Protecting Healthcare Providers' Rights to Benefits Under ERISA: Assignment of Benefits and Right to Sue

Description

Recent court decisions have underscored the importance of AOBs for healthcare providers seeking reimbursement against insurers for services rendered, particularly when providers assert claims under ERISA. Because providers are not ERISA plan participants or beneficiaries, a provider’s standing -- and ability to challenge an insurer’s reimbursement decision -- depends on whether the provider has an enforceable AOB. For example, if a healthcare provider did not get an AOB from a patient, the provider may not be able to pursue litigation at all. And, even if the provider did receive an AOB, the language and breadth of the AOB, or an anti-assignment clause in the underlying health insurance plan, may prevent the provider from bringing suit entirely or from bringing certain claims.

Some federal courts have reached inconsistent conclusions regarding whether an assignment of the right to payment confers standing to sue. For example, in New Jersey Brain & Spine Ctr. v. Aetna Inc. (3d Cir. 2015), the Third Circuit considered whether a patient’s explicit assignment of payment of benefits to the healthcare provider is enough to give the provider standing to sue under ERISA. The court held that a healthcare provider obtains standing when a patient assigns payment of insurance benefits to the provider.

However, in Peacock Med. Lab. v. UnitedHealth Gp. (S.D. Fla. 2015), the district court concluded that a medical lab did not have standing to sue under ERISA despite the patients having signed AOBs. The court determined the assignment only conferred limited standing to receive benefits.

Listen as our authoritative panel of healthcare practitioners examines what healthcare providers can do to protect their rights to benefits under ERISA. The panel will discuss structuring AOBs and right to sue clauses. The panel will also examine lessons that can be learned from recent court decisions and address anti-assignment clauses and steps providers should take to ensure standing.