Even if BCBSMI already paid patients of an out-of-network provider, BCBSMI must pay again directly to the out-of-network provider
Hanover Park, Illinois (PRWEB) August 19, 2013
On August 5, 2013, a federal court concludes that (1) BCBSMI must pay directly to the out-of-network provider with valid ERISA assignment, even after his patients were already paid, (2) the mistaken payments to patients did not extinguish BCBSMI obligation to pay provider under ERISA, (3) the provider’s network participation is immaterial to plan’s obligation to provide EOB, ERISA full and fair reviews and to make payment to the provider under ERISA and (4) the provider’s ERISA assignment is valid, thus entitles him to sue BCBSMI for ERISA SPD statutory penalties, although unavailable in this case. ERISAclaim.com offers new webinars to demystify the first federal court ERISA decision with making or breaking impact on all managed care models.
ERISAclaim.com new webinars will demystify this timely court decision on the national healthcare confusion: does managed care network participation or ERISA regulation truly decide our nation’s health care reimbursement system?
In this case, BCBSMI refused to recognize the ERISA assignment from an out-of-network provider, refused to provide the provider with any benefits EOB, refused to consider any appeals filed by the provider, and made benefits payments to the patients directly, according to the court document.
Both parties filed motions for summary judgment on these claims. “This appears to be a novel issue not yet addressed by any court.” according to the court document.
“This is the first time for the federal court to make the most comprehensive analysis on this decade old national confusion and to have rendered the clearest answers to date: managed care network participation is immaterial, ERISA assignment is the critical controlling factor to health-care benefits reimbursement,” says Dr. Jin Zhou, president of ERISAclaim.com, a national expert on ERISA compliance and appeals.
“While about 74% of the insured Americans in private industry have paid for out-of-network coverage, and the national healthcare expenditure is approaching $3 trillion, this court decision may be way past due but still critically timely with the trillion dollar answers,” says Dr. Zhou.
Case info: Robert Metcalf, v. Blue Cross Blue Shield of Michigan; DaimlerChrysler North America; and Daimler Trucks N.A. LLC UAW Health Benefits Plan, Case 3:11-cv-01305-ST, United States District Court District of Oregon, Portland Division, Decided 08/05113.
Among other things, as the critical significance for out-of-network provider appeals and litigation, the Court concludes the following legal points:
ERISA assignment and notice, rather PPO network participation, entitled a provider to direct reimbursement:
“As discussed elsewhere in this Opinion, defendants were on notice of the assignments entitling Metcalf to direct payment of the benefits due his patients under the Plan, irrespective of whether he was a Network Provider or Nonparticipating Provider.” according to the court document.
Even if BCBSMI already paid patients of an out-of-network provider, BCBSMI must pay again directly to the out-of-network provider:
“Thus, this court concludes that under the state law governing assignments, the debt is not discharged by the debtor who pays the assignor after receiving notice of the assignment. Even though the Plan paid benefits to the participants, its duty to pay benefits to their assignee (Metcalf) was not discharged. As a result, Metcalf, as the assignee, has a claim against the Plan for benefits mistakenly paid to each of his patients-assignors after BCBSM received notice of the assignment……That relief is available under ERISA since payment by the Plan to the patients-assignors did not extinguish the obligation to pay benefits.” according to the court document.
After the court orders BCBSMI to pay the provider directly again, and court finds the provider’s ERISA assignment is valid and entitles the provider to sue the plan for the ERISA SPD statutory penalties, but the court explains why such statutory penalties are not available in this case:
“Given this court's conclusion that he is entitled to payment of those benefits, the imposition of penalties serves no purpose other than as an excessive punishment for defendants failing to promptly correct their mistake of law. Accordingly, even if statutory penalties were available, this court would exercise its discretion against awarding them in this case.” according to the court document.
ERISAclaim.com offers advanced ERISA Compliance and Appeals training for both participating and non-participating hospitals, ASC’s and all providers, to appeal all overpayment denials, recoupment and withholdings or offseting, under the Court guidance in this case in compliance with ERIA and PPACA regulations.
To find out more about PPACA Claims and Appeals Compliance Services from ERISAclaim.com:
Located in a Chicago suburb in Illinois, for over 14 years, ERISAclaim.com is the only ERISA & PPACA consulting, publishing and website resource for healthcare providers in the country. ERISAclaim.com offers free webinars, basic and advanced educational seminars and on-site claims specialist certification programs for doctors, hospitals and commercial companies, as well as numerous pending national ERISA class action litigation support. Dr. Jin Zhou is regarded as the industry “Godfather of ERISA claims” for healthcare providers.
For any questions, please contact Dr. Jin Zhou, president of ERISAclaim.com, at 630-808-7237.