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February 03, 2022

Provider's Claims for COVID-19 Screening Charges Move Forward

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Key Takeaways

  • A district court in Texas has found that a provider may proceed with its lawsuit to recover the full amount of its charges for COVID-19 diagnostic testing under the FFCRA and CARES Act from an insurer.

Addressing motions to dismiss, a district court in Texas has found that a provider may proceed with its lawsuit to recover the full amount of its charges for COVID-19 diagnostic testing under the FFCRA and CARES Act from an insurer. 

The FFCRA and CARES Act require health plans and insurers to pay the amount published by a provider for such screenings without cost-sharing by a plan participant and without the application of prior approval or other medical management procedures.  In this case, the provider published its charge, which was $900 per diagnostic screening.

The court dismissed some counts, but found, most significantly, that the FFCRA and CARES Act afford providers a private right of action to recover their charges for COVID-19 screenings.  While allowing the civil action to proceed, the court left the door open for certain claims to be challenged, where the provider failed to obtain a proper assignment of a participant's claim. Some plans or policies may include a clause prohibiting assignment, but that issue did not arise in this decision.

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