Recoupment Demand Based Upon Health Insurer's Misunderstanding Promptly Resolved

Health insurance companies are quick to accuse and often unwilling to admit mistakes. So when a leading health insurer demanded that thousands of dollars be refunded based upon its misunderstanding of the nature of a provider’s practice and the role of the various physicians involved, it seemed as though it would impossible, without a lawsuit, to change the insurer’s mind. The physician and his practice partners hired QLG to see if the situation could be rectified.

We investigated the merits of the matter and then communicated with the insurer about the legal landscape as to ERISA’s applicability. The purpose of using ERISA here was to show the health insurance company that even if it was right about its concerns, it still had no legal basis to demand a refund of monies previously paid based upon issues relating to patient supervision, the concern of the insurer here.

ERISA actually “takes over” — or what the law calls “preempts” all other law, including certain portions of an in-network doctor’s provider agreement with the insurance company. Once the sections of the provider agreement relied upon by the insurer are preempted, those provisions cannot be used by the health insurer to seek a refund of monies previously paid.

In the current matter, we used various ERISA legal principles and arguments on the facts and the merits to get the insurer — without litigation — to reverse course and give up its claim for money back, with our client paying no refund to the insurer whatsoever.

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