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 Labor (DOL), argued in the 9th and 5th Circuit Courts, advocating for out-of-network providers and patient’s rights against health plans, on whether providers must first balance bill patients before billing health plans. All out of network providers and patients should understand the court impacts of the DOL amicus briefs and oral arguments. Approximately 76% of Americans insured through their employer-sponsored health plans have paid for out-of-network coverage, according to the December 2013 National Composition Summary from DOL Bureau of Labor Statistics.
In arguing for out-of-network patients’ right to timely, vital healthcare and against having to pay full deductibles and coinsurance upfront, the DOL effectively argued against the current out-of-network claim denial practice by United and CIGNA:
“Thousands of healthcare claims are made in this country every day, and some are litigated, and yet no circuit court has ruled that providers must first bill their patients before they may enforce legitimately assigned benefits claims. …. Limiting physicians’ first recourse to their patients will have chilling effects both on providers and plan participants. Participants may forgo or delay vital healthcare because they cannot finance or they cannot pay for their care, and providers may limit their care to those participants whose health plans have previously paid properly signed healthcare claims or participants who are able to first to pay for the care, or the provider can recognize as creditworthy. Affirmance of the district court ruling can only benefit conflicted administrators, such as United, that both fund and administrator ERISA plans, by allowing them to forestall payments for substantially expensive medical care or maybe avoid that payment altogether”, according to the court audio records.
Avym Corporation closely monitors and demystifies the latest federal court developments for all out-of-network patient advocates and claims specialists, with new ERISA and PPACA reimbursement compliance seminars.
“The court rulings from both 9th and 5th Courts of Appeals will have a profound impact on the approximately 76% of Americans insured through employer-sponsored health plans, as they have paid for out-of-network coverage but may not be able to pay upfront for their full deductible and coinsurance before seeking timely, vital healthcare,” says Mark Flores, Vice President/Co-Founder of Avym Corporation and a national expert on ERISA and PPACA compliance appeals.
Case Info: Spinedex Physical Therapy USA, et al v. United Healthcare of Arizona, et al, Case No. 12-17604, in the United States Court of Appeals for the Ninth Circuit, on April 7, 2014. Oral argument recording: http://cdn.ca9.uscourts.gov/datastore/media/2014/04/07/12-17604.wma
Spindex Physical Therapy USA, Inc. Amicus Brief, in support of plaintiffs-appellants and requesting reversal: http://www.dol.gov/sol/media/briefs/spindex(A)-06-05-2013.htm
Case Info: North Cypress Medical Center, et alv. Cigna Health, Case No. 12-20695, in the United States Court of Appeals for the Fifth Circuit, on April 28, 2014. Oral argument recording: https://www.ca5.uscourts.gov/OralArgRecordings/12/12-20695_4-28-2014.wma
North Cypress Medical Center Operating Co. Amicus Brief, in support of plaintiffs-appellants, and requesting reversal: http://www.dol.gov/sol/media/briefs/north-cypress(A)-10-30-2013.htm
Among other things, the DOL added, “Assignee physicians with validly assigned benefits claims have standing to pursue those claims regardless of whether or not if they first billed their patients,” argued Marcia Elizabeth Bove, DOL attorney for the Secretary of Labor, according to the court audio records.
“By listening to the arguments from both sides of the healthcare matrix, out-of-network providers and patients may have much better understanding on the vital difference between patients, providers and health care plans. The federal Courts of Appeals are expected to make these landmark decisions in the next a few months for the market lifespan of the out-of-network and managed care business model,” says Dr. Jin Zhou, president of ERISAclaim.com, a national expert on ERISA and PPACA compliance appeals.
December 2013 National Composition Summary from DOL Bureau of Labor Statistics: