In all overpayment cases, a provider is entitled to insist upon its assigned right to challenge the allegedly wrongful decision to deny benefits through a process that complies with ERISA claims regulation
Hanover Park, IL (PRWEB) May 23, 2013
On May 22, 2013, federal court rules against BCBSRI for its landmark lawsuit for overpayment recoupment against two healthcare providers for the alleged fraudulent billings and rules in favor of the defendant provider’s counterclaims against BCBSRI for withholding monies from future claims.
Now ERISAclaim.com offers advanced compliance webinars to demystify the landmark federal court judicial guidance for the top 1 U. S. healthcare claim denials: alleged overpayment refund demand from past payments, with or without fraud allegations, and automatic withholding of future payments from other patients – No. 1 likely killer of doctor or hospital business practice.
Dr. Jin Zhou, president of ERISAclaim.com, a national expert on ERISA appeal compliance, provided ERISA appeal compliance, fraud and abuse prevention assistance for the two defendant providers in this case from the inception of BCBSRI SIU overpayment and fraud investigation, and subsequent litigation support to the defendant’s counsel.
Case Info: Blue Cross & Blue Shield Of Rhode Island v. Jay S Korsen And Ian D Barlow, Case#: 109-Cv-00317, Filed 05/22/13, United States District Court for The District of Rhode Island.
A copy of the Court Order: http://ww1.prweb.com/prfiles/2013/05/23/10763342/BCBSRI%20v%20Korsen.pdf
Relying upon all relevant recent Supreme Court decisions, and among other things, the court decides the following, according to the Court documents:
(1) Federal law ERISA is the only mechanism available to BCBSRI regardless of BCBSRI PPO contract;
(2) As a matter of ERISA law, BCBSRI can make no recovery for past payments and can withhold no money from future claims;
(3) Both healthcare providers did no wrong as BCBSRI failed to sufficiently present evidence to support fraud, medical unnecessary or mis-coding allegations;
(4) The two providers were not given any opportunity to appeal or have Blue Cross’s determination reviewed, despite the inclusion of review procedures both under ERISA and the Provider PPO Agreements.
(5) Whatever monies BCBSRI paid to two healthcare providers, for alleged fraudulent billing and not medically necessary treatment, rightfully, equitably, and in good conscience belong to the providers;
(6) BCSRI cannot recover the monies already paid out to the providers because those monies are not subject to equitable lien from the BCBSRI PPO contract overpayment provisions.
(7) The court rules for the provider’s counterclaims against BCBSRI for withholding money from future claims and orders BCBSRI to return all monies withheld from future claims with prejudgment interests and attorney fees to be determined by the court.
“With this landmark decision for most every possible aspect of the healthcare overpayment disputes in today’s healthcare market: ERISA or PPO or pure fraud? Overpayment recovery and future payment withholding? This federal court order has finally provided comprehensive judicial guidance for overpayment crisis,” says Dr. Zhou.
“A recent DOL court brief filed in federal appeals court for the 3rd Circuit also provides detailed regulatory interpretation of ERISA claim regulation for all overpayment disputes and appeals,” says Dr. Zhou, “In all overpayment cases, a provider is entitled to insist upon its assigned right to challenge the allegedly wrongful decision to deny benefits through a process that complies with ERISA claims regulation”.
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.
ERISAclaim.com also provided ERISA appeal compliance assistance and litigation support for healthcare providers nationwide in prevailing provider ERISA class action decisions in overpayment disputes: http://www.prweb.com/releases/2012/10/prweb10028942.htm
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.
To find out more about PPACA Claims and Appeals Compliance Services from ERISAclaim.com:
Located in a Chicago suburb in Illinois, for over 13 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.