Court Authorizes ERISA Anti-Discrimination Rights for Out-of-Network Patients - 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 on behalf of a patient and to challenge plan’s ERISA anti-discrimination violations. ERISAclaim.com demystifies this final court victory for all out-of-network patients and providers.

“This is not just about Cigna, it is for all health plan sponsors, administrators, TPA’s, insurance companies, providers and patients as well as attorneys,” added Dr. Zhou.

On March 10, 2015, federal Appeals Court ruled against CIGNA for out-of-network provider’s ERISA article III legal standing and ERISA anti-discrimination rights to sue and to challenge “whether Cigna denied all coverage to patients who were not charged or “billed” for their copays or coinsurance by in-network providers.” On March 23, 2015, ERISAclaim.com announces new PPACA and ERISA compliance seminars and litigation support services to assess the 5th Circuit Court decision, and to explore PPACA’s anti-discrimination protections and remedies for all out-of-network patients and providers under PPACA SEC. 2706 Non-Discrimination in Health Care, also known as Obamacare Anti-Discrimination Patient Protections.

The new PPACA and ERISA anti-discrimination compliance program is designed to research, educate, outreach, and comply with ERISA and PPACA, and to prevent costly and lengthy PPACA and ERISA litigations in health benefits administrations, as the Patient Protection and Affordable Care Act (PPACA) claims regulation adopted ERISA claim regulation in its entirety for all health plans since September 2010, according to Dr. Jin Zhou, president of ERISAclaim.com, a national expert on ERISA appeals and compliance.
http://webapps.dol.gov/FederalRegister/PdfDisplay.aspx?DocId=24056

Specifically, this new PPACA and ERISA anti-discrimination compliance program will assess the 5th Circuit court decision, and brainstorm on the PPACA Non-discrimination mandate under PPACA §2706:

PPACA SEC. 2706. NON-DISCRIMINATION IN HEALTH CARE.

‘‘(a) PROVIDERS.—A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider’s license or certification under applicable State law.”
http://www.dol.gov/ebsa/pdf/affordablecareact.pdf

PPACA §2706 specifically prohibits plan’s discrimination against any health care providers solely based on their participation in plan TPA’s PPO networks with respect to health plan coverage when they are acting within the scope of their license under state laws, explains Dr. Zhou.

The 5th Circuit Court rules on whether Cigna’s “‘fee-forgiving protocol’ to reduce payments” violated ERISA anti-discrimination laws:

“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.\62\...\62\ Another factor to consider at the “legal correctness” stage is “whether the administrator has given the plan a uniform construction.” The third is whether “unanticipated costs” result from the various plan interpretations.” according to court document.

“Under this landmark 5th Circuit Court ERISA decision, for the first time, the federal appeals court clarifies ERISA anti-discrimination protections for both in-network and out-of-network patients, and the court decision may have exposed the fundamental legal flaws in our nation’s managed care business model,” says Dr. Zhou.

“This is not just about Cigna, it is for all health plan sponsors, administrators, TPA’s, insurance companies, providers and patients as well as attorneys,” added Dr. Zhou.

In a holding consistent 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.

The court explains whether CIGNA violated ERISA: “The inquiry is thus whether ordinary plan members who read that “payment for the following is specifically excluded from this plan: . . . charges for which you are not obligated to pay or for which you are not billed,” would understand that they have no insurance coverage if they are not charged for coinsurance. That is, would a plan member understand the language to condition coverage on the collection of coinsurance, rather than simply describing the fact that the insurance does not cover all of a patient’s costs…..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.” according to court document.

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

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.

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Jin Zhou, President
ERISAclaim.com
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