Health Alert February 2012 -- Insurer Challenged On Out-Of-
Network Offsets   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.