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North Cypress Medical v. Aetna Life Insurance Co.

Court: 5th Cir  07/31/2018  Fifth Circuit Affirms Out-of-Network Provider's Discount Billing Scheme as Non-Fraudulent

The Fifth Circuit affirmed that an out-of-network healthcare provider's billing scheme, which offered patients a "prompt payment" discount that ultimately resulted in costs to the patient equivalent to typical "in network" costs but greater costs paid by the health insurer, did not constitute fraud or misrepresentation by the provider where insurer could not establish any element of fraud claims, but that provider could not recover against insurer for its ERISA claims because there was no evidence of underpayment under the healthcare plan.

health insurance, out-of-network, in-network, healthcare billing scheme, ERISA claims, fraud, misrepresentation, prompt payment discount

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