"In sum, a reasonable fact finder could conclude that Reno never received ERISA compliant notice and appeal.” according to the Court document.
Hanover Park, IL (PRWEB) October 23, 2012
On Oct. 12, 2012, Federal Court rules against BCBS in an overpayment ERISA class action by providers nationwide: BCBS overpayment recovery completely failed to comply with federal law ERISA, and provider is entitled to ERISA rights to appeal and to sue, even after the PPO or state law settlement, as defendants’ PPO appeals and settlement failed to substantially comply with ERISA EOB and full and fair requirements. This Court landmark decision is the first federal legal guidance for the provider’s statutory ERISA rights in the skyrocketing healthcare overpayment disputes. The Court also ruled against provider’s motion on class certification, in part due to some providers’ lack of ERISA assignment.
ERISAclaim.com offers ERISA litigation support and advanced ERISA Appeals Assistance to healthcare attorneys, representing both participating and non-participating hospitals, ASC’s and all providers, to appeal administratively and judicially all overpayment denials, recoupment and withholdings or off-settings, under the Court guidance in this case, in compliance with ERIA and PPACA regulations, even after a non-ERISA PPO settlement.
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.
“This is the first time in history that a federal Court ruled that NO non-ERISA compliant overpayment demand or settlement may preclude ERISA appeals and lawsuit”, said Dr. Jin Zhou, president of ERISAclaim.com, a national expert on PPACA and ERISA appeals and compliance.
“Complete ERISA and PPACA compliance for all overpayment disputes is the best defense for health plans, and timely ERISA appeals compliance administratively and judicially shall be the only protection for providers and patients,” said Dr. Zhou.
In particular, the Court rejected the defendant argument that the PPO or state law reviews and settlement may preclude the provider rights to ERISA compliant EOB and full and fair reviews:
“Defendants suggest more broadly that Reno settled any ERISA claims when he paid about $25,000 to Anthem. Beyond their citations to the Virginia statute, however, they make no effort to show that a settlement agreement existed under Virginia law or that of any other state that would preclude Reno's ERISA claims. A reasonable fact finder could conclude that Reno did not agree to settle any possible ERISA claims against defendants. See Va. Elec. & Power Co. v. Norfolk S. Ry. Co., 683 S.E.2d 517, 525 (Va. 2009) (when interpreting contract under Virginia law, courts attempt to determine the intent of the parties, looking primarily at language used by parties in contract). The promissory note signed by Reno states that he agree to pay Anthem in exchange "FOR VALUE RECEIVED," but it does not recite what that value is. Anthem Ex. P. Nothing in the promissory note states that Reno is also giving up any ERISA claims he might have. Reno's attorney's letter, which accompanied the note, states in its entirety "A properly executed promissory note from Dr. Reno is enclosed. I'll assume this ends all matters concerning Anthem's audit of Dr. Reno's claims." Anthem Ex. N. The letter does not state, however, that Reno is settling any claim he might have, much less ERISA claims. From these documents, a reasonable fact finder could conclude that Reno simply paid to end the audit process and Anthem's attempts to recoup larger sums of money, without agreeing to forego bringing his own claims in the future. The same is true of an earlier letter written by Reno's counsel, in which he says that Reno would pay about $9,000 "to resolve all issues raised by Anthem's audit and get this matter behind him." Anthem Ex. J at 2. Moreover, the earlier letter is part of a failed attempt to end the audit for $9,000, and whatever promises Reno might have made if he could have paid only $9,000 are not necessarily promises he made when paying $25,000 later on.” According to the Court document.
The court also ruled that Defendant’s SIU / PPO overpayment reviews utterly failed to comply with ERISA full and fair reviews, with the fiduciary de novo reviews and the requirement for consulting with appropriate healthcare professional. ERISA Appeals cannot be done by SIU fraud investigator 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.