Litigating Against the Out-of-Network Health Plan



Out of network providers frequently receive a higher volume of denials and audits from health insurers whose ultimate aim is to convince the out of network provider to join one of their networks where the reimbursement rates are significantly lower. As a result, many out of network providers face the real possibility of having to litigate with their patients health insurers to obtain proper reimbursement of claims for medical services. Most healthcare litigation must be conducted in federal court. Experienced litigators that understand federal ERISA laws and rules are few and far between and come with exorbitant hourly rates. This presentation aims to assist the out of network provider to make the difficult decision as to whether or not to litigate against a health insurer by providing the pros and cons of such litigation.

Learning Outcomes:
  • Provide the benefits and perils of litigation by an out-of-network provider against a health insurer
  • Arm the out-of-network provider with the necessary tools to make the decision to retain counsel to file litigation in federal court against a health insurer
  • Understand plan limitations that limit a possible damages award
  • Review the contract document and reasons for its importance
  • Explore compensatory and equitable damages
  • Possible health plan counter-claims
  • Discuss whether recovery could outweigh litigation costs
  • The Time-Investment required when litigation is commenced
  • Will court simply remand action back to the administrator if the provider wins?
  • Importance of exhausting administrative remedies
  • Know regulatory complaints
  • Understand statutes of limitations and standing to Litigate/ AOB/ Anti-Assignment clauses
  • Review required patient forms
  • Know requirement that administrative remedies be exhausted
Areas Covered in the Session:
  • The Pros and Cons of Litigation
  • Pre-Suit Strategies
  • Exhausting Appeals/ Employer Appeals
  • Regulatory Complaint
  • Statute of Limitations
  • Possible Litigation Issues
  • Possible ERISA Hurdles
  • Removal to State Court
  • Proper Parties
  • Patient Documents You Should Institute Immediately
    • Assignment of Benefits Form
    • Designated Authorized Representative Form (Carrier-Specific)
    • Email and Text Consent Form
    • Check to Patient Instructions and Financial Agreement
    • SPD and Plan Document Request Form
    • Financial Agreement
    • No Surprise Act Forms (If OON Provider Performs Services at In-Network Facility)
    • Limited Power of Attorney Form
    • Professional Courtesy Policy
    • Financial Hardship Policy
  • No Surprise Act
  • Bundling of Multiple Claims
  • Class Actions
  • Adverse Benefit Determinations
  • Clinical Reasoning
  • Entitlement To Documentation
  • Additional ABD Requirements
  • Failure To Satisfy ABD Requirements
  • Assignment and Anti-Assignment Clauses
  • Plan Exclusions
  • Coverage & Eligibility Determinations
  • Ancillary Causes of Action
  • Cross-Plan Offsetting
  • Appeal Drafting Tips
  • Live Q&A Session
Recommended participants:
  • Healthcare CEOs
  • Healthcare CFOs
  • Healthcare COOs
  • Healthcare Provider Revenue Cycle Staff
  • Healthcare provider Office Managers and Billing Staff and Companies
  • Healthcare Compliance Personnel
  • Healthcare Attorneys
  • Physicians
  • Physician Assistants
  • Nurse Practitioners
  • Surgeons
  • Hospitals and Other Facilities
  • Insurance Companies
  • Healthcare Consultants
  • Practice Manager
  • In and Out of Network Providers
  • Medical Billing Companies
  • Providers Office Staff
Presenter Biography:

Thomas J. Force is a state and federally licensed attorney with over 34 years of experience in the healthcare and insurance industries. As a former U.S. Marine and a successful Wall Street insurance litigator, Mr. Force served as General Counsel for a New York-based Accident and Health Insurance Company, where he also served as Chief Compliance Officer. These experiences led to the founding of The Patriot Group.

Mr. Force is a nationally recognized expert in revenue collection techniques, appeal strategies, and healthcare compliance. He is on the Advisory Board at Hunter Business School, a New York-based school for medical billing and coding students.

Mr. Force is an active member and frequent speaker on managed care and collection techniques for the Health Finance Management Association, several state medical associations, and other healthcare organizations.

On March 29th, 2022, Thomas J. Force, J.D, Esq, President of The Patriot Group, served as moderator for the forum on Clinical Denial Management at Hofstra University, organized by the Health Finance Management Association – Metropolitan Section.

Additional Information:

After registration, You will receive an email with login information and handouts (presentation slides) that you can print and share with all participants at your location.

System Requirement:
  • Internet Speed: Preferably above 1 MBPS
  • Headset: Any decent headset and microphone which can be used to talk and hear clearly
Can’t Listen Live?

No problem. You can get access to an On-Demand webinar. Use it as a training tool at your convenience. For more information, you can reach out to the below contact:
Toll-Free No: +1 800-757-9502