Case 5:20-cv-02255-EJD Document 1 Filed 04/02/20 Page 1 of 50
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`Matthew M. Lavin, Esq. (pro hac vice anticipated)
`Wendy A. Mitchell, Esq. (CA SBN 158553)
`Napoli Shkolnik PLLC
`5757 W. Century Boulevard, Suite 680
`Los Angeles, CA 90045
`(212) 397-1000 / Fax (646) 843-7603
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`Attorneys for Plaintiff and Putative Class
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`UNITED STATES DISTRICT COURT
`NORTHERN DISTRICT OF CALIFORNIA
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`Case No.:
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`CLASS ACTION COMPLAINT
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`JURY TRIAL DEMANDED FOR ALL
`ISSUES SO TRIABLE
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`RJ, as the representative of her beneficiary
`son, and on behalf of and all others similarly
`situated,
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`Plaintiff,
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`vs.
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`CIGNA BEHAVIORAL HEALTH, INC., a
`Minnesota Corporation, and VIANT, INC.,
`a Nevada corporation,
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`Defendants.
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`RJ v. Cigna, et. al. – CLASS ACTION COMPLAINT
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`Case 5:20-cv-02255-EJD Document 1 Filed 04/02/20 Page 2 of 50
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`Table of Contents
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`RJ v. Cigna, et. al. – CLASS ACTION COMPLAINT
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`Introductory Statement
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`Factual Background
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`Usual Customary and Reasonable Rates
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`Intensive Outpatient Treatment Programs
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`Illegal Health Claim Re-Pricing
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`The Alliance of Cigna and Viant
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`Jurisdiction and Venue
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`The Parties
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`Plaintiffs
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`Other Interested Parties
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`General Allegations
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`The Defendants’ Roles and Responsibilities with Respect to Claims
`UCR Reimbursement of IOP Claims
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`Cigna and Viant’s Re-Pricing Scheme
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`Cigna and Viant’s False Representations of UCR Reimbursement
`The Viant Grift
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`The Harm Caused to the Plaintiff and Class
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`Plaintiff’s Allegations
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`Class Action Allegations
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`The Plaintiff Class
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`Rule 23(a)
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`Numerosity
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`Commonality
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`Typicality
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`Adequacy
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`Rule 23(b)
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`Causes of Actions
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`I. Violations of RICO: 18 U.S.C. § 1962(c)
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`On Behalf of Plaintiff and the Class Against Cigna and Viant
`II. Claim for Underpaid Benefits Under Group Plans Governed by ERISA
`On Behalf of Plaintiffs and the Class Against Cigna
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`III. Breach of Plan Provisions in Violation of ERISA § 502(A)(1)(B)
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`On Behalf of Plaintiff and the Class Against Cigna
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`IV. Failure to Provide and Accurate EOC and SPD and Request for Declaratory
`and Injunctive Relief
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`On Behalf of Plaintiff and the Class Against Cigna
`V. Violation of Fiduciary Duties of Loyalty and Due Care and Request for
`Declaratory and Injunctive Relief
`On Behalf of Plaintiffs and the Class Against Cigna
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`Case 5:20-cv-02255-EJD Document 1 Filed 04/02/20 Page 3 of 50
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`VI. Violation of Fiduciary Duties of Full and Fair Review and Request for
`Declaratory and Injunctive Relief
`On Behalf of Plaintiffs and the Class Against Cigna
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`VII. Claim for Equitable Relief to Enjoin Acts and/or Practices
`On Behalf of Plaintiff and the Class Against Cigna and Viant
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`VIII. Claim for Other Appropriate Equitable Relief
`On Behalf of Plaintiff and the Class Against Cigna and Viant
`Jury Trial Demand
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`ii
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`RJ v. Cigna, et. al. – CLASS ACTION COMPLAINT
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`Case 5:20-cv-02255-EJD Document 1 Filed 04/02/20 Page 4 of 50
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`CLASS ACTION COMPLAINT
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`Plaintiff, RJ, on behalf of her son, a behavioral health patient, and of all others similarly
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`situated, brings this action against Defendants, Cigna Behavioral Health, Inc., (“Cigna”) and
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`Viant, Inc. (“Viant”) (collectively, “Defendants”), and alleges the following:
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`INTRODUCTORY STATEMENT
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`RJ files this action on behalf of her son, SJ, (both names are pseudonyms) and all
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`others similarly situated in the United States (the “Plaintiff Class”) whose behavioral health
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`claims for benefits have been systematically undervalued and underpaid by Defendants and who,
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`because of Defendants’ actions, owe money or have paid out-of-pocket all or a portion of the
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`difference between what their insurance should have covered and what was actually paid.
