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

The webinar details attendees about the two cases involving Cigna v. Humble Hospital and Aetna v in the session.

Learn about two court cases engaging Cigna v. Humble Hospital and Aetna v. Humble Hospital in this live webinar session by expert speaker Thomas J. Force, Esq. The two cases involve an out-of-network hospital and issues dealing with billing practices. Mr. Force will detail ways the findings in these cases can affect providers on the basis of their disclosures to insurers and patients, their billing practices, and referral programs. Mr. Force will explain the attendees about each case and the appeal of the Cigna case. He will also talk about the outcomes of cases and ways they affect the financial status of the hospital.

On the basis of the above findings, our expert speaker will also instruct medical providers and their revenue recovery staff on ways to stay compliant and avoid litigation while collecting the proper amount of money from patients and their health plans. This webinar will explain ways to avoid compliance pitfalls and litigation by healthcare providers, “fee forgiveness”, “balance billing” patients, and ERISA regulations and requirements.

Session Objectives:-

The webinar will prove beneficial for the learners as it gives them insights into court cases, their findings, and strategies that will assist their practice in avoiding healthcare plan audits and litigation based upon fee forgiveness, referral arrangements, and failure to balance bill patients. As learners, you will also learn the dos and don’ts associated with how to balance the bill of your patients effectively and the implications of being non-compliant.

Learners will get an inclusive overview of what a provider is entitled to under ERISA and requires doing to stay compliant, including best practices to get claims paid by having a valid assignment of benefits, and to avoid balancing audits, overpayment demands, recoupment litigation by insurers.

Session 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 

Key Points:-

• The attendee will learn 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 manage balance billing in a compliant manner.
• The signifcance 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