2012 U.S. Healthcare CEO: Court & Einstein: $2 Million Overpayment - ERISA, Fraud Or Defamation?

Share Article

ERISAclaim.com offers webinars to healthcare executives on the latest court decisions that reshaped the legal landscape of healthcare claims & revenue cycle: PPACA, ERISA, Overpayment Recoupment (aka, ERISA RAC), Fraud Or Defamation, Beyond The Coding, Billing & Contracting

The Court decides on right or wrong, while Einstein advises on what not to do over and over again.

ERISAclaim.com offers 2012 CEO Einstein Brainstorming Webinars for healthcare executives on the latest federal court decisions that reshaped the legal landscape of healthcare claims & revenue cycle for all participating, non-participating & Ex-PPO providers in this forever changing revenue cycle pyramid in the private sectors.

The reimbursement and revenue cycle pyramid changes, evidenced in the federal courts, are the new standards for the revenue cycle in private sectors for 2012: (1) SIU overpayment demands with fraud allegation by payers & defamation litigation against payers by providers, AND (2) ERISA appeals, THEN (3) coding, billing & managed care contracting disputes. (Encompass Office Solutions, Inc. v. Ingenix, Inc. & UnitedHealth, et al, CASE #: 4:10-cv-00096. U.S. District Court, Eastern District of Texas.)

“The days are long gone for the traditional coding, billing and managed care contracting as the main revenue cycle requirements. Payer SIU (aka ERISA RAC) overpayment demands in millions of dollars are now the main street & court disputes deciding the third party pays,” says Dr. Jin Zhou, president of ERISAclaim.com, a national expert on PPACA and ERISA appeals and compliance.

“A CEO Einstein must avoid healthcare insanity – keep doing the same CBC thing (Coding/Billing/Contracting), over and over again by ignoring ERISA RAC, but expecting different results - Insanity,” added Dr. Zhou.

The Court decides on right or wrong, while Einstein advises on what not to do over and over again, explained Dr. Zhou.

The Webinars will cover the following and more federal court decisions:

$2 Million Overpayment: ERISA, Fraud Or Defamation? For Non-participating providers:

Encompass Office Solutions, Inc. v. Ingenix, Inc. & UnitedHealth, et al, CASE #: 4:10-cv-00096. U.S. District Court, Eastern District of Texas.

A non-par provider, Encompass Office Solutions, was demanded by Inginex / UHC to refund the alleged overpayment in $2,051,896.22 and was also denied for claim reimbursement due to the ASC provider status dispute. Emcompass sued Ingenix and UHC under ERISA for underpayment and denying overpayment. Emcompass also sued Ingenix and UHC for defamation and many other claims. On 031/31/2011, among other things, the Court denied UHC’s motion to dismiss Emcompass’s defamation claim.

The Court decided, on 03/31/2011, in part:

“5. Defamation

……First, “in correspondence from Defendants to Encompass’s patients, Defendants often claimed that they could not pay the claim because they were ‘unable to verify state licensure of a facility or criteria to support the provider billing type. Proof of facility licensure or hospital affiliation is required.’” ¶ 107. Encompass argues that this statement is defamatory because it implies that Encompass was required to be licensed and was not licensed, when in reality it is not required to be licensed. Second, “in a press release, a representative for Ingenix stated that ‘Encompass submitted bills as an ambulatory surgery center [but] Encompass is not an ambulatory surgery center and does not perform medical procedures.’”¶ 111. Encompass argues that this statement is false because it “does perform medical procedures, albeit under the supervision of physicians.” Encompass also argues that the Ingenix statement suggests that Encompass was falsely seeking reimbursement as an ASC when in reality Encompass has never represented itself as such. …… Accordingly, the Defendants’ motion to dismiss Encompass’s defamation claim is DENIED.”

$1 Million In A Hospital PPO Lawsuit: PPO or ERISA? For Participating Providers:

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

In denying hospital’s $1 million non-ERISA PPO suit, the Court decided:

“At all relevant times, Montefiore was an in-network provider…….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), 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 payment—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.”

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 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.


Share article on social media or email:

View article via:

Pdf Print

Contact Author

Jin ZHou
Visit website