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Course Details

Course Information
  • smart_display Format

    On-Demand

  • signal_cellular_alt Difficulty Level

    Intermediate

  • work Practice Area

    ERISA

Date & Time
  • event Date

    Thursday, April 18, 2024

  • schedule Time

    1:00 p.m. ET./10:00 a.m. PT

  • timer Program Length

    90 minutes

Credit Information

  • This 90-minute webinar is eligible in most states for 1.5 CLE credits.

$347.00
CLE
ALL

This CLE course will provide counsel with a thorough and practical guide to pursuing out-of-network payment claims under ERISA and state law theories. The panel will outline the conditions under which providers generally succeed in obtaining reimbursement for out-of-network claims under Section 502(a)(1)(B) and offer guidance on what factors to consider in pursuing or defending a claim. The program will also highlight efforts by out-of-network providers to assert claims that fall outside the scope of ERISA.

Faculty

Alison Lima Andersen
Partner
ArentFox Schiff LLP

Ms. Anderson’s work is primarily in the areas of ERISA and other employee benefits litigation, healthcare litigation, and complex commercial litigation. Her recent litigation work includes representing medical providers seeking reimbursement from commercial health plans and insurers; defending companies and retirement plans against breach of fiduciary duty and benefits claims; and defending several defendants accused of violating the Medicare Secondary Payer Act. She also has recent experience in municipal and corporate bankruptcy; as well as in class action cases involving claims of government lending and disability discrimination.

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David M. Mohl
Attorney
Katten Muchin Rosenman LLP

Mr. Mohl helps clients navigate the complex regulatory landscape of ERISA, the Internal Revenue Code, the Affordable Care Act, COBRA, HIPAA, and various federal and state laws affecting employee benefits. His practice covers the design, implementation and administration of employee benefit plans as well as the defense of plans and plan fiduciaries in government investigations. Mr. Mohl has significant experience representing fiduciaries in complex ERISA litigation disputes in both arbitration and class action lawsuits. He also has experience representing Taft-Hartley plans, focusing on the unique challenges that face multiemployer plans and contributing employers.

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Description

Reimbursement disputes between healthcare providers and out-of-network providers have increased sharply in recent years. These disputes involve critical legal and practical considerations that counsel must have a full understanding of to handle out-of-network payment claims under ERISA effectively.

Section 502(a)(1)(B) claims arise when health plan fiduciaries or administrators deny a claim for benefits that the plaintiff alleges are due under the healthcare plan. Multiple lawsuits challenging the billing and payment practices between out-of-network providers and health insurers emphasize the need for plans to include unambiguous anti-assignment language in health plan documents and summary plan descriptions to avoid or limit out-of-network claims and for medical providers to enter strong assignment and personal representative agreements with their patients and to engage in a fulsome benefit verification process with payors.

ERISA counsel needs a clear understanding of plan language provisions and other factors that will render out-of-network payment denials subject to a successful challenge by providers.

Listen as our experienced panel provides a practical guide to challenges to out-of-network denials under ERISA and offers practical techniques for pursuing claims.

Outline

  1. Challenges to denial of out-of-network payments based on fee-forgiveness provisions
  2. Recent cases and key arguments raised in the pursuit of out-of-network claims
  3. Bad faith claims in network negotiations as a factor in denying out-of-network reimbursement claims
  4. Factors for plaintiff counsel to consider in pursuing claims under ERISA Section 502(a)(1)(B)

Benefits

The panel will review these and other key issues:

  • What is the impact of fee forgiveness provisions in plan documents on out-of-network reimbursement claims?
  • What other factors can lead to successful challenges of out-of-network claim denials by carriers?
  • What is the anticipated impact of recent court decisions on payors' out-of-network policies?