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
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.
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).
- Challenges to denial of out-of-network payments based on fee forgiveness provisions
- North Cypress Medical Center v. CIGNA
- Bad faith claims in network negotiations as a factor in denying out-of-network reimbursement claims
- Factors for plaintiff counsel to consider in pursuing claims under ERISA Section 502(a)(1)(B)
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?
Amanda A. Sonneborn, Partner
Ms. Sonneborn advises clients in the health care, construction, print media, hotel, gaming, manufacturing, transportation, and energy industries. She has considerable experience in the area of ERISA litigation, and she is co-chair of the Firm’s ERISA & Employee Benefits Litigation practice group. Her ERISA and employee benefits litigation experience includes defense of single plaintiff claims for benefits, breach of fiduciary duty claims, cash balance plan claims, breach of contract claims, and ERISA Section 510 employment discrimination claims. She devotes a considerable amount of her practice to litigation of class-action and multi-plaintiff claims. She also frequently advises clients regarding handling of claims brought under benefit plan claims procedures. She handled hundreds of single plaintiff cases brought in federal court under ERISA.
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, particularly on the intersection of the health care and health insurance industries. She is an experienced litigator, with substantial involvement in life, health, and disability litigation. Her practice has included litigating complex issues related to ERISA preemption on behalf of health care providers and insurers. In addition, she advises clients regarding Medicare billing and compliance, including matters related to physician supervision, hospital-based clinical trials, and psychiatric patients.
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