The overpayment denial is now officially the No. 1 reason for claim denials in U.S.A., after the recent court document revealed that the UnitedHealth alone recouped $430 million in 2011, not to mention all other healthcare payers.
Hanover Park, Illinois (PRWEB) August 22, 2013
On August 16, 2013, a federal appeals court sides with Obama Administration (Department of Labor, DOL), against Aetna in a providers’ overpayment ERISA class-action lawsuit, after DOL filed an Amicus Brief on November 30, 2012 and joined the provider in the oral argument on June 26, 2013. The Third Circuit Court of Appeals in Philadelphia vacates an earlier ruling by a District Court in New Jersey in favor of Aetna and rules (1) it was improper for the District Court to rely on Aetna’s competing account to dismiss the provider ERISA class-action, and (2) just because Aetna may have a fraud case against a provider later, it doesn’t mean the provider may not sue Aetna first under ERISA over the overpayment disputes. This is the first appellate court decision to affirm the providers’ rights to sue a health plan first under ERISA in overpayment disputes even if a health plan may assert an alleged fraud case against the provider later.
ERISAclaim.com provided litigation support for the providers in this case. On August 21, 2013 it announced new compliance seminars and executive consulting services on ERISA compliance and appeals for overpayment dispute as well as litigation support, through demystifying (1) this 3rd Cir. Court decision, DOL legal guidance on overpayment disputes, (2) the most recent federal court decisions on providers’ overpayment ERISA class-action, and (3) the ERISA compliant solutions to administrative appeals and inevitable judicial reviews.
“The overpayment denial is now officially the No. 1 reason for claim denials in U.S.A., after the recent court document revealed that the UnitedHealth alone recouped $430 million in 2011, not to mention all other healthcare payers. This appellate court decision, the recent District Court decisions and the DOL Amicus Brief in this case will definitely serve as the most authoritative legal guidance for all overpayment disputes now and for years to come,” says Dr. Jin Zhou, president of ERISAclaim.com, a national expert on ERISA compliance and appeals. http://www.prweb.com/releases/2013/8/prweb10996187.htm1
Among other things, as the critical significance for provider appeals and litigation, the Appeals Court provides the following new guidance:
Just because Aetna may have a fraud case against a provider later, it doesn’t mean the provider may not sue Aetna first under ERISA over the overpayment disputes:
“We are also unconvinced that ERISA’s preemptive reach would mean that allowing Tri3’s suit to proceed would obstruct any suit that Aetna may elect to bring. The fact that an ERISA claim exists against one party does not necessarily mean that that party cannot bring a separate, non-ERISA claim related to similar facts against the opposing party. See LeBlanc v. Cahill, 153 F.3d 134, 147-48, 151-53 (4th Cir. 1998) (holding that ERISA did not preclude a plan from bringing action against parties with respect to plan for fraudulent misrepresentation and also finding that the same facts supported an ERISA claim against a separate set of parties). Just as the validity of Tri3’s claims depends on Tri3’s allegations, the validity of Aetna’s claims will depend on Aetna’s allegations, if and when they are made.” according to the court document.
“Regardless of whether Aetna could have filed suit against Tri3, Aetna has thus far chosen not to do so. Aetna’s delay in asserting its legal rights is no reason why Tri3’s claims should be dismissed….. Tri3. It was thus improper for the District Court to rely on Aetna’s competing account to dismiss the Complaint.” according to court document.
Obama Administration, DOL, argued in support of the provider, as a provider is entitled to insist upon ERISA appeals:
“The crux of the question at issue here is not whether the plaintiff or the defendant is correct in their views of the plan terms, but whether Aetna must comply with the procedures mandated by ERISA section 503 and its accompanying regulations in rendering a determination based on a plan interpretation that is adverse to the plan participants and beneficiaries. …… In either event, Tri3 is entitled to insist upon its assigned right to challenge the allegedly wrongful decision to deny benefits through a process that complies with the claims regulation.” according to DOL Amicus brief document filed in the court.
The 3rd Cir. Court case info: TRI3 Enterprises, LLC, individually and on behalf of all other similarly situated v. Aetna, Inc., et al., in the Court Of Appeals for the Third Circuit, Case#: 12-2308, Document: 003111360892, Date Filed: 08/16/2013, on Appeal from the District Court for the District of New Jersey (No. 3-11-cv-03921).
DOL’s Tri3 Enterprises Amicus Brief, supporting plaintiff-appellant, No. 12-2308, in the 3rd Cir., dated: November 30, 2012: http://www.dol.gov/sol/media/briefs/tri3-enterprises(A)-11-30-2012.htm#.UMfi5z9MHFo
An audio file link to the 3rd Cir. Court for DOL oral in TRI3 Enterprises, Inc. v. Aetna, Inc., et al., case 12-2308 , on 6/26/2013:
To find out more about PPACA Claims and Appeals Compliance Services from ERISAclaim.com:
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.