• Insurer Challenged On Out-Of-Network Offsets
  • February 16, 2012 | Author: Matthew F. Didora
  • Law Firm: Ruskin Moscou Faltischek, P.C. - Uniondale Office
  • The situation is a common one: Mrs. Smith received treatment from her long-time physician, Dr. Goodbody. Mrs. Smith's insurance company does not have Dr. Goodbody as one of its in-network providers. Dr. Goodbody is an out-of-network provider. Fortunately, Mrs. Smith has out-of-network benefits, which she assigned to Dr. Goodbody in partial payment. Dr. Goodbody submitted a reimbursement claim to Mrs. Smith's insurer, as the assignee of Mrs. Smith's benefits. Sometime later, Dr. Goodbody received confirmation from Mrs. Smith's insurer that the services provided were covered by Mrs. Smith's policy; however, the insurer declined to pay any portion of Dr. Goodbody's claim. The insurer's decision was not based on any fact or circumstance related to Mrs. Smith or the medical necessity or adequacy of the care provided to her by Dr. Goodbody. Rather, the insurer's denial was premised upon its unilateral determination that it had overpaid Dr. Goodbody on a discrete and independent claim for services provided to an entirely different and unrelated patient.