Courts' Million-Dollar ERISA Decision Against Hospital Prompts Million-Dollar PPACA Claims Recovery Services

Share Article Announced Million-Dollar PPACA Claims Recovery Services, Prompted by the Recent Federal Courts’ Million-Dollar ERISA Decision against the In-network Hospital, the Congressional PPACA Appeal Report and the Sweeping Federal Health Reform Law PPACA Claims Regulations Effective on Sep. 23, 2010.

Every hospital executive must wake up from the decade long managed care nightmares & failures by these shocking federal courts decisions......

On April 25, 2011, announced new Million-Dollar PPACA-ERISA Claims Recovery Services, prompted by the recent Federal Courts' Million-Dollar ERISA Decision, the Congressional PPACA Report and the sweeping new Federal Healthcare Reform Laws PPACA Claims Regulations. The new Million-Dollar PPACA-ERISA Claims Recovery Services are timely and uniquely designed for hospitals with a single patient claim in over $1 million for the aggregated hospital stays, with options of complete “No-Money-Down” Contingency Program at 45% compensation or “Do-It-Yourself” Recovery Program for hospital in-house training to establish Hospital PACA/ERISA Appeals Department with PPACA-ERISA Claim Specialists Certification Training at minimum $50,000.

On April 21, 2011, federal appeals court ruled, in Montefiore Medical Center v. Teamsters Local 272, against an in-network Hospital, with claims over $1 million, based on ERISA complete preemption. On March 16, 2011 the Congressional GAO PPACA Report revealed that very small portion of denied claims in the nation were appealed (0.5% in Ohio), but 39%-59% appeals reversed initial denials. On September 23, 2010, the sweeping Federal Health Reform Law PPACA Claims Regulations went in effect, for all group health plans and individual policy market for both ERISA and non-ERISA claims. PPACA adopts ERISA claims regulation in its entirety as the minimum PPACA internal appeal standards.

“Every hospital executive must wake up from the decade long managed care nightmares & failures by these shocking federal courts decisions against the in-network hospitals with million-dollar claims, and the sweeping new federal healthcare reform laws PPACA claims regulations, regardless of managed care network participation," warned by Dr. Jin Zhou, President of, a national expert on ERISA and PPACA appeals and compliance.

On April 21, 2011, the Federal Appeals Court in New York, in affirming a prior federal district court decision, ruled against an in-network Hospital for claims over $1 million, made under the state laws for breach of managed care contract. This Court decision is the most comprehensive, most timely and most important for most typical in-network hospitals, out-of-network hospitals and all providers, according to Dr. Zhou.

Pursuant to the United States Supreme Court unanimous ruling in Aetna v. Davila (No. 02—1845, Decided June 21, 2004), the Federal Appeals Court basically ruled that unless for pure PPO discount claims (“amount or execution of payment”), all of the in-network hospital claims, “right to payment”, coverage and benefits determination under the plan, are ERISA claims. The pure PPO discount claims are non-ERISA claims, but if any of the hospital claims are ERISA claims, hospital’s lawsuit under the state law is completely preempted or superseded by federal law ERISA. The federal court will exercise federal jurisdiction on ERISA claims and supplemental jurisdiction on all non-ERISA claims, explained and simplified by Dr. Zhou.

According to the Court documents - Montefiore Medical Center v. Teamsters Local 272, Docket No. 10-1451-cv., United States Court of Appeals, Second Circuit, Decided: April 21, 2011:

“At all relevant times, Montefiore was an in-network provider of the Plan by virtue of its membership in two PPOs. Montefiore contracted with (1) Horizon Healthcare Insurance Company of New York ("Horizon"), from April 2003 until January 1, 2007, and (2) Preferred Choice Management Systems, Inc., d/b/a MagnaCare ("MagnaCare"), from January 1, 2007 through March 11, 2009 (the date Montefiore filed its complaint in this action). These PPOs entered into agreements with the Fund to provide eligible Plan beneficiaries with access to the PPOs' participating hospitals, including Montefiore.”

Federal Appellate Court Judge José A. Cabranes ruled:

“This case is yet another act in the all-too-familiar drama involving patients, their health care providers, and their health care benefit plans. The question presented is whether a health care provider's breach of contract and quasi-contract claims against a benefit plan established pursuant to the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. §§ 1001 et seq., are completely preempted by federal law under the two-pronged test for ERISA preemption established in Aetna Health Inc. v. Davila, 542 U.S. 200, 209 (2004). We hold: (1) an "in-network" health care provider may receive a valid assignment of rights from an ERISA plan beneficiary pursuant to ERISA § 502(a)(1)(B),1 the provision setting forth ERISA's civil enforcement scheme; (2) where a provider's claim involves the right to payment and not simply the amount or execution of payment2—that is, where the claim implicates coverage and benefit determinations as set forth by the terms of the ERISA benefit plan, and not simply the contractually correct payment amount or the proper execution of the monetary transfer3—that claim constitutes a colorable claim for benefits pursuant to ERISA § 502(a)(1)(B); and (3) in the instant case, at least some of plaintiff's claims for reimbursement are completely preempted by federal law; furthermore, the remaining state-law claims are properly subject to the District Court's supplemental jurisdiction.”

For a copy of the official court decision:

Federal Health Reform Laws PPACA Claims Regulations went into effect on Sep. 23, 2010:

On March 16, 2011, the Congress released PPACA mandated GAO Report, indicating that only a very small portion of the denied claims were actually appealed (0.5% in Ohio), but if appealed, 39 to 59% appeals reversed initial denials. (

For Services:

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 any questions, please contact Dr. Jin Zhou, president of, at 630-808-7237.

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