The Out-of-Network Co-Pay Conundrum: To Waive or Not to Waive … and How?

Becker’s ASC Review

Gary W. Herschman, a Member of the Firm, and John D. Barry, an Associate - in the Health Care and Life Sciences practice, in the firm’s Newark office - co-authored an article in Becker’s ASC Review, titled “The Out-of-Network Co-Pay Conundrum: To Waive or Not to Waive ... and How?”

Following is an excerpt:

A recent federal court ruling in Texas highlights a growing trend of private insurers scrutinizing “out-of-network” providers that waive patients' cost-sharing amounts.

On February 15, 2017, the court ruled that Cigna can move forward with its suit to recoup $8 Million in alleged overpayments from a network of ambulatory surgery centers. Cigna alleges that the Employee Retirement Income Security Act of 1974 (“ERISA”) and various state law prohibitions against fraud and negligent misrepresentation were violated when the surgery centers improperly submitted claims to Cigna because the centers had waived patients' financial responsibilities related to out-of-network services. This pending case is one of a handful of recent cases involving insurers suing providers that routinely forgive patient responsibilities for services provided out-of-network.