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`SJ sought treatment for behavioral health disorders, including for mental health
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`and substance use disorders, from licensed, accredited, treatment providers. SJ was a member of
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`an active health insurance policy offering out of network benefits that Cigna administered on
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`behalf of his mother’s employer, Intuit, Inc. Cigna charges higher premiums for plans like
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`Plaintiff’s that give their members the freedom to choose their own healthcare providers,
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`including those outside of Cigna’s “network.” For RJ and SJ, Cigna broke this promise,
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`punishing them for SJ seeing out-of-network providers while reaping large profits from his
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`supposedly premier, gold-plated plan.
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`Cigna and Viant colluded to illegally withhold and systematically underpay out-
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`of-network benefits for SJ. They accomplished this by using a dishonest and self-serving
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`reimbursement scheme. Specifically, Cigna, without Plaintiff’s consent or authority, contracted
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`with Viant to “negotiate” the amounts that Cigna would ultimately pay for Plaintiff’s out-of-
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`network claims. Cigna contracted with Viant to create an illegal enterprise to underpay out-of-
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`network benefits, shield Cigna from the providers and insureds they cheated, and create
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`impenetrable, systemic, administrative barriers to circumvent rights protected by federal laws.
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`Cigna and Viant’s scheme forced Plaintiff and the Class to pay and/or be
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`responsible for, out of their own pockets, the difference between the amount Cigna should have
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`paid and the amount that Cigna did pay for services. This difference often ran into the tens, and
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`Case 5:20-cv-02255-EJD Document 1 Filed 04/02/20 Page 5 of 50
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`sometimes hundreds, of thousands of dollars per patient and is on top of the premium paid for
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`their healthcare plans. Every excess dollar paid by a patient is a dollar that Cigna unjustly
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`retained and used to pay a kick-back to Viant. Consequently, Cigna and Viant unjustly retain
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`tens of millions, or more, of dollars taken from patients who expected Cigna to be “[their] partner
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`in total health and wellness. And we’re here for [them] 24/7 – caring for [their] body and mind.1”
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`Plaintiff brings this suit against Cigna to recover the money she unjustly overpaid
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`or now owes for care that Cigna should have reimbursed. This suit is also brought against Viant
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`for the role it played as Cigna’s agent and claim profiteer in this sordid enterprise.
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`Every claim at issue in this litigation is for intensive outpatient (“IOP”) mental
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`health and/or substance use disorder services that Cigna was required to pay at usual, customary,
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`or reasonable rates. Plaintiff was insured under a Cigna health insurance policy. The policy
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`provided coverage for out-of-network benefits for mental health and substance use disorder
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`treatment at usual, customary or reasonable rates.
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`While Cigna issued, underwrote and/or administered Plaintiff’s health insurance
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`policy, Viant determined the reimbursement rate for every underpaid claim in the present
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`litigation. After receiving treatment, Plaintiff’s claims were submitted to Cigna for pricing and
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`payment according to the out-of-network payment rate.
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`In the plan documents, this rate is referred to as the “Usual, Customary and
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`Reasonable” rate, the “Reasonable and Customary” amount, the “Usual and Customary” amount,
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`the “Reasonable Charge,” the “Prevailing Rate,” the “Usual Fee,” the “Competitive Fee,” or
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`some other similar phrase (hereafter the “UCR” rate).
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`Cigna classifies reimbursement rates as the Maximum Reimbursable Charge
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`(“MRC”). Cigna administered health insurance plans are subcategorized as either MRC I, or
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`MRC II. Plaintiff’s plan, and the plans of the class members are MRC I plans.
