What An OON Provider Should Know & Do Before Preparing A Lawsuit Against Health Plan Including Lessons Learned in 2021-22 From Provider's Perspective.
It is difficult enough for a health care provider to sue a health plan when the provider is “in network”. When there is no network agreement and hence no privity upon which to base claims either for express breach or violations of implied covenants of good faith and fair dealing, then the task becomes even more onerous. Important questions must be carefully considered and answered before a decision to litigate can be made. Without a contract, how does the provider obtain standing? Has the provider strictly complied with all prerequisites required either by the health plan benefit design / summary plan description, such as exhausting administrative remedies? Has the plan administrator itself complied with all of the administrative requirements mandated by the plan design? Can a credible argument that the plan administrator has abused its discretion, violated a plan provision or an express law or regulation even be made out, let alone supported by sufficient (often substantial) evidence? Can the provider even identify the plan administrator (no; it often is not the entity adjudicating the claim)? How likely is it that a “win” will result in a favourable determination by the court instead simply of a referral back to the plan administrator for a second bite at denying the claim? How are all of these questions different when a provider considers suing a commercial health plan, a Medicare Advantage plan, a self-funded ERISA plan? Can the provider afford to sue the plan? Can it afford not to?
The best insight and instruction on these and many other important issues a provider should consider before instituting litigation against a health plan come from a review of current cases. In this informative and highly relevant program, our expert speaker Thomas Force, Esq., will present a selection of timely decisions from the past two years which frame the issues, highlight the legal and operational barriers that faced the litigating provider, demonstrate the advantages and disadvantages of various litigation strategies, and analyze the results. For the provider, the takeaway will be a comprehensive yet manageable “tool box” that will help frame the advantages as well as the disadvantages of litigating a specific issue against a particular health plan in the current legal environment.
Webinar Highlights
Who Should Attend?
This program is of real value not just for health law professionals but also for revenue cycle and patient account directors; case managers and utilization review personnel; and ‘C Suite” executives who often must make the final decision on whether or not to sue.
Date | Conferences | Duration | Price | |
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Nov 30, -0001 | How to Draft Effective Appeal Letters & To Resolve Denials Effectively? | 120 Mins | $399.00 | |
Jun 16, 2020 | How to Defend Against Insurance Company Recoupments, Repayment Demands, and SIU Audits | 60 Mins | $199.00 | |
Aug 20, 2020 | Lessons Learned from the Cigna and Aetna cases against Humble Surgical Hospital | 60 Mins | $199.00 | |
Mar 23, 2021 | The New Federal No Surprise Act – Impact on Out-of-Network Providers | 60 Mins | $199.00 | |
Apr 14, 2021 | How to Draft Appeal Letters & To Resolve Denials Effectively 2021 Updates | 120 Mins | $399.00 | |
Apr 14, 2021 | The Successful Clinical Appeal – A Guide for the reconsideration and Appeal of Medical Necessity Denials | 60 Mins | $199.00 | |
Jun 24, 2021 | An Effective Out-of-Network Workflow to Increase Reimbursement and Stay Compliant | 60 Mins | $199.00 |