Court Authorizes ERISA Rights for Out-of-Network Providers regardless of non-PPO Discount - ERISAclaim.com Demystifies

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On March 10, 2015, a federal appeals court ruled against CIGNA for out-of-network provider’s ERISA right to sue, regardless of a non-PPO Discount Agreement due to ERISA preemption. ERISAclaim.com announced a series of brainstorming classes to assess the profound impact of this landmark case law.

Out-of-network providers received re-pricing and discount requests every day, with little or no options.” says Dr. Zhou,

On March 10, 2015, a federal appeals court ruled against CIGNA for out-of-network provider’s ERISA right to sue for all eligible payments under the plan terms, regardless of any non-PPO Discount Agreement, as usually negotiated by middlemen on behalf of CIGNA. All non-PPO discount agreements will be preempted by ERISA if “[t]he contracts by their terms are subject to the underlying ERISA plans”. As a result of this legal breakthrough, on March 16, 2015, ERISAclaim.com announced a series of new special brainstorming training classes to demystify and assess this unprecedented ERISA managed-care paradigm shift, for all extremely concerned parties, healthcare providers, managed care re-pricing negotiators and self-insured health plans as well as TPA’s.

“The unanticipated but inevitable legal and economic impact of this appellate court decision may fundamentally change our nation’s healthcare landscape under managed-care model. Federal ERISA laws, rather than managed-care contracting for in-network providers and re-pricing negotiation for out-of-network providers, will make or break our healthcare system,” says Dr. Jin Zhou, president of ERISAclaim.com, a national expert on ERISA appeals and compliance.

“Immediately under this appellate court case law, every out-of-network provider with a valid ERISA assignment may sue in federal court for all eligible payments under the terms of the plans, regardless of any previous non-PPO negotiated discount contracts,” predicted Dr. Zhou.

Case Info:
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.
http://www.ca5.uscourts.gov/opinions%5Cpub%5C12/12-20695-CV0.pdf

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.
http://cdn.ca9.uscourts.gov/datastore/opinions/2014/11/05/12-17604.pdf
The 5th Cir. identifies non-PPO discount agreement connection with ERISA plans, as “[t]he contracts by their terms are subject to the underlying ERISA plans”. The Court explains:

“We turn next to the grant of summary judgment against North Cypress’s state contract law claims. According to the hospital, Cigna breached the terms of the “Discount Agreements”—contracts between North Cypress and Cigna requiring Cigna to pay a negotiated amount for specific insurance claims. The contracts by their terms are subject to the underlying ERISA plans.” according to court document.

The 5th Cir. addresses the district court’s ERISA superpower preemption discussion and no ERISA preemption finding for non-PPO Discount Agreement between CIGNA and North Cypress:

“The district court first addressed whether the Discount Agreement claims were preempted by ERISA, which “supersede[s] any and all State laws insofar as they may now or hereafter relate to any employee benefit plan.” This provision is “intended to ensure that employee benefit plan regulation would be ‘exclusively a federal concern,’” and as such, the Supreme Court has commented that the preemption provision is “conspicuous for its breadth” and is “deliberately expansive.” Nonetheless, the district court found that the contract law claims were not preempted because North Cypress could not bring the claims under ERISA….The court went on to rule on the merits, finding no breach because Cigna was entitled to reduce payment under the terms of the “Discount Agreement” contracts,” according to court documents.

The 5th Cir. vacated the district court’s no ERISA preemption decision and found for North Cypress ERISA legal standing to sue, and remanded for ERISA preemption consideration for non-PPO Discount Agreement contracts:

“In holding that North Cypress has standing to bring ERISA claims, we removed the foundation of the district court’s preemption ruling. The parties have not briefed the issue of whether the Discount Agreement claims nonetheless survive un-preempted. Accordingly, we vacate the grant of summary judgment and remand so that the district court may consider the question of preemption in light of our ruling on standing.” according to court document.

“Out-of-network providers received re-pricing and discount requests every day, with little or no options.” says Dr. Zhou, “Now, the federal appellate court clarifies for out-of-network provider’s ERISA legal standing to sue and that no managed care contracting or re-pricing discount agreement can substitute or replace ERISA claim regulation.”

To find out more about PPACA and ERISA 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.

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