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`For each of the claims at issue here, Cigna reported, in both plan language and on
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`telephonic verification of benefits, that it would reimburse patients and/or their assignees at the
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`1 https://www.cigna.com/about-us/ (last visited March 17, 2020)
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`Case 5:20-cv-02255-EJD Document 1 Filed 04/02/20 Page 6 of 50
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`UCR rate for MRC I policies.
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`Cigna, however, does not use the purported methodology to calculate
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`reimbursement rates. Instead, Cigna contracts with Viant to “negotiate” reimbursement rates
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`with providers. For years, Cigna and Viant have systematically failed to properly price the claims
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`according to UCR and have systematically concealed this failure through misrepresentations
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`about pricing and payment methods.
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`Instead of paying UCR, Cigna contracted with Viant
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`to “negotiate”
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`reimbursement rates with providers. For years, Cigna and Viant have systematically failed to
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`properly price the claims according to UCR and have systematically concealed this failure
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`through misrepresentations about pricing and payment methods to their members.
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`FACTUAL BACKGROUND
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`Usual Customary and Reasonable Rates
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`UCR rates are a fixture of the managed care payment system in the United States.
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`When doctors, hospitals or other healthcare providers are out of network and do not have
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`contracts with health insurance companies, the insurers must decide how much to pay. Generally,
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`private insurers claim to reimburse out-of-network providers at UCR rates.
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`The United States’ Centers for Medicare Services (CMS), defines UCR as: “The
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`amount paid for a medical service in a geographic area based on what providers in the area
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`usually charge for the same or similar medical service.”2
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`Insurance policies do not always cover services for out-of-network, non-
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`contracting providers. Premiums for insurance plans that do provide out-of-network coverage,
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`called Preferred Provider Organization (PPO) plans, are substantially more expensive than
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`Health Maintenance Organization (HMO”) or Point of Service (POS) plans that only reimburse
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`in-network or contracting providers.
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`Consumers choose to pay higher premiums for PPO plans because they value the
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`freedom to choose their providers.
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`2 Healthcare.gov “Usual Customary or Reasonable” https://www.healthcare.gov/glossary/UCR-usual-customary-
`and-reasonable/ (accessed March 20, 2020)
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`Case 5:20-cv-02255-EJD Document 1 Filed 04/02/20 Page 7 of 50
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` Most commercial insurance companies claim their PPO policies will pay out of
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`network providers UCR rates for covered services.
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`Cigna provides two standard methodologies by which it claims to calculate its
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`applicable UCR rates. defines as the Maximum Reimbursable Charge (“MRC”). Cigna either
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`MRC I, or MRC II.
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`Cigna describes MRC I reimbursement calculations as:
`[A] data base compiled by FAIR Health, Inc. (an independent non-profit
`company) is used to determine the billed charges made by health care
`professionals or facilities in the same geographic area for the same
`procedure codes using data. The maximum reimbursable amount is then
`determined by applying a percentile (typically the 70th or 80th percentile)
`of billed charges, based upon the FAIR Health, Inc. data. For example, if
`the plan sponsor has selected the 80th percentile, then any portion of a
`charge that is in excess of the 80th percentile of charges billed for the
`particular service in the same relative geographic area (as determined using
`the FAIR Health, Inc. data) will not be considered in determining
`reimbursement and the patient will be fully responsible for such excess.3
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` Cigna describes MRC II reimbursement calculations as:
`[A] schedule of charges established using a methodology similar to that
`used by Medicare to determine allowable fees for services within a
`geographic market or at a particular facility. The schedule amount is then
`multiplied by a percentage (110%, 150% or 200%) selected by the plan
`sponsor to produce the MRC. In the limited situations where a Medicare-
`based amount is not available (e.g., a certain type of health care professional
`or procedure is not covered by Medicare or charges relate to covered
`services for which Medicare has not established a reimbursement rate), the
`MRC is determined based on the lesser of: the health care professional or
`facility's normal charge for a similar service or supply; or the MRC Option
`I methodology based on the 80th percentile of billed charges.4
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`For each of the claims at issue here Cigna reported that it would reimburse
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`patients and/or their assignees at either UCR rates under the MRC I or MRC II calculation
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`methodologies, or based on rates charged by similar providers in a similar geographic area. In
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`fact, Cigna relied on none of these methods. In the case of most mental health and substance use
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`3 https://my.cigna.com/public/legal_disclaimer.html (last visited March 8, 2020)
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`4https://static.cigna.com/assets/chcp/resourceLibrary/clinicalReimbursementPayment/medicalClinicalReimburseO
`utOfNetwork.html (last visited March 9, 2020)
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`Case 5:20-cv-02255-EJD Document 1 Filed 04/02/20 Page 8 of 50
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`disorder IOP treatment, which does not have a correlating Medicare reimbursement rate, MRC
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`I and MRC II pricing methodology are functionally the same. For ease of reference, this
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`complaint uses the term “UCR” to refer to both of Cigna’s above reimbursement methodologies,
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`because MRCI and MRCII are merely methods by which Cigna calculates UCR.
