11th Circuit Denies Appeal by Out-of-Network Physician Seeking Reimbursement

The Eleventh Circuit denied a consolidated appeal by a litigious physician who filed two separate complaints against United Healthcare and the patients’ employers, Coca-Cola and Delta Air Lines, that alleged Employee Retirement Income Security Act (ERISA) violations.

Plaintiff W.A. Griffin’s original actions were nearly identical, stemming from the partial reimbursement she received after submitting coverage claims for two separate patients’ medical care. She argued that she should be treated as an in-network provider after invoking assignment of benefits for each patient — despite being an out-of-network provider — and receive reimbursement for her claims as such, the court explained. After submitting two rounds of appeals to United for each patient, Griffin filed suit.

She found herself in “familiar territory” in the Northern District of Georgia, the Eleventh Circuit panel explained, given she has brought more than two dozen suits in the district court or state court that were removed to the district in the past four years.

Griffin’s argument focus in these cases was that United allegedly failed to disclose her patients’ plans’ anti-assignment provisions, which would bar her from assigning patients’ benefits to the provider, herself, to be treated as an in-network provider. However, the district court found that it was clear in both Coca-Cola’s and Delta’s plans that their anti-assignment provisions “indisputably barred Griffin’s claim for payment,” the court explained. But Griffin soldiered on, appealing to the Eleventh Circuit.

Pointing to “numerous unpublished decisions” in other cases brought by Griffin, the Eleventh Circuit panel found that the lower court did not err in its dismissal of the plaintiff’s claims.

“Griffin effectively asks this Court to invalidate an unambiguous contract provision,” the court said of the patients’ health plans’ anti-assignment provisions, “which is valid and enforceable under our precedent.”

Although Griffin argued that the defendants “waived their right to rely on the anti-assignment provisions because they did not alert her to their existence prior to litigation,” the panel stated that “waiver” may be either direct or implied through conduct. Despite Griffin’s allegation that the defendants “ignored” her requests to see plan documents and any anti-assignment provisions before litigation, the Circuit said that, even if that were true, it would not demonstrate that the defendants “voluntarily or intentionally abandoned a contractual defense to litigation.”

Notwithstanding the stated deficiencies of Griffin’s argument, according to the court, her case still would fail to state a claim, given the court’s affirmation that she was out-of-network from her patients — which is immutable, even if her benefits assignment claims succeeded. 

“Had (the patients) paid Griffin out of pocket and filed a claim for reimbursement with United, United would have been obligated to reimburse the patients according to their policies for out of network providers,” the court explained. “That analysis does not change simply because the patient assigned the payments to Griffin. Because the patients have no right to full reimbursement for the charged services, neither does Griffin.”

The plaintiff is represented by White Arnold & Dowd. Balch & Bingham is representing the defendants.