This court ruling underscores the importance of providers’ ERISA claims & appeals practice for both unpaid claims and the alleged overpayment refund disputes
Hanover Park, IL (PRWEB) June 21, 2011
On June. 20, 2011, the federal District Court in New Jersey allowed a provider ERISA overpayment class action lawsuit against Aetna, Inc. to proceed under ERISA (ASSOCIATION OF NEW JERSEY CHIROPRACTORS et al v. AETNA, INC. Et al, Case 3:09-cv-03761-JAP-TJB, Document 90, Filed 06/20/11). The court dismissed provider’s RICO claims and granted Aetna’s motion to enforce a settlement agreement and release from one provider and motion to compel arbitration and to dismiss two provider’s claims. The federal court ERISA class-action ruling is timely significant for July 1, 2011, the official enforcement date for new federal health reform laws, health-care claims and appeals regulations. ERISAclaim.com provided the ERISA compliance assistance for many provider class representatives in this case, and it will provide free webinars to examine the legal and market impacts of the court ERISA ruling in connection with new PPACA & ERISA claim regulations.
“This court ruling underscores the importance of providers’ ERISA claims & appeals practice for both unpaid claims and the alleged overpayment refund disputes, especially before the July 1, 2011, the official enforcement date of PPACA claims regulations,” says Dr. Jin Zhou, president of ERISAclaim.com, a national expert on PPACA and ERISA appeals and compliance.
According to the court paper, with respect to provider’s ERISA claims, the court states in part:
“The plaintiffs in this case are licensed medical providers or chiropractic professional associations. Defendant Aetna is an insurer that offers, underwrites and administers commercial health plans (“Plans”) through which healthcare expenses incurred by Plan participants for services covered by the Plans are reimbursed by Aetna pursuant to the terms of the Plan.”
“Overall, Plaintiffs are challenging Aetna’s practice of demanding the repayment of healthcare benefits that Aetna later determines had been improperly paid to the provider. Plaintiffs allege that Aetna is required to and failed to comply with certain procedural protections provided by ERISA in demanding such repayment from providers. For example, Plaintiffs assert that Aetna, prior to requesting repayment from a provider, must issue a revised Explanation of Benefits (“EOB”) to the insured. Plaintiffs also challenge Aetna’s “prepayment review” process as to the individual providers, under which Aetna reviews records before it pays a claim submitted by a provider from whom Aetna has requested repayment.”
In deciding on Aetna's overpayment recoupment and “antifraud efforts”, the court states:
“Defendants argue that Plaintiffs’ claims do nothing more than seek to use ERISA to absolve providers from the consequences of fraudulent billing practices and to bring insurer anti-fraud efforts to a standstill. They contend that there exist a number of reasons that dismissal of Plaintiffs’ ERISA claims is warranted.”
“Having carefully reviewed the FAC and accompanying affidavit, the Court is not persuaded that dismissal of Plaintiffs’ ERISA claims is warranted at this time. While Aetna has raised questions as to the viability of Plaintiffs’ ERISA claims, the Court concludes that a more complete factual picture regarding Aetna’s “recoupment”/anti-fraud efforts is necessary to ultimately resolve the issue. Thus, resolution of the issue is not appropriate on a motion under Rule 12(b)(6). The Court denies Aetna’s motion without prejudice to the filing of an appropriate summary judgment motion in the future.”
In deciding on Aetna's motion to dismiss the standing of Association of plaintiffs, the court states:
“The Court finds that dismissal of the Association Plaintiffs is not warranted at this time. Construing the FAC in favor of Plaintiffs as the Court must on a 12(b)(6) motion, the Court finds Plaintiffs’ allegations that the Association Plaintiffs’ members had received payments directly from Aetna sufficient to withstand Defendants’ 12(b)(6) challenge under the first prong of Hunt.”
For a copy of the court opinion: http://ERISAclaim.com/ANJC_v_Aetna.pdf
On March 23, 2010, President Obama signed into law the Health Reform Bill, PPACA (Patient Protection and Affordable Care Act). PPACA claims and appeals regulations went into effect on September 23, 2010. PPACA adopts ERISA claim regulation in its entirety, for group health plans and health insurance coverage in the group and individual markets, for almost all non-Medicare and/or non-Medicaid claims.
Effective on July 1, 2011, the PPACA claims and appeals regulation enforcement date, the DOL, HHS & IRS will start the official enforcement for the new federal Provider’s Bill Of Rights, because now PPACA claims regulation defines a health care provider, with a valid designation of authorized representative, as a claimant, regardless of network participation. This new federal law will make the new federal Patient’s Bill of Rights as same as the new federal Provider's Bill of Rights in U.S. healthcare history, said Dr. Zhou.
Complete PPACA Regulations and Guidance can be found on DOL website:
To find out more about the Total PPACA Claims and Appeals Compliance Services from ERISAclaim.com:
Located in a Chicago suburb in Illinois, ERISAclaim.com is the only ERISA & PPACA consulting, publishing and website resource for healthcare providers in the country. ERISAclaim.com 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 ERISAclaim.com, at 630-808-7237.