companies claim that the plan participants' proposed class subgroups, which are based on plan types and how providers handled claims, defeat the purpose of certification. They also claim that the Viant reimbursement payments were simply "offers" to start negotiations with providers.
However, plan participants disagree, arguing that the subgroups do not substantially affect the crux of the lawsuit. The major issue in the lawsuit concerns the methodology and data that the companies used to reimburse plan participants for the costs of intensive outpatient care, which was an issue common to all plans. Furthermore, they pointed out, a payment from an insurer to a provider is not normally considered to be an offer designed to initiate negotiations between the two parties, rather than a payment for services rendered.
The court previously dismissed the plan participants' RICO claims based on money laundering in September 2022, but most of their claims have survived the companies' motion to dismiss.
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