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 video webinar with Q&A
This CLE course will provide counsel with a thorough and practical guide to pursue out-of-network payment claims under ERISA and state law theories. 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. The program will also highlight efforts by out-of-network providers to assert claims that fall outside the scope of ERISA.
Outline
- Challenges to denial of out-of-network payments based on fee-forgiveness provisions
- Recent cases and key arguments raised in the pursuit of out-of-network claims
- 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)
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
Alison Lima Andersen
Partner
ArentFox Schiff
Ms. Anderson’s work is primarily in the areas of ERISA and other employee benefits litigation, healthcare... | Read More
Ms. Anderson’s work is primarily in the areas of ERISA and other employee benefits litigation, healthcare litigation, and complex commercial litigation. Her recent litigation work includes representing medical providers seeking reimbursement from commercial health plans and insurers; defending companies and retirement plans against breach of fiduciary duty and benefits claims; and defending several defendants accused of violating the Medicare Secondary Payer Act. She also has recent experience in municipal and corporate bankruptcy; as well as in class action cases involving claims of government lending and disability discrimination.
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Eliot T. (Eli) Burriss
Partner
Holland & Knight
Mr. Burriss litigates complex commercial disputes throughout the United States, serving as counsel to global... | Read More
Mr. Burriss litigates complex commercial disputes throughout the United States, serving as counsel to global clients in all aspects of litigation. In recent years, he has had a particular emphasis on representing health care and life sciences companies, as well as a variety of organizations in antitrust, ERISA and other significant matters. He has tried state and federal antitrust claims and government investigations, as well as claims of unfair competition, ERISA, breach of fiduciary duty, deceptive trade practices, trademark violation, breach of contract, vicarious liability, products liability and tortious interference with contractual relationships.
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Bruce D. Pingree
Consultant
ERISA Benefits Consulting
Over the course of Mr. Pingree's legal career, he has focused on employee benefits and executive compensation... | Read More
Over the course of Mr. Pingree's legal career, he has focused on employee benefits and executive compensation expertise. There are few legal issues in the benefits and executive compensation arena that he has not encountered and handled. Rather than attempting to limit his practice solely to “niche” areas of employee benefits law, he maintains broad levels of expertise. In the most recent years, he spends an increasing percentage of time in executive compensation matters, while continuing deep exposure to broader employee benefits issues, including health care reform. His legal career is devoted to attaining client goals and solving problems prior to their occurrence.
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