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`SJ’s insurance plan was an MRC I plan, however, that distinction is immaterial
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`as this complaint alleges that Cigna used neither purported methodology to calculate rates for
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`Plaintiff or any members of the putative Plaintiff Class.
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`Insureds and beneficiaries depend on insurers’ good faith calculation of UCR
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`rates, because they are responsible for the difference between what their healthcare provider
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`charges and what their insurance company pays for services. Where, as here, UCR calculation
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`methodology leads to unreasonably low reimbursements to providers, they bear the expense of
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`insurers’ bad faith calculations.
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`Intensive Outpatient Treatment Programs
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`Intensive outpatient treatment programs (“IOPs”) are an important tool in
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`traditional behavioral health treatment. IOP is a non-residential, semi-structured level of care
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`that is typically rendered pursuant to a schedule that allows patients to reintegrate into society
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`by returning to work, school, and other functions of daily life. Often, IOP programs are designed
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`to be a support system for patients reintegrating into society from higher more structured levels
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`of care, such as residential inpatient treatment and partial hospitalization.
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`Cigna describes Intensive Outpatient Program (IOP) services as those rendered
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`in a structured treatment that teach individuals how to manage stress and cope with emotional
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`and behavioral issue, including include group, individual, and family therapy. According to
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`Cigna, IOP treatment involves frequent visits (usually three to five days per week), takes about
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`three to four hours of treatment per day, and often lasts four to six weeks. Cigna states that IOP
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`treatment is structured so patients can continue with their normal daily routines and provides
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`support from the program and social support from other people in the program.5
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`5 See: Cigna.com “Levels of Mental Health Care” https://www.cigna.com/individuals-families/health-
`wellness/mental-health-care, (Last accessed March 19, 2020);
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`Case 5:20-cv-02255-EJD Document 1 Filed 04/02/20 Page 9 of 50
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`The American Society of Addiction Medicine (“ASAM”), classifies Intensive
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`Outpatient Programs as ASAM Level of Care 2.1. Services may be delivered in any appropriate
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`setting that meets state licensure or certification requirements. According to ASAM, IOP care is
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`rendered by a team of appropriately credentialed addiction treatment professionals including
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`counselors, psychologists, social workers, addiction-credentialed physicians, and program staff,
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`many of whom have cross-training to aid in interpreting mental disorders and deliver intensive
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`outpatient services. Services are typically offered for at least 9 hours per week. The goal of IOP
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`treatment is to provide a support system including medical, psychological, psychiatric,
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`laboratory, and toxicology. Elements of IOP treatment include counseling, educational groups,
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`occupational and recreational therapy, psychotherapy, Medication Assisted Treatment (“MAT”),
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`motivational interviewing, enhancement and engagement strategies, family therapy, or other
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`skilled treatment services.6
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`Illegal Health Claim Re-Pricing
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`As alleged here, however, Cigna does not even use its own purported
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`methodology to calculate reimbursement rates. Instead of paying UCR, Cigna contracted with
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`Viant to “negotiate” reimbursement rates with providers. For years, Cigna and Viant have
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`systematically failed to properly price the claims according to UCR and have systematically
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`concealed this failure through misrepresentations about pricing and payment methods to their
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`members.
