News & Analysis as of

Employee Retirement Income Security Act (ERISA) Out of Network Provider Employee Benefits

Fisher Phillips

Federal Appeals Court Decision Reminds Employers About Their Duty to Monitor Service Providers of ERISA-Covered Health and Welfare...

Fisher Phillips on

A federal appeals court just illustrated the importance of an employer’s duty to monitor service providers that assist with the administration of employee welfare benefit plans. In the May 21 decision of Tiara Yachts v. Blue...more

Hall Benefits Law

9th Circuit Explains ERISA Preemption of State Law Claims Arising from Preservice Coverage Communications

Hall Benefits Law on

The U.S. Court of Appeals for the Ninth Circuit recently issued an opinion with critical implications for the healthcare industry. This court decision clarifies the expansive reach of the Employee Retirement Income Security...more

Robinson+Cole ERISA Claim Defense Blog

Ninth and Second Circuit Courts of Appeals Rule that Preauthorization Process Does Not Impose Independent Contractual Liability on...

Within days of one another, the U.S. Court of Appeals for the Ninth and Second Circuits ruled—on issues of first impression for both—that ERISA expressly preempts state law breach of contract and promissory estoppel claims...more

Troutman Pepper Locke

Ninth Circuit Court of Appeals Restricts Out-of-Network Providers’ Ability to Avoid ERISA Preemption of State Law Claims

Troutman Pepper Locke on

On May 31, the Ninth Circuit Court of Appeals published an opinion in Bristol SL Holdings, Inc. v. Cigna Health and Life Insurance Company, which has significant implications for the healthcare industry, most notably by...more

Snell & Wilmer

2023 End-of-Year Plan Sponsor “To Do” Lists (Part 1) Health and Welfare

Snell & Wilmer on

We are pleased to present our annual End of Year Plan Sponsor “To Do” Lists. This year, we present our “To Do” Lists in four separate Employee Benefits Updates. This Part 1 covers year-end health and welfare plan issues....more

Groom Law Group, Chartered

Surprise! Tri-Agencies Meet Deadline with First Set of Surprise Billing Rules, With More to Come

On July 1, 2021, the Office of Personnel Management, Department of the Treasury, Department of Health and Human Services (“HHS”), and Department of Labor (“DOL”) (collectively, the “Departments”), released the interim final...more

Hinshaw & Culbertson LLP

Ninth Circuit Rules in Favor of Medical Provider in Dispute with Insurer Regarding Anti-Assignment Provisions

The Ninth Circuit significantly limited insurers' ability to rely on anti-assignment provisions in ERISA health plans in Martin Luther King, Jr. Community Hospital v. Community Insurance Company dba Anthem Blue Cross Blue...more

Robinson+Cole ERISA Claim Defense Blog

Second Circuit Addresses Limitations Periods Governing Fraudulent Billing Claims Against Non-Participating Labs

In Connecticut General Life Ins. Co. v. BioHealth Labs., Inc., No. 20-2312-CV, — F.3d –, 2021 WL 476111 (2d Cir. Feb. 10, 2021), Cigna, as administrator of employee health plans, sued six out-of-network lab companies for...more

Foley & Lardner LLP

An Alternative Approach to an ERISA Litigation Conundrum

Foley & Lardner LLP on

Recently, a three-judge panel in the Court of Appeals for the Ninth Circuit overturned a district court dismissal of an out-of-network provider’s claims against Blue Cross and Blue Shield of Illinois (“BCBSIL”). The unanimous...more

Epstein Becker & Green

Ninth Circuit: Insurers Must Honor Their Promises to Out-Of-Network Providers

Epstein Becker & Green on

In July, we reported (here) on a Third Circuit decision that held an out-of-network provider’s direct claims against an insurer for breach of contract and promissory estoppel were not pre-empted by ERISA. That opinion was a...more

Troutman Pepper Locke

New ERISA Case Results in an Assignment for Today – Check your Group Health Plan’s Anti-Assignment Provision!

Troutman Pepper Locke on

Anti-assignment clauses in ERISA health plans are useful to plan sponsors in fending off lawsuits by out-of-network providers.  Federal courts have consistently upheld anti-assignment provisions contained in the plan document...more

Ogletree, Deakins, Nash, Smoak & Stewart,...

