Court decides whether insurers can be sued for underpaid claims

The ruling of a U.S. court of appeal last month weighed whether physicians who are assigned insurance policy benefits have the right to bring lawsuits against insurers that fail to pay correctly for medically necessary services provided to covered patients. The decision was a victory for physicians and patients. The appeals court concluded that an assignment of the right to payment is sufficient to confer standing to sue under the Employee Retirement Income Security Act of 1974 (ERISA). In so doing, it resolves several conflicting lower court rulings. The trial court decision: Easy assignment to ERISA claims denied The North Jersey Brain and Spine Center (NJBSC) operated on three patients who were insured under employee benefit plans administered by Aetna. NJBSC obtained assignments “to all payments for medical services rendered” from each of these patients. All three surgeries were medically necessary and authorized by Aetna, yet the insurer denied or underpaid each of the claims. NJBSC appealed to Aetna without success and so filed a suit under ERISA. A district court agreed with Aetna that the current assignments were insufficient. More specific language was required for patients to assign their full policy benefits to physicians, which would allow physicians to assert ERISA benefit claims. The trial court’s ruling essentially meant that standard assignments of benefits weren’t sufficient to give physicians grounds to file a lawsuit. Instead, physicians w...
Source: AMA Wire - Category: Journals (General) Authors: Source Type: news