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`Essentially, Cigna is attempting to recreate the Ingenix grift that resulted in the
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`largest settlements the healthcare industry had ever seen. In that scam, insurers like Cigna
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`contracted with Ingenix, using their systems and databases, to determine reimbursement rates
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`that were found to be well below UCR and used deeply flawed methodologies. Andrew Cuomo,
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`then New York’s attorney general and now its governor, said of the Ingenix databases, “[t]he
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`lack of accuracy, transparency, and independence surrounding Cigna’s process for setting a
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`‘reasonable and customary rate’ is astounding… the inherent problems with the data it is using
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`6 See: Medicaid Innovation Accelerator Program, “Overview of Substance Use Disorder (SUD) Care Clinical
`Guidelines: A Resource for States Developing SUD Delivery System Reforms,” pp 7, 8, April 2017;
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`Case 5:20-cv-02255-EJD Document 1 Filed 04/02/20 Page 10 of 50
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`clearly demonstrate a broken reimbursement system designed to rip off patients and steer them
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`towards in-network-doctors that cost the insurer less money.”7
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`The Ingenix litigation resulted in a $350 million-dollar class settlement
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`agreement for underpaid claims. It also required insurers to finance an objective database of
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`reimbursements upon which patients and insurers nationally could rely on. The settlement
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`required the insurance companies to underwrite the new database, the “Fair Health” database,
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`with $95 million dollars, it did not require them to use it. Instead of using the FAIR health
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`database for the IOP treatment services at issue here, Cigna replaced Ingenix with Viant.
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`After the Ingenix litigation, Cigna could no longer cheat out of network providers
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`out of payments for claims as it had been doing and found a way to achieve indirectly what it
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`could no longer do directly. It found Viant, a third party repricer.
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`The Alliance of Cigna and Viant
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`Cigna is required to price and pay claims for mental health and addiction
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`treatment services in parity with medical services under the Paul Wellstone and Pete Domenici
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`Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA or “Parity Act”). The Final
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`Rules adopted for the Parity Act state “[t]he Departments did not intend that plans and issuers
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`could exclude intermediate levels of care covered under the plan from MHPAEA’s parity
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`requirements…Plans and issuers must assign covered intermediate mental health and substance
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`use disorder benefits to the existing six benefit classifications in the same way that they assign
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`comparable intermediate medical/surgical benefits to these classifications.” 78 FR 68240
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`(November 13, 2013). IOP services are referred to as “intermediate services” in the Rule. Id. The
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`MHPAEA’s implementing regulations, conspicuously, do not permit plans to classify treatment
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`settings strictly as hospital or non-hospital, recognizing the existence of intermediate levels of
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`care such as IOP.
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`Plaintiff’s son is a member a Cigna administered employee benefit plan, of which
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`7 New York State Office of the Attorney General, Cuomo Announces Industry-wide Investigation in Health
`Insurers; Fraudulent Reimbursement Scheme, February 13, 2008: https://ag.ny.gov/press-release/2008/cuomo-
`announces-industry-wide-investigation-health-insurers-fraudulent (last visited March 6, 2020)
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`7
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`RJ v. Cigna, et. al. – CLASS ACTION COMPLAINT
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`Case 5:20-cv-02255-EJD Document 1 Filed 04/02/20 Page 11 of 50
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`he is a beneficiary. Plaintiff’s plan is funded by her employer, while other class members have
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`plans that are fully insured by Cigna. As most individuals receive their health insurance through
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`their employer, Plaintiff and most class members’ plans are governed Employee Retirement
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`Income Security Act of 1974 (“ERISA”). Under ERISA governed plans, Cigna, as the plan
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`administrator, has a fiduciary duty to ensure that out-of-network claims are properly priced and
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`paid according to UCR as required by the plan documents. For non-ERISA plans, Cigna is bound
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`by the duty of good faith and fair dealing as well as additional state law requirements to ensure
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`that out-of-network claims are properly priced and paid according to UCR as required by the
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`plan documents. These obligations are essentially the same between ERISA and non-ERISA
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`plans in this context.
