Most importantly, the 5th circuit court may have signaled for a legal death penalty for all managed care practice: ERISA prohibits inconsistent plan interpretation and administration... according to Dr. Zhou
Hanover Park, IL (PRWEB) March 15, 2015
In the wake of the new landmark 9th and 5th Circuit Court out-of-network (OON) decisions and in anticipating of escalating OON provider ERISA litigation against self-insured plans, new ERISA litigation support services were announced on March 15, 2015 by ERISAclaim.com for healthcare attorneys, all out-of-network providers and self-insured ERISA plans for the No. 1 healthcare claim total denials over the patient “fee-forgiving discount”, when a out-of-network patient can’t afford to pay for full deductibles and co-insurance expenses.
On March 10, 2015, CIGNA lost court Appeals in the 5th federal appeals court and on November 5, 2014, United Healthcare of Arizona lost court appeals in the 9th federal appeals court over the court fight on whether out-of-network providers have ERISA rights to sue and whether an out-of-network patient will automatically disqualify for all benefits coverage, if unable to pay by a patient or unable to collect by providers, for full deductible and coinsurance expenses.
North Cypress Medical Center Operating Company, Limited; North Cypress Medical Center Operating Company GP, LLC, v. CIGNA Healthcare; Connecticut General Life Insurance Company; CIGNA Healthcare of Texas, Incorporated, Case No. 12-20695, in the United States Court of Appeals for the 5th Circuit, filed on March 10, 2015.
Spinedex Physical Therapy USA, et al v. United Healthcare of Arizona, et al, Case No. 12-17604, in the United States Court of Appeals for the Ninth Circuit, filed on Nov. 5, 2014.
The new ERISA OON litigation support services from ERISAclaim.com will be immediately available to healthcare attorneys, reimbursement consultants, bill and coding professionals, managed care professionals, out-of-network providers, and self-insured ERISA plans as well as third party claim (TPA) administrators. The goals of the new ERISA out-of-network litigation support services are to avoid or mitigate any costly and lengthy litigation for alleged ERISA violations, now with the new legal guidance from the federal court of appeals. The recent appeals court unprecedented landmark decisions will have profound impact on managed care model in USA, says ERISAclaim.com.
ERISA claim.com offers advanced and comprehensive discussion on the new appellate court ERISA decisions and step-by-step roadmaps on all out-of-network claims; practice and strategies for all administrative appeals, ERISA litigation and negotiations; and the unique insight of the new ERISA OON laws in addition to PPACA compliance for antidiscrimination in connection with the managed care practice.
“The recent federal court ERISA OON decisions are desperately timely for all ERISA plans and out-of-network patients and healthcare providers faced with universal claim denials and inevitable bankruptcies. These appellate courts have provided all of us with step-by-step decisive interpretations of the federal ERISA laws, for ERISA plans allegedly wanting to contain the out-of-network costs and for patients and providers allegedly wanting to exercise freedom of choice as promised by health plan and guaranteed by ERISA,” says Dr. Jin Zhou, president of ERISAclaim.com, a national expert on ERISA appeals and compliance.
“It’s a time for all of us to change, comply and go on with our healthcare lives under these unprecedented landmark appellate court ERISA decisions,” explains Dr. Zhou, for the reasons to offer these new services for both sides of ERISA benefits administration and plan participant advocates.
“Failure to do so, without compliance with OON ERISA laws, we all will have to pay,” concluded by Dr. Zhou.
On March 10, 2015, federal Appeals Court ruled against CIGNA for out-of-network provider’s ERISA right to sue and out-of-network patient’s rights to both ERISA discount and PPO discount. In a consistent holding with a recent Ninth Circuit decision on November 5, 2014 for out-of-network provider’s ERISA right to sue, for the first time, the 5th Circuit provides very specific step-by-step ERISA legal guidelines to determine whether all ERISA plans condition full coverage on collection of full deductible and coinsurance, and whether CIGNA violated federal ERISA law in its inconsistent or discriminative out-of-network practice compared to its in-network practice in its ERISA plan administration.
Most importantly, the 5th circuit court may have signaled for a legal death penalty for all managed care practice: ERISA prohibits inconsistent plan interpretation and administration, as the managed care model treats differently on patient obligation to pay deductibles when seeking care from both in-network and out-of-network providers, according to Dr. Zhou.
The 5th circuit court explains:
“Also relevant is whether Cigna denied all coverage to patients who were not charged or “billed” for their copays or coinsurance by in-network providers…..There are strong arguments that Cigna’s plan interpretation is not “legally correct,” in which case the inquiry proceeds to determine whether Cigna nonetheless had discretion to interpret the plan as it did. On a finding that the plans, read correctly, do not condition coverage on collection of coinsurance, the question would be whether Cigna nevertheless had discretion to absolve itself of responsibility for payment of the greater part of thousands of claims…” according to court document.
To find out more about PPACA Claims and Appeals Compliance Services from ERISAclaim.com: http://www.erisaclaim.com/products.htm
Located in a Chicago suburb in Illinois, for over 15 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.