Court Dismissed 996 Surgical Claims Against UnitedHealthcare For Lack of 996 ERISA Assignments

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ERISAclaim.com Offers Webinars To Examine The Federal Court Ruling On Dec 30, 2011 That Dismissed A Lawsuit For 996 Surgical Claims Against Unitedhealthcare By 4 Surgical Centers And 2 Surgeons For Lack Of ERISA Assignment, And Ordered Plaintiffs To Re-File With 996 ERISA Assignments In 30 Days.

In 30 days, if 4 surgical centers and 2 surgeons can not show in court 996 ERISA Assignments, 996 surgeries could have been done for little or nothing.

On Dec 30, 2011, the Federal Court in Southern District of Florida, dismissed a lawsuit (amended complaint), by 4 surgical centers and 2 surgeons with 996 surgical claims, against UnitedHealthcare for lack of ERISA assignment, and ordered the plaintiffs to re-file the case with 996 actual ERISA assignments within 30 days. ERISAclaim.com offers new Webinars to examine the profound impact of this federal court ruling, on ERISA requirements for Assignment of Benefits (AOB), and to discuss on how to secure valid ERISA and PPACA Assignment of Benefits, in order to prevail on all provider appeals and judicial reviews.

The Court case info:

Sanctuary Surgical Ctr., Incorporated, et al. v. UnitedHealthcare Inc., Case No. 10-81589-CV, Document 90 Entered on FLSD Docket 12/30/2011, United States District Court Southern District of Florida

“This court ruling underscores the importance of the urgent providers’ compliance with ERISA and PPACA requirements of Assignments of Benefits. Failure or stubborn ignorant refusal, by doctors, surgical centers or hospitals, to have valid ERISA assignments will ultimately lead to hundreds of millions of dollars in lost revenue for providers," says Dr. Jin Zhou, president of ERISAclaim.com, a national expert on PPACA and ERISA appeals and compliance.

According to court documents, the following are the relevant facts:

"In brief, Plaintiffs are four surgical centers and two medical service providers seeking to recover payment of benefits allegedly due under employer health benefits plans.1 Defendant, UnitedHealthcare, Inc. (“United”) is the insurer providing and administering coverage under the plans. Plaintiffs performed a procedure known as “manipulation under anesthesia” (“MUA”) for which they received preauthorization from Defendant. Although Defendant had previously provided coverage for MUAs by sending payment directly to Plaintiffs or the patients, Defendant later denied coverage on the basis that the MUAs were unproven, experimental, investigational, not medically necessary, or otherwise not a covered service under the particular plan at issue2 and therefore not entitled to coverage.

As in the original Complaint, in the Amended Complaint Plaintiffs assert four claims:

  • Count One: Violation of § 502(a) of the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. § 1132(a)(1)(B), by failing to provide the coverage benefits owed under the plans.
  • Count Two: Violation of § 502(a)(3) of ERISA by breaching the fiduciary duties of care and loyalty under § 3(21)(A), specifically by improperly denying coverage and by granting pre-approvals/pre-authorizations and then denying coverage.
  • Count Three: Failure to provide full and fair review in the process of denying coverage to Plaintiffs.
  • Count Four: Seeking to equitably estop Defendant from denying coverage after having granted pre-approvals on the basis of an inherent ambiguity in the language of each plan.”

In particular, among other things, the Court concluded the following:

"For these reasons, the Court will again grant Defendant’s motion to dismiss. To sufficiently plead its claims, Plaintiffs must establish the existence of the ERISA plans under which they sue."

"Furthermore, to sufficiently plead its standing as an ERISA beneficiary to assert the claims in the Amended Complaint, Plaintiffs must also provide the language of the actual assignments. Defendant has challenged Plaintiff’s standing to sue for breach of fiduciary duty. “Like any other contract, the scope of the assignment depends foremost upon the language of the agreement itself.” Via Christi Reg’l Med. Ctr., Inc. v. Blue Cross & Blue Shield of Kan., Inc., Nos. 04-1253-WEB, 04-1339-WEB, 2006 WL 3469544, *7 (D. Kan. Nov. 30, 2006). Therefore, the Court is unable to determine whether, as a matter of law, the alleged assignments actually conferred upon Plaintiffs standing to assert breach of fiduciary duty claims without reference to the language of the assignments."

"For 36 years, doctors and hospitals nationwide have failed or ignorantly refused to comply with federal law, ERISA, without having valid ERISA assignments. This court decision explained why providers could have lost hundreds of millions of dollars in possible legitimate claims for lack of ERISA compliance and valid assignment," explained Dr. Zhou.

“In 30 days, if 4 surgical centers and 2 surgeons could not show in court 996 ERISA Assignments, 996 surgeries were done for little or nothing,” warned Dr. Zhou.

The ERISAclaim.com’s 2012 Webinars start at $5,000 per 2-hour session and will cover the following topics:

1.    The court factual and legal analysis of surgical centers' MUA surgical clams;
2.    ERISA requirements on valid assignment of benefits;
3.    Difference between ERISA assignment of benefits and traditional assignment of benefits;
4.    How to secure a valid and complete ERISA compliant Assignment of Benefits;
5.    Why is ERISA Assignment of Benefits Form required for both in and out of network providers?

Complete ERISA & PPACA Regulations and Guidance can be found on DOL website:
http://www.dol.gov/ebsa/healthreform/

To find out more about the Total PPACA Claims and Appeals Compliance Services from ERISAclaim.com:
http://www.erisaclaim.com/products.htm

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.

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