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`Cigna, in collusion with Viant, has violated these duties and responsibilities
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`through the intentional, systematic underpricing of claims and the subsequent collusion to cover-
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`up of the evidence of their collusion.
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`Plaintiff and his healthcare provider were deceived from the moment they sought
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`treatment. For every claim at issue in this litigation, prior to accepting a patient for treatment,
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`Plaintiff’s son provided his insurance information, including his insurance card, to nis provider.
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`The provider then contacted Cigna at the number on the back of the health insurance card,
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`verified the out-of-network benefits, asked and were told that these benefits were paid at UCR
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`rates, asked and were told by Cigna that no prior authorization was required prior to rendering
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`IOP services, and asked and were told that these claims were not subject to third-party repricing
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`by Viant.
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`Prior to being admitted for treatment, SJ signed paperwork that creates a contract
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`between himself and the provider to receive IOP services. This contract in every case obligates
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`SJ to be responsible for amounts not paid by Cigna.
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`For SJ and class members in this litigation, they all paid amounts to their
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`providers as ‘balance bills’ that were properly Cigna’s responsibility. All these claims are
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`payment disputes; none of these claims are coverage disputes.
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`SJ and his IOP provider contracted for SJ to receive treatment based on Cigna’s
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`8
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`RJ v. Cigna, et. al. – CLASS ACTION COMPLAINT
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`Case 5:20-cv-02255-EJD Document 1 Filed 04/02/20 Page 12 of 50
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`representation that it would reimburse at actual UCR rates. As an out-of-network facility, the
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`provider had no access to RJ’s actual health insurance plan, had no pre-existing contractual
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`relationship with Cigna, and SJ did not arrive with his insurance policies and Summary Plan
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`Documents (SPDs) in hand.
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`SJ and the class may have chosen out-of-network facilities for any number of
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`reasons. Their reasons for selecting one particular facility are irrelevant, as, in SJ and the class
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`members reasonably believed that they possessed a health insurance policy that permitted them
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`to see out-of-network healthcare providers and that their Cigna healthcare policies would pay
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`the healthcare provider that they chose according to UCR, as provided in the policy.
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`SJ’s policy provided out-of-network coverage for mental health and substance
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`use disorder treatment with benefits to be paid according to UCR rates.
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`Cigna is one of the largest health insurers in the country, and each year processes
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`hundreds of thousands, or more, of claims submitted by patients. Cigna employs Viant to
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`“reprice” claims from patients who elect their right to see providers who are “out-of-network.”
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` While not every claim submitted by a patient is repriced by Viant, there is a
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`disturbing nationwide increase in Cigna’s use of Viant to reprice IOP claims at rates that are a
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`fraction of those that Cigna had previously been paying for out-of-network IOP services.
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`Every claim at issue here was sent by Cigna to Viant for Viant, a third party, to
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`reprice at a substantially lower rate than Cigna had been paying. Neither SJ nor any class
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`member has an agreement of any sort with Viant that permits Viant to negotiate with their
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`providers on their behalf. This is especially true as Viant’s “negotiations” for every claim at issue
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`resulted in the payment by the insured of excessive balance bills.
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`Neither SJ nor any class member were told by Cigna and/or their plan’s sponsors
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`that their claims could be subject to third-party pricing by Viant. No plan document states that
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`out-of-network claims will be paid at UCR unless, Cigna, at its own discretion, chooses to use
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`Viant for the purpose of actually reimbursing claims at well-below UCR.
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`The IOP pricing and payment rates that Viant “offers” to providers on behalf of
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`SJ and the class is no more than a con. Cigna directs the pricing that Viant “offers” as a
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`RJ v. Cigna, et. al. – CLASS ACTION COMPLAINT
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`Case 5:20-cv-02255-EJD Document 1 Filed 04/02/20 Page 13 of 50
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`“negotiation” for payment and states to both patients and providers that the offered amount is
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`based on UCR rates. In reality, Cigna has hidden “cost containment” policies that underlie its
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`contracts with Viant and actually provide financial incentives for Viant to breach the terms of
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`Cigna’s insurance contracts with its members.
