Out-of-Network ERISA Claims after North Cypress Medical: Identifying Provisions Subject to Provider Challenge

Leveraging Ambiguities in Fee Forgiveness Provisions, Bad Faith and Other Factors

Recording of a 90-minute CLE webinar with Q&A


Conducted on Tuesday, February 7, 2017

Recorded event now available

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Program Materials

This CLE webinar will provide ERISA counsel with a thorough and practical guide to the pursuit of out-of-network payment claims under ERISA in the aftermath of the North Cypress Medical Center holding. The panel will outline the conditions under which providers generally succeed in obtaining reimbursement for out-of-network claims under Section 502(a)(1)(B), and offer guidance on what factors to consider in pursuing or defending a claim.

Description

North Cypress Medical Center v. CIGNA (S.D. Tex. Sep. 28, 2016) found that CIGNA abused its discretion by acting in bad faith when interpreting plan provisions with regard to provider North Cypress. This represents the latest in a series of decisions allowing providers to seek payment for out-of-network reimbursements.

In North Cypress, CIGNA cited plan document language to disclaim payment for services under a fee-forgiveness protocol. The district court found that "the evidence suggests that CIGNA targeted North Cypress with its Fee-Forgiving protocol to pressure it to negotiate an in-network contract."

The landscape appears to be changing, as providers’ claims for out-of-network reimbursements have proliferated. ERISA counsel needs a clear understanding of plan language provisions, as well as other factors, that will render out-of-network payment denials subject to successful challenge by providers. As recent cases have illustrated, plan language that denies reimbursement for services in which the provider has a fee-forgiveness provision may no longer be enough to insulate the payor from claims.

Listen as our experienced panel provides a practical guide to challenges to out-of-network denials under ERISA Section 502(1)(10(B).

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Outline

  1. Challenges to denial of out-of-network payments based on fee forgiveness provisions
  2. North Cypress Medical Center v. CIGNA
  3. Bad faith claims in network negotiations as a factor in denying out-of-network reimbursement claims
  4. Factors for plaintiff counsel to consider in pursuing claims under ERISA Section 502(a)(1)(B)

Benefits

The panel will review these and other key issues:

  • What is the impact of fee forgiveness provisions in plan documents on out-of-network reimbursement claims?
  • What other factors can lead to successful challenges of out-of-network claim denials by carriers?
  • What is the anticipated impact of recent court decisions on payors’ out-of-network policies?

Faculty

Amanda A. Sonneborn
Amanda A. Sonneborn

Partner
Seyfarth Shaw

Ms. Sonneborn advises clients in the health care, construction, print media, hotel, gaming, manufacturing,...  |  Read More

Dorothy H. Cornwell
Dorothy H. Cornwell

Of Counsel
Smith Moore Leatherwood

Ms. Cornwell practices in the Firm's health care group, with a focus on litigation and regulatory compliance,...  |  Read More

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