Provider Reimbursement

: : May A Grant of Authority As An Attorney In Fact On A Health Care Provider Confer Standing?

“In 2018, the Third Circuit held in American Orthopedic & Sports Medicine v. Independence Blue Cross Blue Shield, that “anti-assignment clauses in ERISA-governed health insurance plans as a general matter are enforceable.” 890 F.3d 445, 453 (3d. Cir. 2018). Here, Patient’s plan contains an anti-assignment clause. Plaintiff agrees with Defendants that anti-assignment clauses are “valid …

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: : Primer Provider Reimbursement Pleading To Avoid Motion To Dismiss

“Before the Court is Defendants Cigna Healthcare Inc., Cigna Health and Life Insurance Co., Connecticut General Life Insurance Co., and Cigna Healthcare of Arizona’s (collectively, “Cigna”) Motion to Dismiss. In October 2018, PSCC received a letter from Cigna that it had “conducted an internal audit and determined that PSCC had damaged Cigna in an amount …

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: : Plaintiff May Proceed On ERISA Claims Challenging Repricing of Provider Claims

Through this matter, Plaintiffs are attempting to stop Defendants allegedly improper practice of underbilling for chiropractic services that Plaintiffs provided to their patients. Presently before the Court are motions to dismiss the First Amended Complaint filed by the . . . Defendants. Plaintiffs allege that the Cigna and Aetna Defendants hired the Vendor Defendants to …

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: : Provider’s Claims Against CIGNA Dismissed For Failure to Allege Existence of Assignment of Benefits By Plan Participants

By the statute’s terms, only a “participant or beneficiary” may bring a claim. Pascack Valley Hosp. v. Local 464A UFCW Welfare Reimbursement Plan, 388 F.3d 393, 400 (3d Cir. 2004). Nonetheless, a healthcare provider may bring claims if it has a valid assignment of benefits from a plan participant. CardioNet, Inc. v. Cigna Health Corp., …

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: : Court Remands Insurer’s Recoupment Claims Against Provider to State Court Applying Davila Test

Here, plaintiff seeks damages in the amount of $226,562.62, which it contends make up the unpaid balance of overpayments to Dr. Gupta. BCBSLA’s complaint does not seek a constructive trust or an equitable lien on particular funds. Rather, it seeks to recover from Dr. Gupta’s assets generally. Thus, the Court finds that plaintiff’s claims are …

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: : Assurances of Payment of Surgeon At R & C Rates By CIGNA Prove Unreliable

A surgeon at California Spine performed three surgical procedures on J.R., and then “billed Defendants for these services . . . using his standard rates for such services.” California Spine’s “charges for the surgery totaled $37, 000, ” which, the complaint alleges, “reflected the reasonable and customary value of the services at issue.” Neither Cigna …

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:: 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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