News & Analysis as of

Employee Retirement Income Security Act (ERISA) Out of Network Provider Health Care Providers

ArentFox Schiff

Navigating Out-of-Network Claims: Key Takeaways for Providers From Surgery Center Case in New York Federal Court

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The US District Court for the Eastern District of New York in Manalapan Surgery Ctr., et al. v. 1199 SEIU National Benefit Fund, No. 23-CV-03525 (EDNY March 12, 2025), recently granted a motion to dismiss a complaint filed by...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

Proskauer - Health Care Law Brief

No Surprises Here!  Divergent Court Rulings Spotlight Ongoing Challenges in No Surprises Act Implementation; Tee Up Split in...

Two District Courts have reached opposite conclusions on the enforceability of arbitration awards under the No Surprises Act (“NSA”). The two decisions, while far from the final word on the subject, highlight the most recent...more

Hall Benefits Law

DOL, HHS, and Treasury Release FAQs about No Surprises Act after TMA III

Hall Benefits Law on

The U.S. Departments of Labor (DOL), Health and Human Services (HHS), and Treasury, along with the Office of Personnel Management (OPM), released FAQs about the implementation of Title I of Division BB of the Consolidated...more

Arnall Golden Gregory LLP

California Federal District Court Rules That AGG Clients’ Case Against Cigna for Institutional Practice of Under-Reimbursing...

U.S. District Court Judge David O. Carter ruled in favor of AGG’s clients on March 18, 2024, in a case involving “matters of widescale public concern” and a strong “public interest in access” to some of Cigna’s most coveted...more

Hall Benefits Law

The No Surprises Act: A Cost Saving Opportunity for Employer Plan Sponsors

Hall Benefits Law on

Benefits costs continue to increase globally, and in the midst of high inflation and potentially a recession, executives are exploring cost effective methods to manage their self-insured health plans without compromising the...more

King & Spalding

Provider Victory in Latest No Surprises Act Litigation Overturns QPA Rules

King & Spalding on

On August 24, 2023, Judge Kernodle of the Eastern District of Texas issued a fourth judgment overturning additional aspects of the No Surprises Act (NSA) rulemaking and guidance. This latest decision vacated aspects of...more

Hendershot Cowart P.C.

Texas ER Physicians Sue Insurer for Underpayment – Thousands of Claims at Stake

Hendershot Cowart P.C. on

An appeal brought before the Texas Supreme Court could unleash a wave of legal action by out-of-network ER physicians pursuing insurers for underpayment of claims. Unlike in-network providers who negotiate reimbursement...more

Jackson Lewis P.C.

Ohio’s Surprise Billing Law – Impact on Health Plans

Jackson Lewis P.C. on

Ohio’s Surprise Billing Law, R.C. § 3902.51, became effective January 12, 2022, but its impact on health plans is still evolving. The law strives to prevent patients from receiving and paying surprise medical bills,...more

Verrill

Surprise Medical Bills: Texas District Court Vacates Portion of Independent Dispute Resolution (IDR) Process in Agency Rule

Verrill on

The U.S. District Court for the Eastern District of Texas recently vacated a portion of the Requirements Related to Surprise Billing, Part II, Interim Final Rule (the “Rule”) regarding the independent dispute resolution (IDR)...more

Arnall Golden Gregory LLP

Ninth Circuit Sides With Plaintiff, Reviving $8.6M Reimbursement Suit

AGG Healthcare attorneys Matthew M. Lavin and Aaron R. Modiano recently secured a revival of an $8.6 million reimbursement suit against Cigna Health and Life Insurance. In Bristol SL Holding, Inc. v. Cigna Health and Life...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

Holland & Knight LLP

HHS Issues Interim Final Rule Implementing Certain Provisions of the No Surprises Act

Holland & Knight LLP on

The U.S. Departments of Health and Human Services (HHS), Labor and Treasury, along with the Office of Personnel Management, on July 1, 2021, issued a much-anticipated Interim Final Rule with Comment Period (IFC) –...more

Greenbaum, Rowe, Smith & Davis LLP

Federal “No Surprises Act” Brings National Oversight Of Unexpected Billing For Healthcare Services

In the waning days of Donald Trump’s administration, the federal government passed the “No Surprises Act,” which becomes effective January 1, 2022. Like many recent state laws, the legislation is aimed at protecting patients...more

Hogan Lovells

No Surprises Act prohibits balance billing, creates arbitration process for out-of-network providers

Hogan Lovells on

Effective January 1, 2022, the “No Surprises Act” signed into U.S. law as part of H.R. 133, “Consolidated Appropriations Act, 2021,” implicates (1) emergency services provided by non-participating providers at participating...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

Proskauer Rose LLP

No Surprises: Congress Enacts Surprise Bill Law and Adds Mandatory Billing Transparency

Proskauer Rose LLP on

The recently enacted Consolidated Appropriations Act, 2021 (the “Act”) not only funds the government and provides further relief in regard to the impact of the COVID-19 pandemic, but it also adopted a number of new...more

ArentFox Schiff

ERISA Does Not Bar Medical Providers from Enforcing Health Plans’ Payment Promises Under State Law

ArentFox Schiff on

Medical providers treating patients covered by ERISA-governed health plans on an out-of-network basis can assert state-law claims to hold plans to their payment promises without running afoul of ERISA’s preemption provision...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

Dorsey & Whitney LLP

The “War” Between Out-of-Network Providers and Insurers Spreads Into COVID-19 Territory

Dorsey & Whitney LLP on

ERISA litigators know that a war has been raging between “out-of-network” medical providers, on one hand, and the entities that insure and administer group health plans, on the other (collectively, “Insurers”). For years,...more

K&L Gates LLP

K&L Gates Triage: Health Care Provider v. Payor Disputes Simplified: Getting Around ERISA Preemption

K&L Gates LLP on

In this week’s episode, Gary Qualls discusses the recent Louisiana federal district court decision in Crescent City Surgical Centre vs. United Healthcare of Louisiana, in which the court found that an out-of-network...more

Seyfarth Shaw LLP

New Surprise Billing Legislation and Rules Go Into Effect on January 1

Seyfarth Shaw LLP on

New legislation passed in the 2019 session of the Texas Legislature, SB 1264, went into effect on January 1, 2020. The statute protects Texas residents from so-called surprise billing, where patients receive costly medical...more

K&L Gates LLP

Health Care Provider v. Payor Disputes Simplified: Getting Around ERISA Preemption

K&L Gates LLP on

In this article, I try to provide a simplified distillation of Crescent City Surgical Centre v. United Healthcare of La., Inc., [1] a recent dispute between a health care provider and a payor. For ease of reading, anything...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

White and Williams LLP

Cross-Plan Offsetting to Recoup Overpayments to “Out-Of-Network” Providers Held Unreasonable

White and Williams LLP on

In an opinion filed on January 15, 2019, the Eighth Circuit Court of Appeals upheld the district court’s ruling that UnitedHealth Group’s practice of recovering overpayments made to “out-of-network” providers from one plan by...more

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