Provider Reimbursement

:: Another Look At The Legality Of “Balance Billing” Practices

The federal laws which Plaintiffs argue preempt the state lien law are provisions concerning what is referred to as “balance billing.” These provisions mandate that state programs which receive Medicaid funds must only distribute those funds to providers who agree to accept those funds as payment in full and not bill individual patients for the …

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:: Disclaimer Shields Claims Administrator From Mispresentation Claims

Tenet alleges that it provided approximately $ 241,000 worth of medical services to Sylvester based on UniCare’s representation that Sylvester was covered under the Plan. . . .  Pursuant to the Managed Care Agreement, UniCare paid Tenet $ 132,827.34, the negotiated payment under the agreement, on July 27, 2005.  On August 5, 2005, Sheltering Arms …

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:: Strategic Decisions In Pleading (And Defending) Provider Reimbursement Claims – A Case Study

St. Luke’s may amend within thirty days. If St. Luke’s amends to assert an ERISA claim, the personal jurisdiction issue is far simpler.  “[U]nder ERISA’s nationwide service of process provision,” 29 U.S.C. § 1132(e)(2), “[a] court may exercise personal jurisdiction over the defendant if it determines that the defendant has sufficient ties to the United …

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:: HealthNet’s Benefit Denial Based Upon Lack Of Medical Necessity Rejected

he district court concluded that a remand was futile because the Wieners did not show that Jonathan was eligible for GHT under the standards described in IPRO’s decision, which the parties call “the FDA standard.” It is unclear whether the FDA standard defines what is “medically necessary” under the policy. The policy provides, inter alia, …

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:: Health Care Provider’s Equitable Estoppel Claims Dismissed As Contrary to Plan’s MAC Provisions

According to the express language of the Plan, “Billed charges [“the amount a Provider charges for services rendered”] may be different from the amount that [Blue Cross] determines to be the Maximum Allowable Charge for services.” Regency Hosp. of Cincinnati v. Blue Cross Blue Shield of Tenn., 2009 U.S. Dist. LEXIS 37111 (S.D. Ohio May …

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:: ERISA Plan Stands Down In “Overpayments” Dispute With Providers

ollowing an outcry from physicians and discussions with the Medical Assn. of Georgia, one of Atlanta’s largest employers has temporarily halted work by a company it hired to seek supposed overpayments from doctors. Earlier this year, Georgia-Pacific authorized Franklin, Tenn.-based Health Research Insights to send 1,100 letters to doctors in Atlanta, Savannah, Ga., and Brunswick, …

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:: Health Care Provider’s Tort Claims Preempted Under Fifth Circuit ERISA Jurisprudence

The Court did not suggest that all tort claims are completely preempted by ERISA wherever there is an assignment of patient benefits, only that Plaintiffs’ claims in this case were so preempted under controlling Fifth Circuit law. See Transitional Hosps. Corp. v. Blue Cross & Blue Shield of Tex., Inc., 164 F.3d 952, 954 (5th …

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:: Eleventh Circuit Applies Supreme Court’s Davila Test To Health Care Providers’ “Hybrid” Claims

While similar to the Butero test, Davila refines Butero by inquiring about the existence of a separate legal duty, which is not a consideration under Butero. Moreover, a number of other circuits have recognized Davila’s two-part test as the proper test for complete preemption under ERISA . . . In accordance with the Supreme Court’s …

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:: Health Care Providers’ RICO Claims “Reversed Preempted”

Plaintiffs argue that Medical Mutual, in its processing of insurance claims, violated the federal RICO statute. Specifically, Plaintiffs allege that Medical Mutual “acted to delay, diminish and deny payment of . . . lawful claims of patient-insureds as submitted by out-of-network health providers . . . through a scheme or artifice, utilizing the U.S. Mail …

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