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As previously indicated, several lawsuits have been filed challenging the rules under the No Surprises Act regarding the presumption for Independent Dispute Resolution (arbitration) that the Qualified Payment Amount (QPA), the median in-network contract rate, is the proper reimbursement for out-of-network services covered under the No Surprises Act. On December 9, 2021, a new lawsuit […]

Concerns About the Federal No Surprises Act: Interim Final Rules According to an article published by KHN, the federal agencies responsible for issuing the regulations for the implementation of “the No Surprises Act” (NSA) have publicly acknowledged that the concerns raised by legislators, providers and medical associations over the federal legislation have been heard. However, […]

For years, insurance companies have operated networks of physicians and facilities which they pair with company benefit plans and their own insurance policies to facilitate “in-network” coverage for members.  Physician networks are marketed by insurance companies to providers on the basis that joining a network will bring increased volume to the practice at a discount […]

The Women’s Health and Cancer Rights Act (WHCRA), passed by Congress in 1998 and adopted as part of the Employee Retirement Income Security Act (ERISA), was enacted to protect women from abuses related to health plan coverage for a mastectomy and breast reconstruction following a mastectomy. The Act requires that any group health plan providing […]

The Departments of Health & Human Services (HHS), Labor, and the Treasury together with the Office of Personnel Management (OPM) issued, on September 10, 2021, a second set of regulations under the No Surprises Act (NSA). The proposed rule outlines the audit and enforcement actions that apply to insurers, healthcare providers and facilities for non-compliance […]

At face value, it seems logical that insurance companies are responsible for paying health benefit claims. But are they? Determining the entity responsible for paying claims requires an understanding of how health benefit plans are structured and governed. In the US, most private-sector employers offer employees the opportunity to participate in a health benefit plan: […]

The No Surprises Act (NSA) becomes effective on January 1, 2022 and will apply to virtually all commercial medical claims covered by ERISA, Non-ERISA, self-insured and fully insured plans for (1) emergency care performed by an out-of-network provider, (2) out-of-network post-stabilization care during the same facility visit or (3) non-emergency care provided by an out-of-network […]

On July 1, 2021, the Department of Health and Human Services (HHS), the Department of Labor, and the Department of the Treasury issued part I of the regulations in connection with federal No Surprises Act that protects patients from surprise medical bills and is due to go into effect January 1, 2022.  The agencies have […]

Our client, an out-of-network orthopedics practice group, filed a lawsuit against Blue Cross Blue Shield of Alabama (BCBSAL) to dispute the medical reimbursement for a spinal surgery performed on July 12, 2016. The patient in the suit had coverage under a self-funded plan, administered by BCBSAL, and thus governed by the Employee Retirement Income Security […]

We are pleased to share news of a class-action lawsuit filed against United Healthcare (UHC), in a New Jersey federal court, concerning its ongoing denial of reimbursement for co-surgeons (CO) and assistant surgeons (AS) when performing a DIEP Flap reconstructive procedure for breast cancer patients, following a mastectomy. For several years, our firm has challenged […]

In a recent decision by the District Court of New Jersey between our client, an out-of-network New Jersey based medical practice and Aetna regarding services related primarily to emergency care, the Court granted our client’s motion to remand the matter to the state court of New Jersey and denied Aetna’s motion to dismiss the case. […]

True Market Value® is pricing tool developed by the car industry (Edmunds) to help consumers navigate the complicated process of negotiating a fair price for a new or used car.  This concept can be adapted by out-of-network providers to calculate the true maximum value of a claim. By setting clear expectations with your staff, you […]