Hospital That Failed To Precertify Procedure Gets Paid Anyway


A hospital that provided a medically necessary heart catheterization to a health plan participant is entitled to payment by the insurance company even though the hospital failed to precertify the procedure as required by the plan.  That’s what a federal court in Wisconsin ruled last Friday.

James Vana underwent heart catheterization at the University of Wisconsin Hospital.   The insurance plan documents called for the hospital to precertify the procedure, but for some unexplained reason the hospitals didn’t do so.  When the hospital sent its bill, the insurance company refused to pay it, based on the failure to precertify.  So the hospital sued under ERISA.  The insurance company defended its refusal, citing the precertification provision.

The court acknowledged that the plan required the hospital to precertify procedures and that the hospital had failed to meet the requirement.  But the court also noted that the plan did not say that a patient would lose his benefits if there was no precertification.  So Mr. Vana still had a right to his benefits.

And Mr. Vana had assigned his benefits to the hospital because the hospital admission forms, like virtually all such forms, contained an assignment of benefits to the hospital.  So in this case, the hospital had a right—the right Mr. Vana assigned it—to have the bill paid.  The insurance company must pay the bill.


DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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