Flawed Database Underpays Out-of-Network Claims, Doctor Says
9-4-2019 21:25:00

LOS ANGELES (CN) – Kaiser uses a flawed database system to underpay out-of-network claims, a plastic surgeon claims in Los Angeles County Superior Court.

Ryan Spivak Integrative Plastic Surgery, Inc. (RSIPS) sued Kaiser Foundation Health Plan, Inc. for recovery of payment for services rendered, recovery of payment on an open book account, quantum meruit and breach of implied contract.

According to the lawsuit, Spivak provided necessary treatment to a Kaiser member (identified in the lawsuit only as “Patient”) and submitted his bills to Kaiser for payment, but Kaiser did not pay him all he is owed. Spivak contends the database Kaiser uses to determine payments for out-of-network providers is the source of a larger problem.

“RSIPS is informed and believes and thereon alleges that defendant’s system for paying out-of-network claims is flawed, that defendant improperly manipulates the data in its systems to underpay out-of-network medical provider claims, and that defendant’s systems and methods for calculating such rates violate California law. Defendant has used flawed databases and systems to unilaterally determine what amounts it pays to medical providers and has colluded with other insurers to artificially underpay, decrease, limit, and minimize the reimbursement rates paid for services rendered by non-contracted providers. The issue of flawed database has been investigated by the U.S. Congress and New York Attorney General and has been the source of numerous lawsuits and class action suits filed in connection with the databases utilized (known as Ingenix),” the complaint states. (Parentheses in complaint.)

Spivak seeks compensatory damages, restitution plus statutory interest and declaratory relief. He is represented by Alan Nesbit of Nesbit Law Group US in Los Angeles.