BCBS Removes Out of Network Claims Case to Georgia Federal Court

On Thursday a case was removed from the Fulton County Georgia State Court to the Northern District of Georgia. The case was filed by W.A. Griffin, MD against Blue Cross Blue Shield of Georgia. The case is regarding failure to honor assignments of benefits and failure to properly process and pay out of network claims properly per usual and customary payment rates.

The plaintiff, according to the complaint, is a medical provider in Fulton County, Georgia who requires assignments of benefits from patients for billing purposes. This assignment of benefits directs the insurer to pay the medical provider directly instead of paying the patient and requiring the patient to turn the funds over to the provider. The plaintiff accuses BCBS of GA of ignoring those assignments of benefits and sending payments directly to patients, which requires additional expense in recovering those payments from patients.

The plaintiff also accuses BCBS of processing claims for minimal payments without any explanation of the discount amount taken. The plaintiff specifically points to the defendant of having paid claims in amounts that are between 20% and 50% of billed charges with no explanation of the payment amounts. The plaintiff also argues that there no submission of plan documents to support the lower payment amounts as required under ERISA.

The plaintiff is requesting that the court asses the statutory penalty of $100.00 per day for each failure to provide the ERISA documents regarding the payment methodology used in processing the claims. The defendants are represented by Troutman Pepper Hamilton Sanders.