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.

Our attorneys can help clients understand the relevant changes and plan for the future as federal health care reform evolves.