Federal Appeals Court Rules for Wellpoint in ADA UCR ERISA Class-Action: Failure to Complete ERISA Appeals

On Oct. 23, 2012, Federal Court Of Appeals for 11th Circuit rules for Anthem BCBS of California against American Dental Association in an ERISA class-action for all dentists with out-of-network usual, customary and reasonable (UCR) fee disputes, because of the dentists’ failure to complete ERISA appeals. ERISAclaim.com offers webinars in how to correctly complete ERISA appeals.

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"This simplest federal appellate court decision tells every healthcare provider to simply complete ERISA appeals, if the provider wants to get paid properly after denials,” said Dr. Jin Zhou.

Hanover Park, IL (PRWEB) October 25, 2012

On Oct. 23, 2012, the Federal Court of Appeals for 11th Circuit rules for Anthem BCBS of California against American Dental Association in an ERISA class-action for all dentists with out-of-network “usual, customary and reasonable” (UCR) fee disputes, because of the dentists’ failure to complete ERISA appeals. ERISAclaim.com offers webinars, to assess the profound impact of this federal appellate court decision for all out-of-network providers, and provides advanced training on how to correctly complete ERISA appeals. New health care reform law, Patient Protection and Affordable Care Act, PPACA (ACA), mandates compliance with ERISA claim regulations, for both ERISA plans and non-ERISA plans, for all claim disputes by both in-network and out of network providers.

“This simplest federal appellate court decision tells every healthcare provider to simply complete ERISA appeals, if the provider wants to get paid properly after denials,” said Dr. Jin Zhou, president of ERISAclaim.com, a national expert on PPACA and ERISA appeals and compliance.

“Numerous provider class-action lawsuits failed simply because providers never had valid ERISA assignments and never completed ERISA appeals, resulting in a loss of millions of dollars and business bankruptcies,” Dr. Zhou.

The Court case info: American Dental Association, et. al. v. Wellpoint Health Networks Incorporated, Blue Cross of California, Case: 11-11208, Date Filed: 10/23/2012, in the United States Court of Appeals for the Eleventh Circuit.

The Court Per Curiam decision is simple:

“The issue presented in this appeal is whether a periodontist initiated an administrative appeal when he sent a letter to an insurer requesting information about the insurer’s partial reimbursement of a patient, before the doctor filed a complaint against the insurer under the Employee Retirement Income Security Act of 1974. 29 U.S.C. § 1001 et seq. Dr. David W. Richards filed this putative class action against WellPoint Health Networks and alleged that WellPoint uses a faulty method in determining the usual, customary, and reasonable amount for reimbursement of patients for services provided by dentists. WellPoint argues that Richards failed to exhaust his administrative remedies before filing his complaint, and Richards responds that he sought administrative review by sending WellPoint a letter that requested the information underlying its decision. The district court entered summary judgment in favor of WellPoint on the ground that Richards’s request for information failed to seek administrative review of the partial reimbursement. Because we conclude that Richards failed to exhaust his administrative remedies, we affirm.”

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

“Richards is a periodontist in San Diego, California. He is considered an “out-of-network” provider because he has not entered a contract with WellPoint. As an “out-of-network” provider, Richards may charge WellPoint subscribers a customary fee for which WellPoint reimburses the subscribers at a fixed rate.”

“In September 2001, Richards provided a WellPoint subscriber with a comprehensive exam, for which Richards charged him $98. In its “Explanation of Benefits,” WellPoint stated it would reimburse the patient only $57. Both Richards and WellPoint agree that the $57 figure comes from the usual, customary, and reasonable charges provided by WellPoint. The “Explanation of Benefits” explained to the patient that “[s]hould you believe this claim has been wrongfully denied or rejected, or you need further clarification, please contact the WellPoint Dental Customer Service Department . . . .” The “Explanation of Benefits” further provided that a “dental provider may also file a reconsideration on your behalf.” according to Court document.

After Dr. Richards exchanged one letter with Wellpoint after the denial, “WellPoint received the letter and labeled it an “Inquiry” to “explain [uniform, customary, and reasonable rates]….. Richards made no further attempts to correspond with WellPoint.” according to the Court document.

“Most ERISA plans provide at least two level appeals, failure to exhaust all appeals provided by the plan will deprive providers from pursuing lawsuit in federal court in most cases,” according to Dr. Zhou.

“This is also why a recent Congressional study found provider official appeals rare (0.5% in OH), but you could win (39-59%) if you do file ERISA / PPACA Appeals,” said Dr. Zhou.

The Congress concluded in U.S. GAO Report, (GAO-11-268 March 16, 2011): (http://www.gao.gov/products/GAO-11-268)

“Further, the data GAO reviewed indicated that coverage denials, if appealed, were frequently reversed in the consumer's favor. For example, data from four of the six states on the outcomes of appeals filed with insurers indicated that 39 percent to 59 percent of appeals resulted in the insurer reversing its original coverage denial……Ohio data indicated that 0.5 percent of claim denials were internally appealed.”

To find out more about ERISA and 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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Attachments

ADA v Wellpoint ADA v Wellpoint

Out of Network UCR Class ACtion