Court Finds UnitedHealth’s $430 million Overpayment Procedures Violate 3 Specific ERISA Regulations - ERISAclaim.com Demystifies All in New Webinars
Hanover Park, Illinois (PRWEB) August 05, 2013 -- On August 1, 2013, a federal court in New Jersey finds UnitedHealth’s 2011 $430 million overpayment recoupment procedures violate three specific ERISA regulations across the class, but denies providers class certification in a latest provider overpayment ERISA class action. ERISAclaim.com demystifies the landmark Court order for nation’s No. 1 health insurer overpayment recoupment procedures with new litigation support, ERISA appeal webinars and executive consulting.
The Court specifically finds UnitedHealth’overpayment demand notice (1) fails to provide providers with ERISA right to appeal; (2) fails to provide provider with free access to all documents relevant to overpayment determination; (3) fails to provide providers with at least 180 days to appeal overpayment demand under ERISA. The court further decides (1) providers have ERISA rights to sue under ERISA, regardless of Unitedhealth’s anti-assignment practice; (2) An overpayment determination is an ERISA Adverse Benefit Determination (ABD), even if a plan made an alleged duplicate payment or an overpayment from alleged fraud; (3) ERISA guarantees full and fair review for all overpayment determination. However the Court denied the provider’s motion for class certification for ERISA utilization review injunctive relief and ERISA recoupment injunctive relief.
“Numerous federal courts have ordered recently that an overpayment determination or recoupment is an ERISA denial and both health plans and providers must comply with ERISA claim regulations in resolving overpayment dispute regardless of fraud allegations,” says Dr. Jin Zhou, president of ERISAclaim.com and national expert on ERISA appeals and compliance.
http://www.prweb.com/releases/2013/5/prweb10763342.htm
http://www.prweb.com/releases/2012/10/prweb10028942.htm
Case Info: Premier Health Center, P.C., et al. v. UnitedHealth Group, et al., Case#: 2:11-cv-00425-ES-SCM, Filed 08/01/13, United States District Court for The District of New Jersey.
After denying the providers motion for class certification for various reasons, the court finds against UnitedHealth’s overpayment recoupment procedures based on the courts finding of the facts from the class members.
Among other things, as the critical significance for provider appeals and litigation, the Court states:
“To be sure, as previously discussed, United’s recoupment procedures violate three specific ERISA regulations across the class”, according to the court document.
“In 2011, United recovered approximately $430 million in overpayments to providers. 58% of the $430 million was recovered as a result of providers’ voluntarily sending a check to United, while 42% was recovered through offsets”, according to the court document.
“As previously discussed, if an insurer makes an adverse benefit determination (“ABD”) under an ERISA plan, a member or beneficiary of that plan is entitled to certain rights under ERISA, including (1) sufficient notice of the ABD; (2) the right to appeal the ABD; and (3) a full and fair review of the appeal. See 29 C.F.R. § 2560.503-1(g)-(h). “An administrator need only ‘substantially comply’ with the foregoing regulation.” Kao v. Aetna Life Ins. Co.”, according to the court document.
“However, they all violate ERISA in three respects. First, they fail to provide “[a] description of the plan's review procedures and the time limits applicable to such procedures, including a statement of the claimant's right to bring acivil action under section 502(a) of [ERISA] following an adverse benefit determination on review.” 29 C.F.R. § 2650.503-1(g)(1)(iv).25 Second, they fail to indicate that the provider, “upon request and free of charge, [will have] reasonable access to, and copies of, all documents, records, and other information relevant to the” overpayment determination. 29 C.F.R. §2650.503-1(h)(2)(ii). Third, they fail to “[p]rovide claimants at least 180 days following receipt of a notification of an adverse benefit determination within which to appeal the determination.” 29 C.F.R. § 2650.503-1(h)(3)(i).” according to the court document.
“Similarly, overpayment determinations based on fraud cannot defeat commonality. While an insurer’s cause of action against a provider in court for fraud often does not implicate ERISA, see, e.g., Aetna Health Inc. v. Health Goals Chiropractic Ctr., No. 10-5216, 2011 WL1343047, at *6 (D.N.J. Apr. 7, 2011), the administrative procedure by which an insurer attempts to recoup overpayments based on what it believes to be fraudulent activity must allow the provider the opportunity to challenge that determination in accordance with ERISA procedures, lest the determination be accepted at face value. See Davila, 542 U.S. at 214.” according to the court document.
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.
To find out more about PPACA Claims and Appeals Compliance Services from ERISAclaim.com:
http://www.erisaclaim.com/products.htm
Located in a Chicago suburb in Illinois, for over 14 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.
Jin Zhou, President, ERISAclaim.com, http://www.ERISAclaim.com, 630-808-7237, [email protected]
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