Second Circuit Affirms Oxford’s Decision To Pay Reduced Claims to Medical Provider

Oxford Health Plans Inc. did not act arbitrarily and capriciously in reducing the claims it paid to a medical provider after determining that the provider issued a fraudulent coinsurance waiver to a plan beneficiary, the U.S. Court of Appeals for the Second Circuit ruled June 18 (Biomed Pharmaceuticals Inc. v. Oxford Health Plans (NY) Inc., 2d Cir., 12-3023-cv, 6/18/13).

The court found that Oxford’s determination that the beneficiary failed to satisfy the plan’s coinsurance and deductible requirements was “reasonable and supported by substantial evidence.”

The court’s unpublished summary order was joined by Chief Judge Dennis Jacobs, Judge Christopher ...