A federal court decision was made against UnitedHealthcare (UHC) on Feb 8, 2012, for an out-of-network surgical center in a UCR fee dispute. The court found for the provider’s right to sue under ERISA and ordered UHC to produce a master plan document and outpatient facility index in 20 days. The court found for UHC on SPD penalty as UHC has provided SPD to the plaintiff. The court remanded the case to the plan to reconsider provider’s ERISA appeal in 60 days by “substantiating the reasonableness and accuracy of any information from third parties that it relies upon" related to Viant.

"This court decision is extremely important for every out-of-network provider in the nation with respect to how to get paid under federal law ERISA for UCR denials, in advocating patients’ right for the access to the covered healthcare services when they needed the care most," says Dr. Jin Zhou, president of ERISAclaim.com, a national expert on PPACA and ERISA appeals and compliance. “The most important aspect of this decision is the court order for the plan/UHC to produce master plan document to the out-of-network provider in 20 days, as this has profound impact on all ERISA litigations and may change the outcome of most providers lawsuits.

“UCR dispute is a partial claim denial and an adverse benefits determination under ERISA. The only way to get paid properly is to comply with ERISA appeal procedures with a valid ERISA assignment, and to sue under ERISA if necessary," Zhou explains.

The court case info is EDEN SURGICAL CENTER v. CENTRIC GROUP, Case No. CV 10-07024, United States District Court, C.D. California. Feb. 8, 2012. According to the court document, “Centric Group, LLC ("Centric") maintains the Centric Group Health Benefit Plan ("Plan") for its employees. Centric is the Plan Administrator for the Plan, and United Healthcare ("UHC") is the third-party claims administrator."

The court rejected UHC's argument as "absurd" and found for provider’s right to payment and right to sue for failure to pay. “There is no dispute that this provision constitutes a valid assignment ... Based on this valid assignment, the Ninth Circuit found that the doctor had standing to sue for deficiencies in payment. Id. at 1379. The pertinent facts in Misic are strikingly similar to those of the current case. Moreover, it is well-established in California that courts should interpret contractual language in light of the facts and circumstances, and in a reasonable and practical manner so as to avoid absurdity and invalidity. Sayble v. Feinman, 76 Cal.App.3d 509 (1978). Applying those principles, the Court finds that the provision conferred to Plaintiff all the rights coterminous with the right to payment of benefits, including the right to appeal and sue for failure to pay. Finding otherwise would lead to an absurd result: a right to a party's payment, but no recourse against that party should it fail to pay. For these reasons, the Court finds that Plaintiff has standing in this action."

The court found UHC violated ERISA for failing to timely respond to the provider’s ERISA appeal: “Based on the evidence contained in the Administrative Record, it appears that UHC made its benefits determination based on the adjusted "reasonable and customary" amounts calculated by Viant. Plaintiff made a proper and timely appeal of the benefits determinations.6 The Plan provides that a final decision will be rendered no later than 45 days from the date the written appeal is received. The Administrative Record indicates that no final decision was ever communicated to Plaintiff. Therefore, the Court finds that Defendants failed to comply with the Plan requirements for processing appeals."

The Court ruled as follows:

“(1) The Court hereby remands Plaintiff's claim for benefits to the Plan Administrator to review Plaintiff's appeal. In doing so, the Plan Administrator must reconsider any relevant information, including any information it may need to justify its determination. Furthermore, the Plan Administrator must diligently exercise its discretion by substantiating the reasonableness and accuracy of any information from third parties that it relies upon. The Plan's decision shall be rendered within 60 days from the date this Order is entered.
(2) Pursuant to 29 U.S.C. §§ 1024(b) and 1133(2), Centric shall produce the Master Plan Document and Outpatient Facility Index within 20 days from the date this Order is entered.
(3) The Court will not impose statutory penalties pursuant to 29 U.S.C. § 1132 (c)."

“Master plan document and outpatient facility index are the most important documents under ERISA for UCR definition and determination," states Vincent Flores, a certified PPACA and ERISA claim specialist, and VP of YF Corp. in Los Angeles.

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