Federal Court Ruled for Aetna: ERISA Pre-empts PPO Doctor’s PPO and TX Prompt Pay Claims

Share Article

ERISAclaim.com offers webinars to examine the new Federal Court decision on Feb. 29, 2012 for Aetna and against a PPO doctor, because PPO provider’s breach of PPO contract claims and Texas prompt pay claims are completely pre-empted by federal law ERISA.

“Obviously, Texas prompt pay state law is completely invalided and pre-empted by ERISA for all ERISA claims,” added Dr. Zhou.

ERISAclaim.com is now offering webinars to examine the new federal court decision handed on Feb. 29, 2012 for Aetna. The webinar examines the decision against the PPO doctor in the complaint. The court document reveals that the PPO provider’s breach of PPO contract claims in addition to Texas prompt pay claims are completely pre-empted by federal law ERISA. This federal court decision is important for every PPO healthcare provider and hospital, because the Court ruled that as long as “at least one of Plaintiff's claims involves a coverage determination” or “right of payment”, federal law completely pre-empts state prompt pay laws and all breach of PPO contract claims. The Webinar will provide in-depth discussion on how ERISA compliance by providers will protect all PPO providers for all claim coverage denials.

“To make this billion dollar question a no-brainer for all PPO providers, federal law ERISA controls claim coverage determination or rights of payment for 'how much money' first, then PPO contract controls only PPO discount and provider-PPO relationship. Only when there is no coverage dispute at all, PPO discount then kicks in,” says Dr. Jin Zhou, President of ERISAclaim.com, a national expert on PPACA and ERISA appeals and compliance.

“Obviously, Texas prompt pay state law is completely invalided and pre-empted by ERISA for all ERISA claims,” added Dr. Zhou.

The court case info: Markey v. Aetna Health Inc, Case #: No. SA-11-CA-1075-XR, United States District Court, W.D. Texas, San Antonio Division, February 29, 2012

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

“On April 2, 1997, medical service provider Keith L. Markey, M.D., P.A. ("Plaintiff"), entered into a contract with health insurance provider Aetna Health Inc. ("Defendant"), formerly known as Aetna Health Plans of Texas, Inc. d/b/a Aetna U.S. Healthcare. Pl.'s Orig. State Ct. Pet. The contract, titled Specialist Physician Agreement, stated that Plaintiff would provide covered medical services to individuals covered by or enrolled in certain health benefit plans and that Defendant would pay Plaintiff for services rendered according to a price term promulgated by Defendant. Id. Plaintiff alleges (1) that Defendant failed to correctly pay for services rendered according to the contract, and (2) that Defendant failed to timely pay claims within the Texas Insurance Code's statutory timelines. Plaintiff asserts violations of the Texas Prompt Pay Act (TPPA), codified in Chapters 843 and 1301 of the Texas Insurance Code, and seeks the damages available to him under the Act, including unpaid contract sums, statutory penalties, statutory interest, attorney's fees and court costs.”

The Court explains how to decide on PPO or ERISA:

“Thus, whether a federal question exists in this case, and thus whether this Court has jurisdiction, will turn on whether at least one of Plaintiff's claims involves a coverage determination.”

The Court finds facts for ERISA rather than PPO:

“In the second spreadsheet, Plaintiff lists a claim that was completely denied by Defendant. Specifically, Plaintiff claims that on March 20, 2008, he provided a service to patient PS at a contracted rate of $1,200 for which he received no payment from Defendant. See Claim Spreadsheet 2-B (Docket No. 4, Ex. 2-B). Defendant asserts that Plaintiff's claim was denied in its entirety because the procedure involved the use of an assistant surgeon, which, according to Defendant, was not covered under the patient's plan. Aff. of Jay Tidwell ¶ 5 (Docket No. 4, Ex. 5). Thus, the Court will have to conduct a coverage determination to resolve Plaintiff's claim. Since Plaintiff's claim involves the "right of payment" it is preempted by ERISA and, as a result, a federal question arises.”

The Court concluded for Aetna, federal law ERISA pre-empts the plaintiff’s state law PPO and prompt pay claims:

“Here, Plaintiff has alleged a cause of action that falls within ERISA's enforcement scheme and, as a result, ERISA preempts the state claim. Consequently, although Plaintiff pled his claim under state law, the claim is "necessarily federal in character" and this Court has jurisdiction.”

In addition, the Court also finds for Aetna on timely removal to federal court claim.

“What does this Court decision really mean to all providers? If a provider wants a prompt and rightful payment from an ERISA plan, he/she must comply with ERISA first, then state law or PPO contract second. All state prompt pay laws are powerless or useless for ERISA plans,” explained Dr. Zhou.

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.

Dr. Jin Zhou & ERISAclaim.com were nominated for White House Champions of Change PPACA Program in 2012 for educating others about the new health care law to raise awareness about the benefits of the Patient Protection & Affordable Care Act (PPACA). (http://www.sfgate.com/cgi-bin/article.cgi?f=/g/a/2012/02/11/prweb9189619.DTL)

For any questions, please contact Dr. Jin Zhou, president of ERISAclaim.com, at 630-808-7237.

Share article on social media or email:

View article via:

Pdf Print

Contact Author

Jin Zhou
Visit website