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`The rates that Viant offers in its “negotiations” for IOP treatment are determined
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`with no relationship to the UCR outlined in SJ and the class members’ Cigna policies. For
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`instance, there is no reimbursement variation based on provider location. During the
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`“negotiation,” Viant claims that the rate it offers is based on the UCR for the provider’s
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`geographic location; however, it beggars belief that the UCR for Silicon Valley, CA is the same
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`as it is in, for example, Altoona, PA or Paris, TX.
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` While purporting to consider geographic area, Viant is, in fact, “negotiating” at
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`the essentially the same flat, low rate across the entire country. Despite having access to a wealth
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`of charge data for hundreds of thousands, or more, of claims, Cigna and Viant do not price and
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`pay IOP claims according to legitimate UCR calculation methodologies. Instead, Cigna has made
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`the financial decision that claims are to be paid at levels designed to drive out-of-network
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`providers out of business. Cigna does this because out-of-network providers cost Cigna more.
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`Even though this is ostensibly reflected in the higher premiums attached to these plans, Cigna
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`still chooses to place its profits over its members who are forced to pay twice for their treatment.
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`Plaintiff and The Class first pay for their treatment in the form of insurance
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`premiums and then pay again to cover the cost of excessive balance bills sent to them as the
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`result of Viant’s “negotiation” and Cigna’s underpayment.
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`Viant is employed by Cigna, not SJ, the Class, or any individual provider
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`receiving IOP services. They receive financial incentives that are essentially kick-backs for every
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`dollar they “save” Cigna from paying on IOP claims.
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`Cigna does not transmit plan terms or language to Viant when it has Viant reprice
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`out-of-network claims. Cigna’s contract with Viant is independent of individual members’ plans
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`and blind and ignorant as to any individual plan or plan terms.
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`Viant has no defense or excuse for claiming to “negotiate” on behalf of the
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`Case 5:20-cv-02255-EJD Document 1 Filed 04/02/20 Page 14 of 50
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`Plaintiffs and the Class when it has no knowledge of actual plan terms. Cigna, the drafter of the
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`plans, chooses not to send the plan terms to Viant.
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`Cigna never told RJ, SJ or the provider that claims were subject to third party
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`repricing until after they entered into a binding contract with the IOP provider and received
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`treatment. Cigna and Viant’s actions created overly large balance bills, often amounting to tens
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`of thousands of dollars, or more, for SJ and the Class.
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`Viant is the face of these “negotiations” and the tool for Cigna’s underpayment.
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`When patients or providers contact Viant seeking UCR, Viant claims it has offered UCR. It has
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`not offered UCR, it has offered an amount it represents as UCR that is actually the product of a
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`secret, proprietary, database and/or pricing method. Viant refuses to provide patients, providers,
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`or even plan sponsors any transparency into the methodology used to arrive at their UCR. This
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`refusal is because the rates are not based on UCR.
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`Upon information and belief, Viant receives a base rate and maximum rate from
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`Cigna for IOP treatment. This base rate is well below UCR and is applied, with minimal variation,
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`nationwide. The maximum rate is the small amount that Cigna permits Viant to ‘negotiate’ up
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`to.
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`Upon information and belief, Viant earns its profits from Cigna by paying no
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`more than the initial rate or as little as possible over it because if Viant were ‘settle’ at the ‘up
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`to’ amount, it would earn nothing for that claim. Cigna then uses Viant’s ‘negotiated’ rate to
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`underpay for treatment, and Viant gets its cut of the graft.
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`Cigna and Viant both know that they are not offering and/or paying the UCR rates
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`as required under the terms of SJ’s and the Class’ insurance policies. Cigna and Viant are aware
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`that the costs of underpayment are borne by SJ and the Class from whom Cigna collects inflated
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`premiums.
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` While the exact number of patients who have relapsed and providers who have
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`been forced out of business as a result of these practices is unknown, a substantial number of
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`lives and livelihoods have been lost in furtherance of corporate profits and executive bonuses.
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`Cigna and Viant have both made false representations regarding UCR and
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