The claim denials involving Medicare and ERISA plans are everyday story for providers. Dual coverage usually turned out to be no coverage from either Medicare or ERISA plans.
Hanover Park, IL (PRWEB) February 09, 2012
ERISAclaim.com offers new Executive Webinars to examine the latest federal court decision on Feb 7, 2012 against UnitedHealthcare. The Court finds that its decision to reduce or offset the benefits payment by 80% for the nonexistent or erroneous Medicare Coordination of Benefits (COB) is against the plan SPD (Summary Plan Description) under ERISA, when the treating physician has elected to opt out of Medicare and Medicare does not cover the intravenous ("IV") antibiotic therapy used to treat Lyme disease unless a physician is present. This Court decision is significantly important for all healthcare providers treating patients with both Medicare and ERISA plan coverage from all employer-sponsored health plans.
Of newsworthy and importance to all healthcare executives and attorneys are (1) the plan SPD is the most important governing documents for determining Medicare coordination of benefits, (2) the named defendants include the plan administrator / employer / plan sponsor (AT&T), the plan TPA (United Healthcare Insurance Company / UHIC), and the ERISA plan (AT&T Inc. Medical Plan), (3) after plaintiff completed administrative appeals, the litigation commenced in the federal ERISA court, instead of the state court, as frequently so chosen by healthcare providers.
The Court case info: GILES v. AT&T, INC.: SHERIE A. GILES and LEWIS P. GILES, Plaintiffs, v. AT&T, INC., UNITED HEALTHCARE INSURANCE COMPANY, and AT&T, INC. MEDICAL PLAN, Defendants, No. 6:09-cv-293 (MAD/ATB), United States District Court, N.D. New York, February 7, 2012.
“The claim denials involving Medicare and ERISA plans are everyday story for providers. Dual coverage usually turned out to be no coverage from either Medicare or ERISA plans. This court decision explains how to get paid under ERISA, especially for all self-insured plans,” says Dr. Jin Zhou, President of ERISAclaim.com, a national expert on PPACA and ERISA appeals and compliance.
According to the 33 page Court document, the following are the Court’s interpretation of plan SPD on Medicare coordination of benefits (COB) and the Court decision in part:
“In effect, under the guise of interpretation, Defendant UHIC has taken it upon itself to rewrite the Plan by adding terms where none previously existed. Defendant UHIC claims that the language it relied on allows it to exclude an arbitrary eighty percent of the costs of services that are not covered by Medicare, despite the fact that the cited language in the Plan only contemplates reducing payment when the beneficiary selects to receive services otherwise covered by Medicare from a provider who has opted out of Medicare or when the beneficiary could be, but has not enrolled in Medicare. The Plan does not state that benefits will be reduced "even if the services would not otherwise be covered by Medicare because it is a service that Medicare does not cover. ……
Further, Defendant UHIC's interpretation of the Plan is contrary to its actual language. Specifically, the plan provides that benefits will be reduced "when Medicare would be the Primary Coverage Plan[;]" it does not provide that benefits will be reduced "regardless of whether Medicare would be the Primary Coverage Plan[.]" See AR at 278 (emphasis added). Defendant UHIC conceded that, even if Dr. Liegner still participated in Medicare, the IV antibiotic treatments would not be covered by Medicare. See id. at 2594. Therefore, Medicare would not have been the "Primary Coverage Plan" and Defendant UHIC acted arbitrarily and capriciously in reducing Plaintiff Sherie Giles' benefits in accordance with this provision. Further, even if it was not arbitrary and capricious for Defendant UHIC to interpret Medicare as being the "Primary Coverage Plan," the only possible non-arbitrary "estimated" Medicare reduction is zero, since the service was not covered by Medicare.”
Among other things, the Court concludes in part:
“Based on the foregoing, the Court finds that Defendant UHIC's interpretation of the Plan and decision to reimburse Plaintiff Sherie Giles for only twenty percent of the in-home treatments she received was arbitrary and capricious. As such, the Court grants this part of Plaintiffs' motion for summary judgment.”
“It is critically important in this case to understand that a TPA’s (UHIC) non-SPD “Medical Policies” are not enforceable if contrary to the plan (AT&T) SPD's actual language. It is also very important to obtain a copy of the specific and actual plan SPD even before filing an ERISA claim,” says Mark Flores, a certified PPACA & ERISA Claim Specialist, Director of Healthcare Revenue & Consulting, YF Corporation in Los Angeles, CA.
The new Executive Webinar will provide in-depth discussion on the following topics:
1. Brief discussion of the case facts and ERISA law relating to the ERISA appeals
2. How to read ERISA Plan’s Summary Plan Description (SPD) v. TPA/insurer non-SPD “Medical Policies”;
3. Medicare Secondary Payer (MSP) laws and ERISA Coordination of Benefits (EOB)
4. ERISA litigation support and administrative appeal strategies.
To find out more about PPACA Claims and Appeals Compliance Services from ERISAclaim.com:
Located in a Chicago suburb in Illinois, 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.