The Out-of-Network Battle Heats Up Further - Recent Ruling Favors Providers

Vorys attorneys Jonathan Ishee and Kristen Shemory authored an article for the American Bar Association's Health Law Section. Their article focuses on the battle between providers adopting an out-of-network strategy and commercial payors.

The article states:

"This battle reflects the growing trend of insurance companies suing out-of-network private providers on the basis that any copayments or out-of-network fees waived by the private providers when treating an insured cannot later be sought from the insurance company in reimbursement. These cases have largely settled before verdict, making it difficult to ascertain if payors would prevail on such claims. This article discusses a recent case, Connecticut General Life Insurance Company, et al., v. Humble Surgical Hospital, LLC, and the court’s rationale for ultimately denying all of Cigna’s alleged claims.

It is not unusual for health plans to attempt to contain costs from out-of-network providers. However, health plans must avoid discriminating against out-of-network providers in denying claims and ensure that their insureds’ right to choose a healthcare provider is not unfairly impeded. As discussed in our previous article,¹ Humble Surgical is not the first case to litigate out-of-network provider claim denial practices by health plans,² but it is one of the first cases in which a court has issued a ruling in favor of a provider."

To read the full article, click here.