Insights on Managed Care, Payer Disputes & Reimbursement

Medical providers treating patients covered by ERISA-governed health plans on an out-of-network basis can assert state-law claims to hold plans to their payment promises without running afoul of ERISA’s preemption provision (ERISA § 514(a), 29 U.S.C. § 1144(a)).

For health care providers that are out-of-network with a patient’s insurance, navigating reimbursement is a tactical imperative. The current economic environment makes it more difficult for patients to pay coinsurance, while insurers are increasingly motivated to cut expenses.

Below are six reimbursement issues that health care providers should be on “high alert” for as the COVID-19 crisis persists.

“Save the ER for emergencies – or you’ll be responsible for the cost.” This warning was included in a 2017 letter Blue Cross and Blue Shield of Georgia, Inc. (BCBS) sent to its insureds, alerting them to a new policy for reviewing and paying emergency room medical claims. 

Lawmakers remain in negotiations among the three key committees in the House of Representatives: Energy & Commerce, Ways & Means, and Education & Labor, along with the Senate Committee on Health, Education, Labor and Pensions (HELP), about the best way to address surprise medical bills.