Banned Provider - Self Funded Plan

[Christine Roberts]

Can a self-funded plan expressly and indefinitely ban a healthcare provider from its group of providers eligible for direct payment or reimbursement under the plan?

Is this accomplished by listing the banned provider in the SPD, by name?

Would this possibly subject the plan administrator to a defamation claim? Would ERISA preempt?

Provider in question was successfully sued for defrauding the plan and barred from list of approved providers. 10 years later, the plan receives a claim based on treatment by the same dentist.

[GBurns]

As far as I know or have seen, a Plan is free to NOT contract with any provider it chooses. The Plan is free to establish its own list of eligible providers or to place limits on the members of any provider network that it contracts with. In contracting with any network, IPO, IPA or any group of providers, the Plan can negotiate exclusion of any member provider. The only exception would be in a state with an applicable "any willing provider" law.

In my opinion, listing the name of undesired providers is not only unnecessary but should be slander, defamation or be subject to some similar litigation.

If the accepted or desired providers are listed, and any providers not listed are deemed as "Restricted Access" and subject to a punitive co-pay higher than normal "out of network", that should be sufficient deterrent to the employees.

The use of Providers should be taught as part of Open Enrollment.

Why is this provider even available to the employees, anyhow? Remember, the problem is not the dentist, the problem is the employee who chose this dentist and the availability of the name (to the employee) as a provider.