Dive Brief:
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A precedent-setting decision by the US Court of Appeals for the Third Circuit has ruled a patient's assignment of the payment of insurance benefits to their healthcare provider grants the provider the standing to sue for those benefits, reports the New Jersey Law Journal.
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The issue is critical to patients and providers because it allows treatment to take place without the concern of whether the patient can pay the provider for services up front.
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In North Jersey Brain & Spine Center v. Aetna, Aetna had argued the assignment of benefits must explicitly grant the provider the right to sue, but the appeals court said it would not distinguish between a patient's assignment of benefits and the provider's right to enforce it.
Dive Insight:
The ruling, which reverses a district court's earlier dismissal of the case, benefits patient/provider relationships in which requiring proof of the ability to pay for care in advance imposes a high burden, such as with cancer patients, the representative for the plaintiff said.
The ruling "pragmatically recognizes that when a dispute arises regarding insurance coverage for healthcare treatment, it is the doctor that is in the best position, both professionally and financially, to challenge that insurance decision, not the patient," Eric Katz of Mazie Slater Katz & Freeman, is quoted by the New Jersey Law Journal.
Aetna representative Edward Wardell of Connell Foley did not comment on the ruling.
As FierceHealthPayer notes, a recent New York law relies heavily on the same concept, as it states patients can complete an assignment of benefits form to require their provider and insurer to directly resolve payment of surprise out-of-network bills.