Wellness WordPress.com weblog

Posts tagged ‘Insurance’

L.A. jury sides with doctor in Anthem Blue Cross case

Jury awards $3.8 million in damages to a Porter Ranch doctor who contends insurer
Anthem Blue Cross retaliated against him for being a strong patient advocate.
By Chad Terhune, Los Angeles Times
5:00 AM PDT, April 10, 2013
In a rare case, a Los Angeles jury awarded $3.8 million in
compensatory damages to a Porter Ranch doctor who
contended insurance giant Anthem Blue Cross retaliated
against him for being a strong patient advocate.
The jury ruled late Monday in favor of Jeffrey Nordella, 58,
an urgent-care and family-practice doctor who alleged that
Anthem barred him from its network in 2010, when he
applied to be a preferred provider. The damages could climb
higher Friday, when the 12-person panel reconvenes and
considers punitive damages against Anthem, a unit of
insurance giant WellPoint Inc.
The jury found that Anthem, the state’s largest for-profit
health insurer, violated Nordella’s right to “fair procedure,”
and the company did so with “malice, oppression or fraud.” That latter finding prompted the hearing Friday
in Los Angeles County Superior Court to determine punitive damages.
Anthem denies Nordella’s allegations and is considering an appeal.
Nordella said he was turned away because he had challenged the denial of hundreds of patient claims over the
years when he was previously included in Anthem’s network. He said he often protested Anthem’s conclusion
that care wasn’t medically necessary and would not be covered. Nordella went so far as to meet with top
Anthem officials in 2001.
Anthem “held this grudge and continued to lie and deceive,” Nordella said in an interview.
Doctors and health insurers have battled over reimbursements and the denial of claims in court for years. But
legal experts said cases like Nordella’s usually never reach trial or result in multimillion-dollar verdicts.
“I was surprised by the size of the verdict, and it’s really the first case I’m aware of in years,” said Carol
Lucas, a healthcare lawyer in Los Angeles who represents doctors and medical groups. “Insurance companies
will likely look at what happened here to Anthem, and they will make sure they can justify any exclusions
from their networks.”
This case comes as health insurers, in a bid to hold down costs, are increasingly dropping doctors and
hospitals and promoting smaller networks. Insurers typically try to negotiate lower rates with the fewer
providers left in the network, who get higher patient volume in return.
Last fall, Anthem persuaded the city of Los Angeles to adopt a lower-priced “narrow network” that excluded
certain doctors affiliated with UCLA and Cedars-Sinai Medical Center. That decision prompted loud protests
from some city workers.
Nordella said many doctors are unwilling to challenge powerful insurance companies because their incomes
are so dependent on being in these provider networks. “Physicians are so afraid to come forward,” he said,
“and I hope this changes that.”
Anthem Blue Cross “is disappointed in the outcome and will examine our options in filing an appeal,” said
spokesman Darrel Ng.
The company rejected Nordella’s application for its PPO network because he wasn’t board certified in family
medicine and because Anthem already had a sufficient number of primary-care physicians, Ng said. At the
time, Nordella was medical director at Porter Ranch Quality Care, a walk-in clinic that offers urgent care and
family medicine.
Theresa Barta, a Newport Beach attorney who represents Nordella, said the insurance company contended it
had 137 primary-care physicians in its network within 10 miles of Porter Ranch. At trial, Anthem could name
only seven of those doctors, Barta said.
Because of frequent changes in its list of physicians since 2010, Anthem said, it could not retrieve all of the
requested information. The company maintains that its doctor network was adequate when Nordella applied.
In California, the most influential case on this issue has been a state Supreme Court ruling in 2000 in favor of
a doctor who challenged his termination from another insurer’s network. That ruling, experts say, established
the precedent that health insurers must grant doctors due process when they bar them from their networks if
the insurer’s members represent a significant part of the physician’s income.
“The insurance company’s decision can’t be arbitrary or for reasons beyond the ability of the physician to
practice medicine,” said Thomas Jeffry, a healthcare attorney in Los Angeles who represents medical
providers.
Barta said that at the hearing Friday over punitive damages, she will tell jurors that Anthem Blue Cross in
California generated $525 million in profit in 2010 for the parent company, WellPoint, which also runs Blue
Cross plans in 13 other states.
During closing arguments at trial, Barta said Anthem intentionally limits its physician roster to make it more
difficult for PPO patients to get care, which reduces Anthem’s medical costs and boosts its profits.
Nordella’s wife was murdered and two of his children were assaulted in 2005. He said that gave him a deep
appreciation for what patients face. He received the news of the verdict while riding his John Deere tractor
and planting grass seed for his daughter’s outdoor wedding this summer.
“It puts life in different perspective,” he said, “when you are sitting on that side, as a patient.”

Yours for Better Health, Dr. Shapero

EXPECT MIRACLES – WE DO
www.premierhealthcaresc.com

Advertisements
%d bloggers like this: