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Payers are Using ERISA to Challenge Provider Reimbursement Actions

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by Stacey Zill
California Health Law News
Winter 2015

Stacey Zill's article, "Payers are Using ERISA to Challenge Provider Reimbursement Actions," was published in the Winter 2015 issue of California Health Law News.

From the article...

"Consider this scenario: A California provider delivers care and treatment to a patient enrolled in an employee medical benefits plan, after informing the payer that the services will be provided, confirming coverage, and receiving authorization from the payer. Subsequently,invoices are sent to the payer, which tenders the provider an amount that falls significantly short of what is reasonable and customary. The provider then opts for a lawsuit in a California court, seeking reimbursement for the shortfall. Before the provider argues what it should have been paid, it must first tackle the Employee Retirement Income Security Act of 1974,1 (ERISA), which may be the payer’s first line of defense. If the case is not already in federal court, ERISA likely will be used to invoke federal question subject matter jurisdiction. Once in federal court, ERISA will generally to be used as a ground to request dismissal."

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