On Sep. 15, 2014, in the United States Supreme Court, Blue Cross Blue Shield Association, et al. filed an Amici Curiae Brief in support of BCBSM, appealing a Sixth Circuit Court award of $6.1 million to a self-insured plan. The implications of this Supreme Court decision could potentially return billions of dollars to self-insured health more »
On September 3, 2014, a California federal judge ruled in favor of a Los Angeles surgical center by dismissing with prejudice, Cigna’s overpayment lawsuit against La Peer Surgery Center after Cigna administered self-insured plans were counter-sued by the surgical center. The dismissal came in spite of the fact Cigna prevailed over the provider’s motion to more »
Get A Copy Of The Full Health Plan– The complete Plan usually will not be a SBC, SPD (benefit summary) or a print-out from a website. It will be, on average, at least 25-50 pages long. The insurance company or claims administrator will likely not have a copy of the full Health Plan. You can more »
On April 7, 2014 and April 28, 2014, the Obama administration’s Department of Labor (DOL), argued in the 9th and 5th Circuit Courts, on behalf of out-of-network providers and patients against health plans, on whether providers must balance bill patients before billing health plans. On April 7, 2014 and April 28, 2014, the Department of more »
On March 28, 2014, a federal ERISA court ruled against BCBS (Independence Blue Cross, IBC) overpayment practice by granting a permanent injunction and ruling in favor of providers in an ERISA overpayment class-action. According to the court’s opinion, the insurer’s “practices come nowhere near substantial compliance with ERISA’s notice and appeal requirement.” This might be more »
On November 7, 2013, the United States District Court for the Northern District of Illinois granted in Summary Judgment against BCBS in an overpayment ERISA class action for certain plaintiff providers. The court clarified among other issues that: Providers are entitled to sue under ERISA; Certain BCBS entities completely violated ERISA; These providers are not more »
A Federal Court in Tennessee orders United Healthcare of Tennessee, Inc (United) to pay $99,000 in ERISA penalties for failing to provide a patient with treatment guidelines for 900 days. The $99,000 ERISA penalty is almost 3 times the amount of the medical claim benefits owed of $35,724.80 The US District Court Eastern District of more »
A recent case may help out of network providers, which have complete valid ERISA assignments regarding appeal and reimbursement rights, receive checks directly from insurers. For the first time federal courts have rendered the clearest answers to date: managed care network participation is immaterial, ERISA assignment is the critical controlling factor to health-care benefits reimbursement. more »
All employer sponsored health plans must comply with federal ERISA regulations when making demands for overpayment refunds. Attempts to recoup or withhold monies from providers are and should be treated as any other claim denials. Providers should submit compliant appeals requesting due process and a full and fair review. The number of stories appearing in more »
The 7th circuit panel, citing a recent Supreme Court decision, seems to have established new insurance verification laws under ERISA, in a case where a patient is entitled to a $77,974 monetary damage award after her health plan falsely verified coverage for a procedure when none existed thereby creating an ERISA fiduciary breach, holding the more »