These disputes include underpayment and denial claims, network termination challenges, allegations of improper billing practices, and disagreements over medical necessity determinations.
Claims may sound in contract, unjust enrichment, or under state prompt payment statutes.
Alternative Names:
Payer-Provider Disputes, Insurer-Provider Litigation
Why it Matters?
ERISA preemption shapes much of this litigation, because a provider suing as assignee of a member's benefits faces the limited ERISA remedy scheme while a direct contract claim does not. Structuring the claim as a breach of the provider agreement rather than a benefits claim is the recurring strategic decision. Anti-assignment clauses in plan documents are the payer's response, and their enforceability varies.
Frequently Confused with
Related terms
Frequently asked questions
Why does ERISA preemption matter?
What are anti-assignment clauses?
