Out-of-Network ERISA Claims: Identifying Provisions Subject to Provider Challenge

Anti-Assignment Clauses, Leveraging Ambiguities in Fee Forgiveness Provisions, Bad Faith, and Other Factors

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


Conducted on Wednesday, January 22, 2020

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. 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

Reimbursement disputes between healthcare providers and payers involving out-of-network claims have increased sharply in recent years. These disputes involve critical legal and practical considerations that ERISA counsel must have a full understanding of to handle out-of-network payment claims under ERISA effectively.

Section 502(a)(1)(B) claims arise when health plan fiduciaries or administrators deny a claim for benefits that the plaintiff alleges are due under the healthcare plan. Multiple lawsuits challenging the billing and payment practices between out-of-network providers and health insurers emphasize the need for plans to include unambiguous anti-assignment language in health plan documents and summary plan descriptions to avoid or limit out-of-network claims, and for medical providers to enter strong assignment and personal representative agreements with their patients.

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 and offers practical techniques for pursuing claims.

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Outline

  1. Challenges to denial of out-of-network payments based on fee-forgiveness provisions
  2. Recent cases and key arguments raised in the pursuit of out-of-network claims
  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

Andersen, Alison
Alison Lima Andersen

Partner
Arent Fox

Ms. Andersen's recent litigation work includes representing medical providers seeking reimbursement from commercial...  |  Read More

Hamelsky, Andrew
Andrew I. Hamelsky

Partner
White and Williams

For more than 20 years Mr. Hamelsky has been a commercial litigator with experience before state and federal courts and...  |  Read More

Johnson, Mark
Mark Johnson, Ph.D., J.D.

Founder
ERISA Benefits Consulting

Mr. Johnson has a 30 year career history bridging four closely related areas in Employee Retirement Income Security Act...  |  Read More

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