Amy Gordon Discusses Conflict Over Health Claims Data with Bloomberg Law

Winston & Strawn Partner Amy Gordon spoke with Bloomberg Law about the latest lawsuit filed by an employer health plan against its health insurance administrator, demanding access to their medical claims data to perform their fiduciary duties in assessing whether payments for health services are correct and reasonable. The lawsuit, filed by Owens & Minor Inc., stated that Anthem Health Plans of Virginia Inc. has refused to turn over claims data requested since 2021.

“It’s sort of a fine line, because if you are self-insuring your coverage,” Amy said, “you have this financial obligation to pay those claims.” Transparency rules that took effect in 2022 “were supposed to essentially fix this problem,” she said. But health-care payments are complicated, with many payment arrangements between providers and insurers and administrators, such as reference-based pricing and pay for performance systems, she continued.

“Anthem is saying we’ve got all these proprietary arrangements that we don’t want to get out into the public, and yet Owens & Minor is saying we have a fiduciary obligation to our plan participants to know that what we’re paying is fair and reasonable for the services that they are getting,” she said.

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