Out of Network Provider

News & Analysis as of

New Law Continues to Require Out-of-Network Facility-Based Physicians to Notify Patients of Mediation Rights

Early last week, Gov. Greg Abbott signed SB 481 into law. The new law, which will become effective on September 1st, gives Texas consumers the option to mediate medical bills that they receive from out-of-network...more

Out-of-Network, Out of Luck? A Growing Body of Caselaw Addressing Claims by Out-of-Network Providers Seeking Full Reimbursement...

It’s become a common scenario for medical providers: a provider treats a patient covered by employer-provided health insurance for which the provider is out-of-network, receives an assignment of benefits from the patient and...more

Legislation Proposed In New Jersey to Alert Patients to Out-of-Network Costs

On May 14, 2015, four New Jersey legislators introduced the Out-of-Network Consumer Protection, Transparency, Cost Containment and Accountability Act (the "Legislation"). If enacted, the Legislation would increase health care...more

Surprise Bills Laws Enacted in California and New York

What Do They Mean for Providers? - Both California and New York have recently enacted so-called “Surprise Bills Laws” that require out-of-network providers to give notice to patients that a particular item or service...more

Fifth Circuit Finds Out-Of-Network Medical Provider Has Standing To Sue Health Plan

The Fifth Circuit recently addressed an out-of-network provider’s right to sue and whether coverage may be conditioned on collections of patient’s out of pocket costs. North Cypress Medical Ctr. Operating Co., et al. v. Cigna...more

How New York’s Emergency Medical Services and Surprise Bills Law Impacts Providers and Plans

Last year New York passed legislation known as the “Emergency Medical Services and Surprise Bills” law, a much-heralded consumer protection law primarily intended to guard against surprise bills for out of network (OON)...more

Illinois joins growing list of states to adopt anti-markup legislation; statute impacts all payors

After three years of negotiations between several constituencies, including pathologists, dermatologists and other specialist associations, Illinois has joined 25 states that have enacted laws addressing the practice of some...more

New York’s Surprise Medical Bill Law Goes into Effect

New York’s Emergency Medical Services and Surprise Bills law went into effect yesterday, which means consumers who receive out of network (OON) emergency services will no longer have to pay more than their usual in-network...more

Health Care: Out-of-Network Provider Coverage, Notice, Disclosure, and Dispute Resolution (3/15)

New York State has adopted legislation to address consumer complaints related to health insurance coverage and "surprise bills" for health care services performed by out-of-network physicians and providers....more

Recent Federal Court Ruling on Application of Texas Prompt Pay Laws to Self-Funded, Medicaid and Out-of-State Plans and Their...

What's new? A Dallas federal district court recently ruled that the Texas Prompt Pay Law does not apply to employer-funded health plans, Medicaid plans, or out of state patients that use Texas providers, or to a Third Party...more

Aetna Out of Patience With Hospital’s Alleged Out-of-Network Billing Scheme

Aetna Life Insurance Company (Aetna) is going on the offensive against a Northwest Houston hospital with an out-of-network strategy. On February 23, 2015, Aetna filed suit in Texas federal court against Robert A. Behar, M.D....more

The Unique Risks Of Investing In Out-Of-Network Providers

For several years, industry observers have been predicting the demise of out-of-network business models, yet they still survive. For some providers in certain specialties and certain geographies, a predominantly...more

New York Enacts Out-Of-Network Transparency and Coverage Reform

Last month, a woman sued a health plan, claiming that she was intentionally misled about which physicians were participating providers in the company’s online health insurance exchange established under the Affordable Care...more

Practical considerations to protect against being ‘out of network’

Practical considerations to protect against being ‘out of network’ The disengagement of Highmark and UPMC is looming on the horizon; most of the hospital participation agreements between these two competing healthcare...more

Healthcare Legal News - February 2014 • Volume 4, Number 1

In This Issue: - CMS ISSUES FINAL RULE ON DIRECT ACCESS OF LAB TEST RESULTS BY PATIENTS: On February 3, 2014, the Centers for Medicare and Medicaid Services (CMS) released a final rule that permits patients or...more

Employee Benefits Developments - January 2014

CASES - Court Finds Former NFL Player’s First Wife Is Surviving Spouse - A recent decision by the U.S. Court of Appeals for the Third Circuit demonstrates once again the importance of divorcing your first spouse...more

Mississippi Governor Rescinds Executive Order Requiring Blue Cross of Mississippi to Grant “In Network” Status to Excluded...

In early November, Mississippi Governor Phil Bryant rescinded an Executive Order (Executive Order 1327), issued only weeks earlier, that would have compelled Blue Cross of Mississippi to continue to offer “in-network” status...more

To Waive or Not to Waive, That is the Question

A burgeoning problem is developing for out of-network healthcare providers that systemically fail to collect deductibles and coinsurance from patients. Insurance companies often seek to deny insurance coverage to subscribers...more

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