Health Reform WK-EDGE Provider failed to show discriminatory practices in claims reimbursement
News
Tuesday, February 12, 2019

Provider failed to show discriminatory practices in claims reimbursement

By Deirdre Kennedy, J.D.

A health care provider claimed that she was discriminated against when she wasn’t paid at the out-of-network benefit level, but failed to show that other non-minority providers were treated differently.

The US Court of Appeals upheld a district court’s dismissal of a provider’s claim of discrimination under Section 1557 of the Patient Protection and Affordable Care Act (ACA) noting that the provider failed to show that the insurer had different processes for handling claims brought by minority or women providers compared to claims brought by white males (Griffin v. General Electric Company, Case No. 1:15-cv-04439-AT, January 28, 2019, per curium).

The provider was a female, African-American medical provider who practiced in Fulton County, Georgia. She treated a patient insured by General Electric’s (defendant) employer-based health plan, and requested that the patient sign an assignment of benefits authorizing the plan to pay benefits directly to her. The provider submitted claims to GE seeking payment for her services as an out-of-network provider, but she did not receive payment at the benefit level she says was promised to her as an out-of-network provider. The provider filed suit asserting discrimination under Section 1557 of the ACA.

The district court granted the defendants’ motions to dismiss, concluding that the provider’s complaint was devoid of sufficient factual support to allow her claims to proceed.

Discrimination. The provider claimed that GE raised a defense of anti-assignment against her because of her race and gender, and that it did not raise the defense against white male plaintiffs. The provider pointed to four cases she believed were analogous to hers which show that GE applied "more restrictive assignment of benefit criteria to her as compared to other providers who have sued GE under ERISA."

The district court concluded that the provider’s amended complaint failed to sufficiently plead viable claims. The appeals court affirmed, noting that nothing in the four comparator cases cited by the provider suggested that GE had a different process for handling claims brought by minority or women providers compared to claims brought by white males. In all of the cited cases, GE brought the same or similar challenges to the plaintiff’s claims.

The case is No. 18-10046.

Attorneys: W. A. Griffin, pro se. Cavender Crosby Kimble (Balch & Bingham, LLP) for General Electric Co. and Blue Cross and Blue Shield of Alabama.

Companies: General Electric Co.; Blue Cross and Blue Shield of Alabama

Cases: CaseDecisions GeneralNews ProviderPaymentNews AlabamaNews FloridaNews GeorgiaNews NewsFeed

Back to Top

Interested in submitting an article?

Submit your information to us today!

Learn More
Health Reform WK-EDGE

Health Reform WK-EDGE: Breaking legal news at your fingertips

Sign up today for your free trial to this daily reporting service created by attorneys, for attorneys. Stay up to date on health reform legal matters with same-day coverage of breaking news, court decisions, legislation, and regulatory activity with easy access through email or mobile app.

Free Trial Learn More