Physicians generally do not have direct standing to bring a claim for benefits under an ERISA group health plan. Rather, a physician’s standing derives from the patient’s status as a plan participant and must be assigned. It thus requires a valid assignment and is subject to any restrictions in the ERISA plan. In an emergency room—where patients are triaged as they come in—the intake-nurse may not know in advance which physician will assist a patient. For this reason, hospital assignment forms will often contain broad language such as assigning benefits to “any practitioner providing care and treatment to [the patient].”
Recently, several emergency room doctor groups alleged that multiple Blue Cross Blue Shield-affiliated plans (the “Blue Plans”) underpaid their claims for reimbursement. These doctor groups had relied on the hospitals’ intake processes to secure patient assignments of claims and requested plan documents from the Blue Plans but to no avail.
The Blue Plans claimed, in part, that these assignments were invalid because the doctor groups were not expressly named in the assignments, the assignments did not include an express right to sue, and the underlying Blue Plans contained valid anti-assignment clauses. The Blue Plans also claimed they were not required to provide the plan documents (which contained the required appeals process and the anti-assignment clause) to the doctor groups, because the doctor groups used the wrong appeals process to request the documents. The U.S. Court of Appeals for the Fifth Circuit discounted this circular argument and made the following points:
- When assignment forms are broadly drafted, they may be ambiguous as to who the assignee is, but that does not invalidate the assignments.
- There is not a requirement that an assignment form include a standalone “right to sue” provision when the form assigns “all rights” or “all insurance benefits.”
- An ERISA plan administrator may be prevented from enforcing plan provisions (such as “anti-assignment” or “exhaustion of remedies” provisions) against a claimant if the administrator refuses to provide the document containing those provisions to the claimant.
What is the takeaway for employers? Be cautious when denying a third-party document request, including requests made directly to the plan’s third-party administrator. The failure of the plan administrator to provide requested plan documents that are required to be disclosed under ERISA may relieve the requesting provider from any obligation to follow and exhaust the plan’s claims review and appeal procedures and may also nullify the right of the plan administrator to rely on the plan’s anti-assignment provisions. This case illustrates that an ounce of prevention could prevent a pound of legal filings.
Angelina Emergency Med. Assoc. v. Blue Cross and Blue Shield of Ala., No. 24-10306 (5th Cir. Aug. 8, 2025) can be found here.
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