emp grp/provider contract dispute

[lkc15507]

What is the name of your state (only U.S. law)? Missouri. I hope to keep this a concise as possible, but its very nature is going to make that difficult at best. This question regards a contractual issue between a self-funded health plan and a provider on behalf of one plan participant (and the employer group) for transplant services. I chose the health insurance forum, but if it is better suited to the consumer contracts (or another) forum, please advise.

Third Party Administrator requested the reinsurer for an employer group to access a contract to transplant services on behalf of the group & participant due to the fact the TPA had no direct or transplant network contracting ability with the specified provider. That process was undertaken by the reinsurer who also involved an oversight case management company to complete the task. As a fiduciary of the employer plan, the TPA, via email communications with the oversight CM company and the reinsurer voiced many concerns with regard to the ambiguity of the contract language in primarily one, but several areas of the contract. The employer group ultimately signed the contract and the actual language of the contract was not altered or amended. The TPA retains all of those email communications between the principals. Of course, the worst happened and the contract language is in dispute.

The question is does/will/can these emails carry weight as to the actual understanding between the parties if it ends up in court, or is it likely that the (un)plain language of the contract will be left entirely to a judge's interpretation of the contract itself?

I appreciate any input. The TPA contends that the contract combined with the emails makes the interpretation of the contract language clear. The provider wishes to ignore the email and submit their after-the-fact interpretation of the contract. It's a pick-your-battles decision at this point. The sum in question is significant for the employer group, but could pale in comparison to legal costs. It all hinges on the email. TPA personnel have differing opinions whether to uptake the battle or not. Compliance officer thinks there are 2 or 3 legs of 4 to stand on, I from the case management side think we have all 4 solidly beneath us. We have no in house legal, so even an initial legal review with outside council will cost the group.

lkc15507

[ecmst12]

I think you're gonna have to spring for that legal consult.

[lkc15507]

Ecmst12

Thanks for the reply. It is as I expected, yet I was hoping for pie in the sky. Coming from you, whose answers I respect on these boards, I will amend my actions to press for the consult. Much, much detail to the situation that couldn't be included in the post, but my ultimate goal as a case manager, nurse, and patient advocate is to save my patient from being the ultimate innocent victim of these charges. I am afraid he will be caught in the vacuum of insurer vs. provider. And, as we know, the healthcare recipient is always responsible. Given all my info, plan appeal procedures, etc., I don't think the provider is going to win against the group payer, but the one ultimately left holding the bag will be my patient. It's impossible to convince a bean counter the wisdom of spending a dime (I know, I was a bean counter in a previous life), especially when the bean counter thinks I am / should be on his side. Actually, I am. As plan fiduciary and patient advocate, that is my job—to walk that line that benefits both. Sometimes however, it proves to be impossible to walk that line. I am simply desperate to find something to leverage against the provider. I have nothing to leverage against the payer. Thanks again, lkc15507