the No. 1 health care claim denials today in USA have been the payer overpayment recoupment and offset practice, without any ERISA compliance, according to Dr. Zhou
Hanover Park, Illinois (PRWEB) July 07, 2014
On June 23, 2014, UnitedHealthcare (UHC) was sued by a new provider class-action in its overpayment recoupment and offset practice for alleged ERISA violations and fiduciary fraud. The new ERISA class-action suit filed in a federal court in Minnesota alleges that UHC has been withholding or offsetting new payments in part or in whole from the providers when the patients and the plan sponsors were misinformed as if the payments were made to the providers, and also alleges that UHC has never complied with ERISA claims regulation when requesting for the alleged overpayment and offsetting new payments from other patients. The new putative class on behalf of all similarly situated providers is seeking for ERISA benefits payments due, injunctive and declaratory relief, and ERISA notice and appeal rights.
On 4th of July, 2014, ERISAclaim.com announced a serious of new healthcare executive brainstorming programs to assess and demystify the new ERISA overpayment recoupment and offset class-action, because the No. 1 health care claim denials today in USA have been the payer overpayment recoupment and offset practice, without any ERISA compliance, for several years in the past for all or certain types of claims, potentially resulting in inevitable provider bankruptcy and subsequent patient bankruptcy, according to Dr. Jin Zhou, president of ERISAclaim.com, a national expert on ERISA compliance and appeals.
The court case info: Peterson, D. C, et al v. UnitedHealth Group Inc. et al, U.S. District Court U.S. District of Minnesota (DMN), Civil Docket For Case #: 0:14-cv-02101-PAM-SER, Filed 06/23/14.
Significantly, this ERISA putative provider class-action for the “Offset Class” was filed in the wake of and in accordance with a similar provider class-action filed recently in New Jersey for the “Recoupment Class”:
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.
A copy of the Court Order: http://ww1.prweb.com/prfiles/2013/08/05/10996187/Premier%20v%20UHC.pdf
In the last year court decision in Premier Health Center, P.C., et al. v. UnitedHealth Group, et al., the court ruled against UHC in its overpayment recoupment practice:
“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.
“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.
However, in last week’s provider class-action in Minnesota, healthcare providers alleged additional ERISA violations by UnitedHhealthcare Group for withholding and offsetting newly adjudicated claim payments from one patient to satisfy another alleged overpayment in the past from other unidentified patients in complete ERISA violations, and even worse, by misrepresenting to the patients and the plan sponsors on patient EOB’s that “payment made to provider”, when in truth and in fact no such payment was ever made to the providers, according to the Court Complaint.
In particular, the plaintiff Lutz Surgical Partners alleged the following:
“For example, ……Instead, United identified a different United Insured covered by a different United Plan who had been treated by Lutz on December 16, 2012. According to the PEOB, United caused that United Plan to pay Lutz $19,460.00 for this treatment which was now characterized by United as the “ORIGINAL OVERPAYMENT AMOUNT.” The PEOB then explained that the entire amount owed to Lutz for the services provided to the June 12, 2013 patient ($2,700.00) was being unilaterally offset against the prior alleged overpayment relating to the December 16, 2012 patient ($19,460.00), with the added explanation that “THIS REPRESENTS PREVIOUS BENEFITS THAT WERE PAID IN ERROR.” United therefore reported that the “TOTAL PAID TO THE PROVIDER” for services rendered to the June 12, 2013 patient was $0.00. In the “REMARKS” section of the PEOB, United stated: “The amount payable for this Explanation of Benefits has been used to reduce an overpayment made on the given claim(s). Please adjust your patient account balance accordingly.” according to the court document.
To find out more about PPACA Claims and Appeals Compliance Services from ERISAclaim.com:
Located in a Chicago suburb in Illinois, for over 15 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.