WHAT YOU NEED TO KNOW IN A MINUTE OR LESS - For health care providers offering items and services to out-of-network (OON) patients1 in certain emergency and nonemergency settings, the federal No Surprises Act (NSA)...more
WHAT YOU NEED TO KNOW IN A MINUTE OR LESS - For health care providers offering items and services to out-of-network (OON) patients in certain emergency and nonemergency settings, the federal No Surprises Act (NSA) establishes...more
In this episode, Steven Pine and Gary Qualls discuss the arbitration provision under the federal No Surprises Act, controversy around the qualifying payment amount (QPA), a recent decision in a Texas federal court that...more
For providers offering items and services to out-of-network (OON) patients in certain emergency and nonemergency settings, the No Surprises Act (NSA) establishes a new federal independent dispute resolution (IDR) process...more
In this week’s episode, Gary Qualls discusses a recent case decided in the Western District of Louisiana, which highlights how the application of the arbitrary and capricious standard as applied to payor coverage...more
8/6/2020
/ Abuse of Discretion ,
Appeals ,
Arbitrary and Capricious ,
Blue Cross ,
Denial of Benefits ,
Denial of Insurance Coverage ,
Health Care Providers ,
Health Insurance ,
Healthcare Facilities ,
Inpatient Billing ,
Insurance Litigation ,
Medical Necessity ,
Mental Health ,
Motion for Summary Judgment ,
Physicians ,
Substantial Evidence ,
Suicide
In this week’s episode, Gary Qualls discusses the recent Louisiana federal district court decision in Crescent City Surgical Centre vs. United Healthcare of Louisiana, in which the court found that an out-of-network...more
In this article, I try to provide a simplified distillation of Crescent City Surgical Centre v. United Healthcare of La., Inc., [1] a recent dispute between a health care provider and a payor. For ease of reading, anything...more
In this episode, Gary Qualls discusses a recent development in payer litigation which implicates a number of recurring issues often raised in Employee Retirement Income Security Act (ERISA) cases. Specifically, a federal...more
2/7/2019
/ Administrative Remedies ,
Anti-Assignment Clauses ,
Assignment of Benefits (AOB) ,
Breach of Duty ,
Employee Retirement Income Security Act (ERISA) ,
Fiduciary Duty ,
Health Care Providers ,
Health Insurance ,
Hospitals ,
Motion to Dismiss ,
Patients ,
Payor Contracts ,
Plan Administrators ,
Preemption
In this episode, Gary Qualls discusses a recent development in payer litigation, regarding a provider’s recovery of Medicare Advantage payments pursuant to a Medicare Advantage contract. Specifically, a recent federal case...more
7/26/2018
/ Administrative Appeals ,
Administrative Remedies ,
Breach of Contract ,
Centers for Medicare & Medicaid Services (CMS) ,
Health Care Providers ,
Health Insurance ,
Hospitals ,
Insurer Liability ,
Jurisdiction ,
Medicare ,
Medicare Advantage ,
Medicare Advantage Organizations (MAOs) ,
Patients ,
Payor Contracts ,
Preemption ,
State Law Claims ,
Underpayment
The existence and scope of assignments of benefits from patients to health care providers continues to be critically important to a provider’s ability to challenge an insurer’s reimbursement decision under the Employee...more
Recently, the North Carolina Court of Appeals confirmed the state’s statutory peer review privilege by holding that documents produced or considered by a hospital’s Medical Review Committee (“MRC”) were protected from...more
On January 21, 2016, the United States Court of Appeals for the Fourth Circuit (the “Court”) upheld Virginia’s Certificate of Public Need (“CON”) Program against a constitutional challenge. The Appeals Court held that the CON...more