In BCBS Overpayment ERISA Class Action, Provider Plaintiffs Seek For Class Certification And Remedies

Share Article Offers Webinars To Examine Provider Plaintiffs’ Motion, Filed On March 17, 2011, In PCA v. BCBSA Et Al Class Action Lawsuit, To Certify Class, Seeking For Remedies In Injunctive Relief, Asking Court To Find That 23 BCBS Entities Violated Federal Law ERISA And BCBS Must Return Wrongfully Recouped Money.

The importance of this class action is to seek for judicial guidance when hundreds of billions of dollars are at stake with little or no legal guidance.

On March 17, 2011, the provider plaintiffs in PCA v. BCBSA Et Al Class Action Lawsuit (Case: 1:09-cv-05619), filed motion to certify class in Northern District Court of Illinois, seeking for remedies in Injunctive Relief, asking Federal Court to find that Federal law ERISA govern BCBS overpayment dispute; 23 BCBS entities violated ERISA in their overpayment recoupment; and BCBS must comply with ERISA in all future overpayment recoupment, and more importantly, BCBS entities must refund all providers all of the money recouped in any violative practice. This motion was filed after the Court ruled, on May 17, 2010, that the plaintiffs ERISA class action may proceed against 23 BCBS entities, rejecting defendant BCBS state law and provider contract arguments under ERISA complete State law pre-emption ruling by U.S. Supreme Court. offers free webinars to assess this case, as the overpayment recoupment is a billion dollar healthcare market with little judicial guidance, and a court historical decision may profoundly reshape the U.S. healthcare market and finance.

“The importance of this class action is to seek for judicial guidance when hundreds of billions of dollars are at stake with little or no legal guidance, when more than 60% of national personal bankruptcies are due to medical bills,” said Dr. Jin Zhou, President of, a national expert in ERISA claims and compliance.

According to the court records, provider plaintiffs’ motion to certify class, seeking for remedies states in part:
(Case: 1:09-cv-05619 Document #: 460 Filed: 03/17/11 Page 37 of 63 PageID #:18756)

“The Appropriate Remedy for Defendants’ ERISA Violations is a Common Issue for All Class Members

Defendants may assert many different reasons for seeking repayments of previously paid benefits from Class Members. The Court need not adjudicate the validity of those retroactive Adverse Benefit Determinations, however. As demonstrated above, Plaintiffs seek a finding that (1) ERISA governs Defendants’ efforts to recover previously paid ERISA benefits, and (2) Defendants violated ERISA by making repayment demands and recouping benefits without complying with ERISA, including by failing to comply with ERISA’s requirements for a full and fair review. Once the ERISA violations have been established, the Court will not be required to review the underlying repayment demands. Instead, the proper remedy will be to void the violative repayment demands and remand to Defendants, where they can reconsider the payments and, if they elect to pursue repayment, do so in compliance with ERISA. The remedy sought by Plaintiffs is therefore injunctive.”

“The common relief sought in the present action is the identical return to the status quo prior to the violation of ERISA and classwide injunctive relief requiring Defendants to comply with ERISA – including by providing a full and fair review of any overpayment determination – should they elect to pursue further post-payment audits and repayment demands going forward.”

For a copy of the Plaintiffs’ Motion:

“The court ruling on this ERISA class action with respect to the provider plaintiffs’ remedy in Injunctive relief will be profound under newly effective federal health reform law, PPACA, and a new report from Congress on March 16, 2011, indicating that 39% to 59% appeals successfully reversed insurance denials, but with only a very small portion (0.5% in OH) of the denial appealed,” commented Dr. Zhou.

On March 14, 2011, AMA reported that More Texas Doctors Dipping Into Personal Reserves To Keep Practices Alive (

On March 16, 2010, Congress released a report by its Government Accountability Office (GAO): Private Health Insurance: Data on Application and Coverage Denials. Nationwide data collected by HHS from insurers indicated that 39% to 59% of appeals reversed original coverage denials, but only a small portion of denials are challenged, “Specifically, for the first quarter of calendar year 2010, Ohio data indicated that 0.5 percent of claim denials were internally appealed”.

U.S. GAO, (GAO-11-268 March 16, 2011): Private Health Insurance: Data on Application and Coverage Denials, reports the following in part (

“Further, the data GAO reviewed indicated that coverage denials, if appealed, were frequently reversed in the consumer's favor. For example, data from four of the six states on the outcomes of appeals filed with insurers indicated that 39 percent to 59 percent of appeals resulted in the insurer reversing its original coverage denial. Data from a national study conducted by a trade association for insurance companies on the outcomes of appeals filed with states for an independent, external review indicated that coverage denials were reversed about 40 percent of the time.”

“Reversals of coverage denials were limited to denials for which an appeal was initiated. The data we reviewed did not allow for a systematic calculation of an “appeal rate”—the number of coverage denials for which an appeal was initiated—for several reasons, including different data sources or data years for denials and appeals data. Data from Ohio did provide limited information; specifically, for the first quarter of calendar year 2010, Ohio data indicated that 0.5 percent of claim denials were internally appealed.”

A copy of the GAO full report is available at:

A copy of the GAO Highlights Page is available at:

Located in a Chicago suburb in Illinois, is the only ERISA & PPACA consulting, publishing and website resource for healthcare providers in the country. offers free webinars, basic and advanced educational seminars and on-site claims specialist certification programs for doctors, hospitals and commercial companies, as well as litigation support. Dr. Jin Zhou is regarded as the industry “Godfather of ERISA claims” for healthcare providers.

For more info on’s new services:

For a free PPACA Webinar for your Organization or Institution, please contact Dr. Jin Zhou, President of, at 630-808-7237.

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