Court: $1.1 Million Denied by UnitedHealthcare? Hospital Must do ERISA in 16 Days!

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ERISAclaim.com Offers Webinars to Examine the Latest Federal Court Decision, on Jan 11, 2012, that “Memorial Hermann Must Amend to Assert ERISA Causes of Action No Later than January 27, 2012” and “The Causes of Action for Breach of Contract, Promissory Estoppel, and Quantum Meruit are Preempted by ERISA”

“No ERISA = No $1,110,221.03” for the Hospital, Simplified by Dr. Zhou

ERISAclaim.com offers webinars to examine the latest federal court decision, on Jan 11, 2012, that “Memorial Hermann must amend to assert ERISA causes of action no later than January 27, 2012” and “the causes of action for breach of contract, promissory estoppel, and quantum meruit are preempted by ERISA”, after the Memorial Hermann Hospital filed a lawsuit against UnitedHealthcare (UHC) in the State Court with various HMO/PPO claims and alleged TX Insurance Code violations under Texas laws, because the hospital was a HMO/PPO provider with UHC and was allegedly denied for $1,110,221.03 by UHC.

On Jan 25, 2012, the Hospital finally amended its lawsuit to assert ERISA causes of action in the federal court.

The Court Case Info:
Memorial Hermann Hospital System v. UnitedHealthcare Insurance Company and UnitedHealthcare of Texas, Inc., Case 4:11-cv-03545, in the United States District for the Southern District of Texas Houston Division

ERISAclaim.com offers webinars to examine why the Federal Court orders the hospital to do ERISA and why ERISA supersedes or pre-empts hospital’s state law HMO/PPO claim “causes of action for breach of contract, promissory estoppel, and quantum meruit” for over $1.1 million of the denied claims.

“If any hospital keeps doing non-ERISA over and over again but expecting different results with all of those multi-million dollar claim denials, Einstein has diagnosed this as healthcare insanity,” says Dr. Jin Zhou, President of ERISAclaim.com, a national expert on PPACA and ERISA appeals and compliance.

“Every hospital in USA must comply with ERISA laws for all claim denials from the day one, rather than last minute or not forever, if we still wanted to get paid,” said Mark Flores, a certified PPACA & ERISA Claim Specialist, Director of Healthcare Revenue & Consulting, YF Corporation in Los Angeles, CA.

According to the Court Document, the following is the case background:

“This lawsuit arose after UnitedHealthcare refused to pay 45 claims that Memorial Hermann submitted. The disputed claims fall into two categories. Some relate to patients who are HMO/PPO members allegedly covered by a UnitedHealthcare policy. Others relate to patients who are members of self-funded ERISA plans. As to the second category, UnitedHealthcare acts as third-party administrator for the patients’ claims. The disputed claims total approximately $1.1 million. Memorial Hermann incorporated these claims, a spreadsheet summary of which it attached to its motion to remand, by reference in its state-court petition. Memorial Hermann divides the disputed claims into three categories. The first is claims that were denied on the basis of no coverage. These claims comprise the majority of the disputed claims. The second is claims that were denied based on the lack of notice or preauthorization, as required by the Agreement. The third is claims that were denied based on the lack of medical necessity. UnitedHealthcare does not appear to dispute this division, although it adds claims that were denied based on the members’ failure to cooperate in coordinating benefits in the third group.

According to UnitedHealthcare, “[s]everal of the claims in dispute involve ERISA-governed employee benefit plans that provide certain health benefits to eligible members and are sponsored and funded by employers for the benefit of their employees”. UnitedHealthcare has submitted documents summarizing three self-funded ERISA plans, as well as exemplar claims submitted under those plans. As to claims relating to patients covered by self-funded plans, Memorial Hermann asserts negligent misrepresentation causes of action. It bases these causes of actions on the allegation that, following the patient’s admission, UnitedHealthcare informed Memorial Hermann that the patient was covered by a healthcare plan, but UnitedHealthcare later denied the claim on the basis of no coverage. As to claims relating to patients who are HMO/PPO members covered under UnitedHealthcare policies, Memorial Hermann asserts causes of action for breach of contract, negligence and negligent misrepresentation, violations of the Texas Insurance Code, promissory estoppel, and quantum meruit.

The question for the court is the extent to which Memorial Hermann’s state-law causes of action, on the current record, are preempted by ERISA.”

According to the Court Document, on 01/11/12, the Court ordered:

“Based on the current record and recent authority, the causes of action for breach of contract, promissory estoppel, and quantum meruit are preempted by ERISA. Memorial Hermann’s motion to remand is denied. The nonpreempted state-law causes of action—negligent misrepresentation and violations of the Texas Insurance Code based on misrepresentation—are within this court’s supplemental jurisdiction. Memorial Hermann must amend to assert ERISA causes of action no later than January 27, 2012.”

“No ERISA = No $1,110,221.03” for the hospital, simplified by Dr. Zhou.

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

Located in a Chicago suburb in Illinois, for over 12 years, 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 numerous pending national ERISA class action 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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