Out of Network Provider

News & Analysis as of

Court Orders Cigna to Pay Out-of-Network Surgical Claims

On June 1, 2016, the United States District Court for the Southern District of Texas ordered Cigna to pay nearly $13.7 million to Humble Surgical Hospital, LLC (“Humble”). Of the nearly $13.7 million, almost $11.4 million...more

Employee Benefits Developments - May 2016

Agencies Issue New FAQs on the Affordable Care Act.The Departments of Labor, Health and Human Services, and the Treasury (the agencies) issued another set of frequently asked questions (FAQs) regarding the implementation of...more

Health Care Providers Can Fight Back Against Insurer Recoupment Demands Using ERISA

In the daily skirmishes between health care providers and payors, this scenario is not uncommon: A health care provider renders services to a patient and submits a reimbursement claim to the patient’s insurer. The insurer...more

After New York, Florida Curbs Surprise Bills for Emergency and Out-of-Network Services

It is generally understood that if a managed care member utilizes the services of a non-participating provider, the member could incur significant out of pocket expenses. However, there are instances where a member may...more

New ACA, et. al. FAQs Cover Items From “Top” to “Bottom”

On April 20, the “Big Three” agencies (DOL, Treasury/IRS, and HHS) released another set of FAQs (the 31st, for those of you counting at home). Consistent with earlier FAQs, the new FAQs cover a broad range of items under the...more

HHS Sets New Requirements to Limit Surprise Medical Bills from Out-of-Network Providers

The U.S. Department of Health and Human Services (“HHS”) recently released a final rule titled “Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2017” (“Final Rule”)[1] that sets...more

New Affordable Care Act FAQs Released on Rescissions of Coverage, Preventive Care Mandate, Out-of-Network Emergency Service...

The U.S. Department of Labor, the Department of Health and Human Services, and the Department of the Treasury (collectively, the “Departments”) have jointly issued a new set of answers to frequently asked questions about the...more

Insurer Actions Cut the Heart Out of Out-of-Network Providers

Aetna Life Insurance Company recently won a $37 million verdict against a group of Northern California surgical centers, Bay Area Surgical Management, LLC and its affiliates (collectively, Bay Area), for an alleged...more

Aetna vs. BASM: Pigs Get Fat and Hogs Get Slaughtered

On April 13, 2016, a jury in Santa Clara, California awarded Aetna, Inc. $37.4 million from Bay Area Surgical Management, LLC (“BASM”), six of its affiliated surgery centers and its three principals. Aetna had accused the...more

Court Rules Hospitals Must Exhaust HHS Administrative Appeals Process for Medicare Advantage Out-of-Network Payment Dispute

According to a Georgia federal district court ruling issued on February 11, 2016, a group of hospitals must exhaust their out-of-network Medicare Advantage (MA) payment dispute through the Department of Health and Human...more

CMS Takes Action Against Network Transparency While New Jersey Legislation Hits a Snag

Just as the Centers for Medicare & Medicaid Services (CMS) began holding federal health care plans accountable for their provider network transparency obligations, the New Jersey legislature stalled in its bid to pass a law...more

Health Update - January 2016

The Megatrends Reshaping Healthcare: Managing Change and Maximizing Opportunity - Editor's Note: In 2013, Manatt Health identified 10 megatrends that would reinvent the healthcare marketplace across the next decade. In a...more

SURPRISE!!! The NJ Out-of-Network Consumer Protection, Transparency, Cost Containment, and Accountability Act Goes Forward and...

On November 17, 2015, New Jersey lawmakers forged ahead with the controversial legislation that addresses, among other things, “surprise” medical bills from out of network providers. According to its sponsors, the purpose of...more

Insurers May Not Terminate Physicians for Recommending Out-of-Network Providers

Under a new Texas law, effective September 1, 2015, health maintenance organizations (HMOs) and Preferred Provider Benefit Plans (PPO) (collectively referred to as "Insurers") can no longer terminate a physician from their...more

UnitedHealthcare Services Denied Injunction Against Out-of-Network Physician Seeking to Bar Balance Billing of the Patient

In UnitedHealthcare Servs., Inc. v Asprinio (2015 NY Slip Op 25298), decided on August 31, 2015, in the Supreme Court of Westchester County, UnitedHealthcare suffered a set-back against attempts to prevent balance billing by...more

New Texas Legislation Helps “Stretch” The Concepts of Narrow Networks

In the past five years or so an increasing number of health insurers have been using “narrow networks” of providers in an attempt to hold down medical costs and insurance premium rates. A key part of the narrow network...more

Client Alert: AB 533 Defeated

Johan Swanepoel © 123RF.com Controversial AB 533 did not obtain the necessary votes for approval and failed to pass. Assembly Health Committee Chair Rob Bonta proposed AB 533 in an attempt to purportedly address the problems...more

Texas Hospital Strikes Back at Aetna

On February 23, 2015, Aetna filed suit in Texas federal court against Robert A. Behar, M.D. and North Cypress Medical Center (North Cypress), alleging that Dr. Behar, the CEO of North Cypress, offered impermissible ownership...more

HMOs May Not Terminate Physicians for Recommending Out-of-Network Providers

Under a new Texas law, effective September 1, 2015, health maintenance organizations (HMOs) can no longer terminate a physician from their networks solely because the physician informs his or her patients about the full range...more

IREG Update - August 2015 #2

Hot Topic: New York Emergency Medical Services and Surprise Bills Law - Earlier this year, New York’s Emergency Medical Services and Surprise Bills Law went into effect (the full text of the bill is available on the...more

Waivers of Co-Pays and Deductibles: Insurance Benefit Exclusions Grow

Recent changes to policy and plan language and increased litigation by third-party payers suggests that out-of-network providers who waive co-pays and deductibles may be in for some rough sailing. Providers must be aware of...more

ERISA’s Exhausting and Exasperating Exhaustion Requirement and the Exceptions Medical Providers Seeking Full Reimbursement From...

The first Alert in this two-part series discussed three common issues facing out-of-network medical providers in asserting reimbursement claims against employee benefits plan administrators (whether an insurance company or...more

Providers Get Rare Win in New Texas Law Protecting Out-of-Network Referrals

On June 1, 2015, Texas Governor Greg Abbott signed House Bill 574 into law protecting physicians and other providers from having their participating provider agreements terminated by an insurer solely because the provider’s...more

Connecticut Passes Law Imposing New Burdens On Health Insurance Companies

Public Act 15-146, "An Act Concerning Hospitals, Carriers and Health Care Consumers," was signed into law by Governor Malloy on June 30, 2015 and will have a significant impact on health insurance companies in Connecticut....more

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

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