Cigna v. Humble– Impact on Balance Billing and OON Providers

Event Information
Product Format
Prerecorded Event
60 minutes
Product Description

Recent Ruling of Cigna v. Humble is a Victory for Out-of-Network Providers

In a recent landmark decision for out-of-network (OON) providers nationwide, a federal judge in Texas ruled against Cigna and ordered the insurer to pay $11.4 million to cover underpaid claims, and an additional $2.3 million in ERISA penalties. This is the first instance in which a claims administrator was ordered to pay ERISA penalties to a medical provider.

In what will most likely result in a major shift in the treatment of OON reimbursement and claims processing, the court ruled that Cigna could not deny claims based on the purported waiver by Humble of patients’ deductibles, co-pays or co-insurance. According to the court, Cigna had no right under ERISA to absolve itself of its responsibility to pay the claims because it assumed that it could demand upfront payment of deductibles, co-pays and co-insurance.

OON providers need to understand the significant impact of this court decision on their ability to compel health insurers to pay OON claims correctly. Join expert speaker and licensed attorney Thomas J. Force, Esq. in this informative session to get an easy breakdown of this complicated decision and how it impacts OON providers.

This 60-minute session is packed with tips and tricks regarding balance billing issues in the wake of this important victory for a physician-owned hospital.

Session Highlights:

  • A clear analysis of the Cigna v. Humble Surgical Hospital decision
    • Facts of the case, and why they matter
    • How fee forgiveness played a part
    • Details on the lawsuit under ERISA
    • The court’s rulings on Cigna’s claims and Humble’s counterclaims
    • The big victory for Humble
    • Jurisdiction: Where is this case considered precedent?
    • Impact on OON non-paid claims held up due to failure to balance bill/collect coinsurance and deductibles
    • Impact on OON balance bill audits
    • Impact on OON claims
    • How the court enforced ERISA’s appeals and claims guidelines
  • How this new development redefines “fee-forgiving”
  • How the court viewed balance billing
  • ERISA violations for the insurance company based on its bad faith actions
  • How providers can protect themselves from similar situations

Who should attend

  • Healthcare executives
  • Physicians
  • Front office and billing staff
  • Revenue cycle personnel
  • Practice managers
  • Compliance professionals & 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 counsel and...   More Info
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