Blue Cross Health Insurance

A lawsuit filed on behalf of a doctor in San Diego claims that despite being entitled to reimbursement from Anthem Blue Cross as a non-participating provider, the health insurer was discounting and reducing the physician’s rates of reimbursement, his attorney said Wednesday.

Dr. James Ochi, a pediatric otolaryngologist who owns an independent practice in San Diego, alleges in the suit filed in San Diego Superior Court that Anthem Blue Cross unlawfully and fraudulently treated him — with respect to calculating his claims payments — as a participating provider without his consent.

Darrel Ng, a spokesman for Anthem Blue Cross, declined to comment on the active litigation brought of behalf of Ochi, a specialist in children’s ear, nose and throat conditions.

According to the lawsuit, Ochi received Explanation of Benefits from Anthem Blue Cross that identified him as a non-participating provider, but showed “allowed amounts” that were reduced and discounted well below the “reasonable” rates for non-participating provider charges.

Anthem Blue Cross’ actions are unfair and harmful to both doctors and patients, because the lower amount that Anthem Blue Cross pays to its out-of-network providers, the more patients have to pay when they go out of network, according to the lawsuit.

— City News Service

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