Reconciling Cigna v. Humble with Aetna v. Humble and Their Impact on the Out-of-Network Provider

Event Information
Product Format
Prerecorded Event
60 minutes
Product Description

Recent Cases and How OON Providers Can Avoid Adverse Outcomes Regarding Balance Billing, Fee Forgiveness and Referral Policies

Last year, Humble Surgery Center was involved in two major lawsuits in federal court in Texas that both dealt with out-of-network (OON) provider issues. In Cigna v. Humble Surgical Hospital, Humble won a major victory, but in Aetna v. Humble Surgical Hospital, Aetna walked away the winner. What happened, and what do these vastly different outcomes mean for OON providers and facilities today?

In this session, expert speaker Thomas J. Force, Esq. will closely examine both cases and offer advice for OON facilities on how to avoid adverse outcomes regarding balance billing, fee forgiveness and referral deals with physicians. Thomas will also outline strategies and techniques that will help you address insurance companies’ growing concerns about referral arrangements, balance billing and fee forgiveness by OON facilities. You will also be given a complete listing of essential policies and forms for your facility, and you’ll learn about current best practices for OONs. By examining a major OON facility and its experience in court with two insurance companies, Thomas will teach you how to properly set up an OON facility’s claims processing procedures and billing practices in light of these two important cases.

Session Highlights:

  • Summary of Aetna v. Humble Surgical Hospital court decision, facts, reasoning and outcome
  • Summary of Cigna v. Humble Surgical Hospital court decision, facts, reasoning and outcome
  • Discussion of why the cases differed so substantially and what OON providers can learn from them
  • Techniques to avoid insurance company scrutiny regarding patient billing and referral practices
  • Policies to have in place and current best practices to deal with OON patient billing

Agenda Details

  • Facts of Cigna v. Humble, June 2016
  • Why Cigna held up claims due to fee forgiveness
  • Humble’s counterclaim under ERISA
  • The court’s rulings on Cigna’s claim, including on referrals and use fees
  • Why this was a big victory for Humble
  • Jurisdiction and where this case is precedent
  • Impact on OON non-paid claims held up due to failure to balance bill or otherwise collect coinsurance and deductibles
  • Impact on OON balance bill audits
  • Impact on OON claims, including failure to provide plan documents and other information
  • How the court enforced ERISA appeals and claims guidelines
  • Facts of Aetna v. Humble, December 2016
  • Aetna’s claims for money had and received, fraud, negligent misrepresentation and ERISA relief
  • The court’s holding that the assignments at issue were invalid
  • Why the outcomes were so different for the same facility
  • What we can learn from the cases
  • How to handle referral schemes

Who Should Attend:

  • OON healthcare providers
  • Ambulatory surgery centers
  • Surgical centers and hospitals
  • Hospitals’ revenue recovery and billing staffs
  • Consultants for providers and facilities
  • Healthcare attorneys

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About Our Speaker

Thomas Force - Compliance Coding Expert

Thomas J. Force, Esq. is a licensed attorney since 1994 in both state and federal courts in New Jersey and New York, with 27 years of experience in the healthcare and insurance industries. He is the president and founder of The Patriot Group, a full-service healthcare physician advocacy and revenue recovery company providing billing, appeals, collections and follow-up services for healthcare. Thomas is also the former CEO, general...   More Info
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