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The ISDN employees sued BCBSO under ERISA Sections 1132(a)(1)(b) and 1106(b), claiming that (1) BCBSO was liable them for the difference between the co-payment actually made (i.e., 20% of the total bill) and 20% of the actual charges and (2) BCBSO breached its fiduciary duties by failing to disclose the discounts and by using the discount scheme for its own benefit at the expense of plan participants.
BCBSO argued that the insurance certificate's language allowed it to negotiate discounts without disclosing them to insureds.
Under this doctrine, the court held that BCBSO was required to pay 80% of the total amount received by the hospital, and that the claimants' obligation was 20% of that amount.
Applying this doctrine, the court determined that the insureds had no reason to know from the certificate or EOBs that BCBSO paid less than 80% of the hospital charges.
DataGate serves as a central routing hub, translating messages and transmitting them to different systems while linking the internal systems -- in this case, BCBSO's mainframe corporate membership system and the master patient index.
The corporate membership system contains all of BCBSO's subscribers.
"So, as a patient walks into a clinic, we know immediately that he or she is a Health Ohio member, and we know right away what their copay and eligibility benefits are," says Tim Sargi, systems development coordinator for BCBSO. "That information is also available throughout the clinic.
BCBSO is proud to be the largest health insurer in Oregon.
Now, as the nation's health care delivery system is changing dramatically, BCBSO is flexible in meeting new demands of the marketplace and changing government regulations.
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