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Strategies and Solutions to Maximize Out-of-Network Reimbursements, Part IV: Know Who Is Paying Your Claim?

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: […]

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Does State Law Now Preempt ERISA Under The No Surprises Act (NSA)

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 […]

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No Surprises Act Regulations Part I Released

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 […]

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Court Denies BCBSAL Motion to Dismiss Based on Anti-Assignment Clause in Medical Reimbursement Dispute Finding Derivative Standing Exists Under ERISA

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 […]

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Class Action Suit Filed Against UHC for Denied Breast Reconstruction Medical Claims

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 […]

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District Court of New Jersey Remands Case to State Court Declaring ERISA Preemption Does Not Apply

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. […]

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Strategies and Solutions to Maximize Out-of-Network Reimbursements, Part III: How to Decode the True Maximum Value of a Medical Claim

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 […]

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Will the No Surprises Act be Implemented as Lawmakers Intended?

Xavier Becerra, Secretary of the U.S. Department of Health and Human Services (HHS) recently informed the House Appropriations Committee that he would be seeking feedback from stakeholders before enacting a policy to end surprise billing although he did not affirm whether he would use the formal rulemaking process. Typically, the rulemaking process sets out proposed […]

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NY Lawmakers Reignite Single-Payor Bill

Reportedly, the New York Health Act which aims to replace employer-based private health insurance and force all New Yorkers onto a government-run healthcare plan is expected to be introduced by Senator Gustavo Rivera, chairman of the state’s Senate Health Committee. It is not the first-time New York state lawmakers have tried to advance the legislation, […]

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Strategies and Solutions to Maximize Out-of-Network Reimbursements, Part II: Verification of Benefits — A Vital Process Re-Examined

While most practices understand, the first step towards obtaining optimum reimbursement from an insurance company is to operationalize a consistent and timely verification process. Even with a process in place to verify benefits, however, it is not uncommon for insurance companies to make specific representations regarding a member’s insurance coverage, that are not honored after […]

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Finding the Sweet Spot Under Surprise Bills

Congratulations to the Cohen Howard Surprise Bill team who recently handled a New Jersey Surprise Bill claim for our client, an out-of-network plastic surgeon. Following submission of our arbitration brief, the arbitrator determined our client’s final offer of $60,000 was a more fair and reasonable reimbursement for services rendered rather than the insurance company’s final […]

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Ninth Circuit Court Holds ER Providers Have Independent Legal Claim Against United Healthcare

OON Emergency Providers Challenging United Healthcare Recently, in Emergency Group of Arizona Professional Corporation, et al., v. United Healthcare, Inc., 838 Fed. Appx. 299 (9th Cir. 2021) a group of out-of-network emergency medical providers challenged United Healthcare’s (“United”) rate of reimbursement for services rendered to its members in the emergency room. The District Court found […]

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