This decision is also vital to the nationwide epidemic overpayment recoupment war between the payers and providers,” says Dr. Jin Zhou,
HAnover Park, IL (PRWEB) April 04, 2014
On March 26, 2014, a Texas state court dismissed with prejudice all of Aetna’s claims against two Texas physicians for alleged unlawful out-of-network referrals, except for Aetna’s “equitable accounting” claim. In advocating for patient’s freedom of choice, the two Texas physicians were vindicated accordingly, under this court order, for all of Aetna’s claims dismissed with prejudice. ERISAclaim.com demystifies the impact of this court decision for all physicians, as numerous similar lawsuits by other insurance companies have been filed in many other states.
Case info: Aetna Health , Inc v. Michael L. Blackwell, M.D. et al, Case No.: 2013-76814, filed March 26, 2014, in the District Court of Harris County, Texas.
Today, ERISAclaim.com announced a new ERISA and PPACA Patient Advocacy Program with compliance for reimbursement and freedom of choice, to timely discuss and demystify all important court decisions, such as this Texas Aetna decision, and to inform physicians of the in-depth judicial guidance, in order to better protect all patients and physicians in seeking for out-of-network quality healthcare.
“This court decision is significant for more than 76% of the insured patients who paid for out-of-network coverage under all employer-sponsored health plans in USA, when exercising their freedom of choice of the network physicians. This decision is also vital to the nationwide epidemic overpayment recoupment war between the payers and providers,” says Dr. Jin Zhou, President of ERISAclaim.com, a national expert of ERISA and PPACA compliance.
“Although Aetna’s claims were dismissed with prejudice for two Texas physicians, Aetna’s lawsuit demonstrates the importance of the strict compliance with all applicable federal and state laws for all physicians when advocating for patient freedom of choice for out-of-network physicians,” added Dr. Zhou.
On December 26, 2013, Aetna filed a lawsuit against two Texas physicians in the Harris County court, seeking for overpayment refund in millions of dollars, “equitable accounting” and permanent injunction to prohibit alleged unlawful out-of-network referrals in violation of Texas laws. (Case No.: 2013-76814, in the District Court of Harris County, Texas)
On March 26, 2014, the Texas state court judge, Robert Schaffer, dismissed with prejudice all of the Aetna’s claims against the two physicians, except for, temporarily, Aetna’s “equitable accounting” claim.
Without any detailed discussion, the court orders the following in part:
“It is, therefore, ordered that Defendants’ Plea to the Jurisdiction as to all of the Plaintiff’s claims except the claims for equitable accounting is granted and all such claims against Defendants Ifeolumipo O. Sofola, M.D., Michael L Blackwell, M.D., Batjac Surgical Group, PLLC, and Starlight Surgical, PLLC are dismissed with prejudice. It is further ordered that Defendants’ Plea to the Jurisdiction as to Plaintiffs’ claims against Defendants Ifeolumipo O. Sofola, M.D., Michael L Blackwell, M.D., Batjac Surgical Group, PLLC, and Starlight Surgical, PLLC for equitable accounting is denied.” According to court document
The court dismissed the following Aetna original claims with prejudice in part:
“Count One (injunctive relief): 19. Defendants are engaging in practices that violated Texas law, their in-network agreements, and other applicable standards of conduct that prohibit them from receiving facility fee as kickbacks in exchange for patient referrals…..”, according to court document.
“Count One (Injunctive Relief): 22. A permanent injunction is proper because: (i) there will be needed and irreparable harm if Drs. Blackwell and Sofola continue to refer Aetna member patients to out-of-network facilities in exchange for receiving a percentage of hospital’s facility fees as kickbacks; (ii) Aetna has no other adequate remedy at law; (iii) a greater injury will result from denying the injunction than from its being granted; and (iv) the injunction will not disserve the public interest., according to court document.
“Count Three (Money Had and Received): 30. Texas law prohibits Drs. Blackwell and Sofola’s acceptance of kickbacks in exchange for patient referrals. Moreover, the SPA’s prohibit Drs. Blackwell and Sofola’s acceptance of more than their contracted rates for the medical services they provided to Aetna patients. Drs. Blackwell and Sofola received payment from Aetna for their professional services, and also accepted kickbacks for their patient referrals in the amount of 30% of the hospital facility fees Aetna paid. Accordingly, Drs. Blackwell and Sofola hold money in equity and in good conscience should be returned to Aetna.” according to court document.
A copy of the original Aetna Complaint was attached with this press release with its “equitable accounting” claim.
To find out more about ERISA & 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.