After PCA v. BCBSA, it is too obviously wrong for anyone to wear two hats at the same time, one as the fiduciary and one as the fraud investigator,” said Dr. Zhou.
Hanover Park, IL (PRWEB) October 20, 2012
On Oct. 12, 2012, Federal Court rules against BCBS in an overpayment ERISA class action by providers nationwide: BCBS overpayment recovery by SIU completely failed to comply with federal law ERISA, by failing to provide providers with ERISA compliant EOB notes and full and fair reviews. The Court also ruled against provider’s motion on class certification, in part due to some providers’ lack of ERISA assignment. This Court landmark decision is the first federal legal guidance for the skyrocketing healthcare overpayment dispute. The new federal health reform law, PPACA, mandates ERISA compliance for all group and individual health claims.
ERISAclaim.com offers ERISA Compliance Assistance Webinars for ERISA plan sponsors and TPA’s to assess the new landscape changes in plan compliance liability and potential litigation explosions when most ERISA plans’ with TPA’s employed SIU (Special Investigation Unit) to conduct the alleged overpayment fraud investigation and now mandatory ERISA fiduciary full and fair reviews together and simultaneously, with structural and appearance of conflict of interest, in possible statutory violation of fiduciary duties under 29 USC §1104 - Fiduciary duties.
The Webinars will explore new industry compliant overpayment recovery models to separately and independently conduct alleged fraud investigation by SIU and now mandatory ERISA fiduciary full and fair reviews by SPD designated fiduciary in compliance with both ERISA and PPACA, to void increasing class actions and provider litigations against plan sponsors for alleged fiduciary breach and ERISA violations.
The case information: PENNSYLVANIA CHIROPRACTIC ASSOCIATION v. BLUE CROSS BLUESHIELD ASSOCIATION, Case: 1:09-cv-05619, United States District Court, N.D. Illinois, decided on October 12, 2012.
“While PPACA provides new anti-fraud enforcement for 2 years, ERISA mandates fiduciary duty compliance for 37 years. All SIU’s must be a compliance role model first before investigating alleged fraud by others. The simplest solution to this challenge is to do them separately,” said Dr. Jin Zhou, president of ERISAclaim.com, a national expert on PPACA and ERISA appeals and compliance.
“After PCA v. BCBSA, it is too obviously wrong for anyone to wear two hats at the same time, one as the fiduciary and one as the fraud investigator,” said Dr. Zhou.
The Court made the summary judgment against the Defendants on the following critical issues, among other things, in favor of the plaintiffs:
1. “Entitlement to ERISA notice and appeal rights”;
2. “Adverse benefit determination”
3. “Appeal rights”
5. “Authorized representative”
In particular, the Court ruled that the Defendant’s SIU failed to comply with ERISA notice requirements in its overpayment demand:
“ERISA regulations, however, expressly confer notice and appeal rights upon a person who is a "claimant." 29 C.F.R. § 2560.503-1(g) & (h). The regulations define claimants as "participants and beneficiaries." Id. § 2560.503-1(a). As stated above, the language of ERISA itself defines a beneficiary as a person "who is or may be entitled to a benefit." 29 U.S.C. § 1002(7). Thus the plain language of ERISA and its regulations provides beneficiaries notice and appeal rights. If Reno is a beneficiary, he is entitled to an ERISA-compliant notice and appeal process without regard to whether his patients purported to assign him their notice and appeal rights. Defendants have not offered any authority for the proposition that only persons specifically assigned a participant's notice and appeal rights are beneficiaries or are entitled to notice and appeal rights.” according to the Court document.
The court also ruled that Defendant’s SIU overpayment reviews utterly failed to comply with ERISA full and fair reviews, with the fiduciary De Novo reviews and the consulting with appropriate healthcare professional requirements. ERISA Appeal cannot be done by SIU fraud investigators named Wendy Bohannon.
“Defendants contend that Reno received an appeal, but they provide no explanation for how the process Reno underwent substantially complied with the requirements of ERISA. A reasonable fact finder could determine that the review received by Reno did not substantially comply with ERISA's requirements. The evidence presented by defendants shows that throughout the entire process that resulted in a reduction in the repayment demand, Reno and his counsel dealt with the same person who wrote the initial repayment demand letter, an investigator named Wendy Bohannon. Anthem Ex. F, I, K, L. A reasonable fact finder thus could find that Reno never had the opportunity to have an individual who had not been involved in the initial adverse benefit determination review the repayment demand as required by ERISA regulations. Furthermore, a reasonable fact finder could conclude that when Anthem reviewed its determination that the Vax-D treatments provided by Reno were not medically necessary, it did not consult an appropriate healthcare professional. There is no evidence in the record suggesting that Anthem did consult with any such professional. In sum, a reasonable fact finder could conclude that Reno never received ERISA compliant notice and appeal.” according to the Court document.
To find out more about PPACA Claims and Appeals Compliance Services from ERISAclaim.com:
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.