Surprise Medical Billing Protections Coming for Participants in 2022

Beginning in 2022, employer-sponsored health plans will be required to pay providers certain emergency and out-of-network charges that would have otherwise been balance billed to participants. That is the centerpiece of...more

Epstein Becker & Green

Third Circuit: Provider’s Out-of-Network Claims not Pre-empted by ERISA

Epstein Becker & Green on

In an important win for healthcare providers, on July 17, 2020, the Third Circuit determined in a published opinion that an out-of-network provider’s direct claims against in insurer for breach of contract and promissory...more

Hinshaw & Culbertson LLP

The LHD/ERISA Advisor: Eighth Circuit Upholds Payment for Out-of-Network Air Ambulance Flight at 150 Percent of Medicare Rates

In Mitchell v. Blue Cross Blue Shield of N.D., 2020 U.S. App. LEXIS 8818 (8th Cir. Mar. 20, 2020), the Eighth Circuit upheld the payment of 150% of Medicare rates for an out-of-network air ambulance flight, although the...more

Hinshaw & Culbertson LLP

The LHD/ERISA Advisor: Sixth Circuit Rejects MSPA and ERISA Discrimination Claims

Seeking to control healthcare costs, many group health plans have adopted amendments that lower reimbursement rates for the treatment of end-stage renal disease ("ESRD"), which requires long-term dialysis treatment or a...more

Sheppard Mullin Richter & Hampton LLP

Cross-Plan Offsetting in the Balance: UnitedHealth Group, Inc. Petitions the Supreme Court to Allow Cross-Plan Offsetting;...

In its decision, the Court concluded that UnitedHealth Group, Inc. (“United”) was not authorized to engage in “cross-plan offsetting.” What is cross-plan offsetting? It is a “self-help” practice that third party...more

Proskauer - Employee Benefits & Executive...

Third Circuit Upholds Health Plan’s Anti-Assignment Clause

The Third Circuit recently held that anti-assignment clauses in ERISA-governed healthcare plans are enforceable as long as they are unambiguous. The Court concluded that the anti-assignment clause clearly stated that...more

Seyfarth Shaw LLP

Out Of Network Provider’s Claim Against Health Insurer Avoids ERISA Preemption

Seyfarth Shaw LLP on

Seyfarth Synopsis: A provider that is not seeking benefits based upon an assignment of a patient’s claims under ERISA but instead is pursuing state law claims based solely on agreements and representations made directly by...more

King & Spalding

Eighth Circuit Questions Whether Cross-Plan Offsetting Violates ERISA in Recent Decision Holding that the Underlying Plan...

King & Spalding on

On January 15, 2019, the United States Court of Appeals for the Eighth Circuit considered whether certain plan documents allowed UnitedHealth Group Inc. and affiliates (“United”) to engage in a practice known as “cross-plan...more

McDermott Will & Schulte

Eighth Circuit Rejects Cross-Plan Offsetting

A recent Eighth Circuit decision regarding “cross-plan offsetting” serves as an important reminder of how ERISA’s fiduciary duties impact both employers and fiduciaries who handle claims. The case involved the common...more

King & Spalding

Eighth Circuit Rules that Cross-Plan Offsetting of Payments Is Unreasonable

King & Spalding on

On January 15, 2019, the U.S. Court of Appeals for the Eighth Circuit issued an order affirming a lower court’s ruling that UnitedHealth’s interpretation of ERISA plan documents to authorize cross-plan offsetting was...more

Kilpatrick

A New Twist in the Ongoing Out-of-Network Provider Lawsuit Saga

Kilpatrick on

The Northern District of California recently considered a case brought by a hospital against a self-funded health plan claiming the underpayment of out-of-network claims (Salinas Valley Memorial Healthcare System vs. Rocket...more

K&L Gates LLP

American Orthopedic — Third Circuit Addresses Anti-Assignment Clauses and Powers of Attorney in ERISA-Governed Health Insurance...

K&L Gates LLP on

Recently, the U.S. Court of Appeals for the Third Circuit handed the insurance industry a small victory by holding that, in American Orthopedic & Sports Med. v. Indep. Blue Cross Blue Shield, unambiguous anti-assignment...more

Robinson+Cole ERISA Claim Defense Blog

Ninth Circuit Rejects Arguments Challenging the Enforceability of an ERISA Plan Anti-Assignment Provision

In Eden Surgical Ctr. v. Cognizant Tech. Sols. Corp., No. 16-56422, 2018 U.S. App. LEXIS 10597 (9th Cir., Apr. 26, 2018), the U.S. Court of Appeals for the Ninth Circuit upheld the District Court’s Order dismissing the...more

Verrill

Near Unity Among the Circuits: Anti-Assignment Provisions are Enforceable

Verrill on

U.S. Courts of Appeals in all but four Circuits have now held that anti-assignment provisions in health insurance plans governed by ERISA are enforceable. In American Orthopaedic & Sports Medicine v. Independence Blue Cross...more

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