Lessons Learned from the Cigna and Aetna Cases Against Humble Surgical Hospital

Thomas J. Force, Esq.

Thomas J. Force, Esq.

As a state and federally licensed attorney in both New Jersey and New York, Mr. Force has over 30 years of experience in the healthcare and insurance industries. His success as a Wall Street insurance litigator and his tenure as General Counsel for a New York-based Accident and Health Insurance Company where he served as Chief Compliance...
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60 Mins
Thomas J. Force, Esq.

Guidance for Balance Billing and the Out-of-Network Healthcare Provider

This information-packed webinar by expert speaker Thomas J. Force, Esq. will discuss two court cases involving Cigna v. Humble Hospital and Aetna v. Humble Hospital. The facts of the cases and findings and holdings of the Courts will be discussed and explained. Both cases involve an out-of-network hospital and issues with its billing practices. Mr. Force will explain how the findings in these cases can impact providers based upon their disclosures to insurers and patients, their billing practices, and referral programs.  Mr. Force will walk the attendees through each case and the appeal of the Cigna case. He will discuss the outcomes of the cases and how they affected the financial status of the hospital.

Based on those findings, Mr. Force will instruct medical providers and their revenue recovery staff on how to maintain compliance and avoid litigation while collecting the proper amount of money from patients and their health plans. This session will explain how you may avoid compliance pitfalls and litigation by health plans. There will be an analysis of litigation pertaining to out-of-network healthcare providers, “fee forgiveness”, “balance billing” patients, and ERISA regulations and requirements.

Webinar Objectives

By attending this informative session, you will learn important court cases, their findings, and strategies that will assist your practice in avoiding health plan audits and litigation based upon fee forgiveness, referral arrangements, and failure to balance bill patients. You will learn the dos and don’ts regarding how to effectively balance bill your patients and the implications of being non-compliant.

Attendees will get a comprehensive overview of what a provider is entitled to under ERISA and needs to be doing to remain compliant, including best practices to get claims paid by having a valid assignment of benefits, and to avoid balance billing audits, overpayment demands, recoupment, and litigation by insurers.

Webinar Agenda

  • The background and facts of the Cigna v. Humble case
  • The Court findings of the Cigna v. Humble case
  • The background and facts of the Aetna v. Humble case
  • The Court findings of the Aetna v. Humble case
  • The Appeal of the Cigna v. Humble case
  • The cases involve an out-of-network hospital and its billing practices and referral programs
  • The issues in the cases involve allegations of fee-forgiving by the provider, overpayment claims, fraud and misrepresentation and referral and use fees.
  • The cases also address the providers’ rights under ERISA, including full and fair review of its claims and the right to receive plan documents
  • Texas law prohibits hospitals from billing patients and health plans differently (Tex. Ins. Code § 1204.055; Tex. Oee. Code § 101.201); hence the claims submitted to Aetna were fraudulent.
  • What type of arrangement is considered a kickback to physicians
  • What happened to Humble Hospital as a result of the litigations
  • A discussion of ERISA 

Webinar Highlights

  • The attendee will learn why they should never agree in advance to waive or limit cost-sharing from patients and not make promises that they will be the same or better off than if they used in-network facilities.
  • Any financial assistance policies must be uniformly applied and allow for reasonable verification of the applicants’ information. Why Payment plans, if offered, should be without interest.
  • How to handle balance billing in a compliant manner.
  • The importance of making proper disclosures that you are “out of network”.
  • Importance of patient signed, valid assignment of benefits that also includes the right to pursue all of the members’ legal and equitable remedies as “beneficiaries” of a plan.
  • Personal payment obligation agreements for any claims for services later denied payment as “not covered” or for which the patient was ineligible on the dates the services were performed
  • If an ERISA plan grants to the plan administrator the “discretion” to interpret and apply plan language, the administrator may exercise that right in any way that is reasonable and that is supported by the facts even if others – including a court - reasonably may disagree.
  • The dangers of referral programs.
  • Plans cannot stop paying claims as otherwise required by contract or by law simply because there is a pending balance billing audit of the provider.
  • Until a plan has processed a claim and issued an explanation of benefits, a provider cannot determine the allowable amounts necessary to calculate the balance personally due to the plan members/patients.
  • Insurers must respond to demands made by providers for plan documents and other documents under ERISA and the failure of the insurer to do so when specifically requested constituted “bad faith”.

Who Should Attend

  • Medical Practices – Owners and Revenue Cycle personnel
  • Medical Facilities- Owners and Revenue Cycle personnel
  • Healthcare Consultants
  • Healthcare Attorneys
  • OON healthcare providers
  • Ambulatory surgery centers
  • Consultants for providers and facilities
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