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Medical Provider Cannot Sue For Recoupment Via Assignment – N.D. Tx.

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  • Medical Provider Cannot Sue For Recoupment Via Assignment – N.D. Tx.

    Medical Provider Cannot Sue For Recoupment Via Assignment – N.D. Tx.

    Attached hereto is a case out of the Northern District of Texas, Weiner v. Blue Cross and Blue Shield of Louisiana. In this case, a medical provider filed suit, pursuant to an assignment signed by his patient, against defendant for improper recoupment of payments made. The court ultimately found that Weiner cannot file suit on behalf of the patient due to an anti-assignment provision in the policy. The court also found that claims for recoupment cannot be brought via an assignment of benefits.

    BCBSLA also contends that Dr. Weiner is not authorized to sue under ERISA because disputes concerning recoupment are outside the scope of the purported assignments. “A healthcare provider-assignee ‘stands in the shoes of the beneficiary,’ and can only assert claims that could have been brought by patients themselves.” Brown v. BlueCross BlueShield of Tenn., 827 F.3d 543, 548 (6th Cir. 2016) (quoting Blue Cross of Cal. v. Anesthesia Care Assocs. Med. Grp., Inc., 187 F.3d 1045, 1051 (9th Cir. 1999)). According to BCBSLA, it could not recoup funds from its members; therefore, the members could not sue to recover recouped funds. And, because an assignment cannot convey more rights than the members possess, the members could not assign the right to bring suit to recover recouped funds to the healthcare provider, Dr. Weiner. See id. at 549.

    Generally, a claim regarding recoupments is not a suit to recover benefits under the ERISA plan. Rather, the claim relates to the insurer’s process of post-payment claims review and practice of recouping erroneous payments. These are claims that the health care provider’s patient-assignors could not assert as any recoupment would come from providers and not from the patients. See DB Healthcare, LLC v. Blue Cross Blue Shield of Ariz., Inc. 852 F.3d 868, 877 (9th Cir. 2017). The claims therefore do not fall within the scope of the assignments. See id. (“Although a ‘dispute ... over the right to payment, ... might be said to depend on the patients’ assignments to the Providers,’ the dispute over recoupment ‘depends on the terms of the provider agreements,’ not on the assignment.” (quoting Anesthesia Care Assocs., 187 F.3d at 1051)); Brown, 827 F.3d at 548-49 (holding that a health care provider’s claims regarding recoupment were “outside the scope of [the provider’s] assigned standing,” because “the patient-assignors are not party to the Provider Agreement that governs the recoupment process, and [the insurer] has no right to recoup payments for medical care made to its members”).

    Dr. Weiner provides services under a direct contract with BCBSTX (the “provider agreement”), and BCBSLA’s insured’s have access to BCBSTX’s provider network for services. See Dkt. No. 46 at 1. The provider agreement is not included in the summary judgment evidence, and the portions of the Plan that are included in the summary judgment evidence contain no provisions authorizing plan members to sue to recover recouped funds. See Dkt. No. 40.

    Dr. Weiner alleges that BCBSLA violated ERISA’s appeal procedures concerning the recoupment of funds that BCBSLA claimed were wrongfully paid for treatment of one patient from those due for treatment of a different patient. See Dkt. No. 8. These are claims that the patients were not authorized to assert.

    Accordingly, under the summary judgment evidence, and even if the assignments from Dr. Weiner’s patients were valid, they would not assign the right to sue for recovery of recouped funds because the patients did not possess that right.
    Attached Files

  • ealfa2
    Leila, thanks for posting. So essentially the court is holding that this is merely a contractual issue between the provider and the carrier. Not sure that would hold if the provider is non-contracted.

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