Overpayment: PPO or ERISA? Federal Court Rules against BCBS in Overpayment ERISA Class Action

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On Oct. 12, 2012, Federal Court rules against BCBS in an overpayment ERISA class action by providers nationwide: BCBS PPO overpayment recovery completely failed to comply with federal law ERISA, as defendants’ PPO appeals failed to substantially comply with ERISA requirements.

PPO or ERISA is like “To Be or Not to Be” for all participating hospitals and providers in the overpayment crisis survivals. PPO anti-balancing billing may be in violation of federal laws in case of ERISA denials,” said Dr. Jin Zhou

On Oct. 12, 2012, Federal Court rules in summary judgment against BCBS in an overpayment ERISA class action by providers nationwide: BCBS PPO overpayment recovery completely failed to comply with federal law ERISA, as defendants’ PPO appeals failed to substantially comply with ERISA EOB and full and fair requirements. The Court rejects all defendants’ PPO augments on the scope of ERISA v. PPO, PPO anti-balance billing v. ERISA adverse benefit determination, PPO Notice v. ERISA EOB’s, and PPO SIU Reviews v. ERISA Full and Fair Reviews. This Court landmark decision is the first federal legal guidance for the skyrocketing healthcare overpayment dispute, especially for all participating providers. The Court also ruled against provider’s motion on class certification, in part due to some providers’ lack of ERISA assignment.

ERISAclaim.com offers advanced ERISA Compliance and Appeals training for both participating and non-participating hospitals, ASC’s and all providers, to appeal all overpayment denials, recoupment and withholdings or offseting, under the Court guidance in this case in compliance with ERIA and PPACA regulations.

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.
http://ww1.prweb.com/prfiles/2012/10/18/10028942/PCA%20v%20BCBSA.pdf

“PPO or ERISA is like “To Be or Not to Be” for all participating hospitals and providers in the overpayment crisis survivals. PPO anti-balancing billing may be in violation of federal laws in case of ERISA denials,” said Dr. Jin Zhou, president of ERISAclaim.com, a national expert on PPACA and ERISA appeals and compliance.

“This is the first time in history that a federal Court ruled that the PPO anti-balance billing instruction in ERISA overpayment denials failed to comply with or violated federal law ERISA,” said Dr. Zhou.

In particular, the Court rejected the defendant argument that PPO anti-balance billing instructions could escape ERISA compliance by BCBS, and the provider’s option not to collect a patient debt forfeited a provider’s right to ERISA appeal:

“A reasonable fact finder could conclude from these exhibits that defendants in fact had denied claims that involved Reno providing spinal decompression to his patients. Contrary to Anthem's claim that it was not rejecting any individual patient's claim, it demanded repayment from Reno for every spinal decompression he had performed on the ground that the service was not covered. Further, Anthem told Reno that Vax-D services were considered not medically necessary, a type of denial specifically mentioned in the definition of adverse benefit determination. 29 C.F.R. § 2560.503-1(m)(4). A reasonable fact finder could conclude that Anthem's repayment demand was an adverse benefit determination, because it denied coverage for every instance of a specific procedure. The mere fact that Anthem stated it was not denying any specific claims does not change the fact that as a result of its actions, Reno received no payment for any instance in which he provided Vax-D to patients under certain benefit plans.” according to the Court document.

In rejecting BCBS PPO anti-balance instruction defense, the Court reasons:

“Defendants also contend that its repayment demands did not expose Reno's patients to increased financial liability. As just discussed, however, a reasonable fact finder could conclude that Anthem's repayment demand in fact denied a certain group of claims on the grounds the services were not covered and were not medically necessary. Reno thus could have sought to bill those patients for the amount not covered by insurance. Reno's assignment of benefits forms stated that patients were "financially liable for all charges whether or not paid by insurance." Anthem Ex. Q. Reno also testified that he had the ability to bill his patients for the amounts he repaid to Anthem but chose not to do so out of concern that it would harm his relationship with them.”

The Court explains that PPO anti-balance practice is inconsistent with ERISA regulations:

“Defendants do not contend that Reno's contractual agreement with them prevented him from billing his patients.

The DOL interpretation of the ERISA regulations cited by defendants provides that a dispute between a benefit plan and a provider can be an adverse benefit determination when "the medical provider will continue to have recourse against the claimants for amounts unpaid by the plan." FAQs About the Benefit Claims Procedure Regulation at A-8. Although it is undisputed that Reno did not seek repayment from his patients, a reasonable fact finder could conclude that he had the ability to do so.”

The Court concludes that PPO overpayment anti-balance billing violated ERISA:

“In sum, a reasonable fact finder could conclude that Reno and his patients suffered adverse benefit determinations when defendants demanded that Reno repay the money he had received for Vax-D services.”

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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