More Providers Are Leaving PPO Networks……And Suing

angrydocOver the past decade, there has been a significant increase in the number of physicians who have dropped out of Preferred Provider Organization (‘‘PPO’’) and Health Maintenance Organizations and have attempted to negotiate their own reimbursement schedules. With this growing trend we are beginning to see a wave of provider lawsuits begging for larger reimbursements.

Plan sponsors are fighting back:

“Another alternative for employers is to amend their ERISA health care plans to include an anti-assignment clause for benefits and benefit claims. If an employer fears having its plan sued repeatedly by out-of-network providers, the addition of an anti-assignment clause may bar an out-of-network provider from having standing to sue the plan in federal court.

For example, in one of the suits brought by the New Jersey orthopedic surgical providers referenced above, the ERISA plan at issue contained an express anti-assignment clause:

‘‘The right of a Covered Person to receive benefit payments under this coverage is personal to the Covered Person and is not assignable in whole or in part to any person, Hospital, or other entity nor may benefit of this coverage be transferred, either before or after Covered Services are rendered ….’’9 In that case, the court found that the out-of-network provider did not have standing as a participant or beneficiary to bring a benefit denial claim under ERISA Section 502(a)(1)(B) because that anti-assignment clause was enforceable.”

See full article here – Out of Network Strategies

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