Aetna Sued for Alleged Illegal Overpayment Offset in ERISA Violations - ERISAclaim.com Demystifies

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On Oct. 24, 2014, Aetna was sued in a new ERISA provider class-action for alleged illegal overpayment recoupment and offset from different patients, by alleging ERISA violation and seeking for payments and injunctive and declaratory relief. ERISAclaim.com demystifies.

the worst mistakes for healthcare providers are ignoring overpayment requests from health plans until disastrous overpayment offset on every patient, says Dr. Zhou

On Oct. 24, 2014, Aetna was sued in a new ERISA provider class-action for alleged illegal overpayment recoupment and offset from different patients, by alleging ERISA violation and seeking for payments and injunctive and declaratory relief. ERISAclaim.com demystifies this provider ERISA class-action in a series of educational, consulting and litigation support programs, as insurance overpayment withholding or offset denials are No. 1 crisis for increasing number of healthcare providers nationwide.

On Oct. 25th, 2014, ERISAclaim.com announced a series of new ERISA overpayment programs to assess and demystify this new ERISA overpayment recoupment and offset class-action, to review legal developments in case laws in all provider class actions in federal court for all overpayment denials and offset, to provide ERISA compliant resolution in overpayment administrative appeals, judicial reviews and litigation support. The increasing numbers of insurance overpayment crisis are 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.

In addition to the recent case laws from federal courts, ERISAclaim.com also offers new special ERISA compliance assistance programs for all overpayment dispute in accordance with DOL ERISA enforcement interpretations and guidance: “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.” http://www.dol.gov/sol/media/briefs/tri3-enterprises(A)-11-30-2012.htm#.UMfi5z9MHFo

The court case info: RALPH MAYER, JR., M.D., LUTZ SURGICAL PARTNERS PLLC, and NYC CORRECTIVE CHIROPRACTIC CARE P.C., on their own behalf and on behalf of all others similarly situated, v. AETNA INC. and AETNA LIFE INSURANCE COMPANY, in the UNITED STATES DISTRICT COURT CENTRAL DISTRICT OF CALIFORNIA, Civil Docket For Case #: 2:14-cv-08266, Filed 10/24/14.

“The worst mistakes for attorneys for healthcare providers are fighting overpayment dispute only under the state laws, the worst mistakes for healthcare providers are ignoring overpayment requests from health plans until disastrous overpayment offset on every patient, and the worst mistakes for self-insured plan sponsors are ignorant of any potential plan assets embezzlement”, says Dr. Zhou, “as the ERISA plan participants and beneficiaries, the hard-working Americans and their families are the ultimate victims of any ERISA violations”.

In this provider ERISA class-action, providers alleged the following facts in part:

“Aetna has unilaterally withheld payment on these uncontroverted claims, without obtaining the permission of Plaintiffs or those patients, in order to satisfy a prior and disputed debt that Aetna believes that Plaintiffs may owe to different Aetna Plans. This prior and disputed debt relates to benefits that these different Aetna plans allegedly paid Plaintiffs in the past for different services Plaintiffs provided to different patients.” according to court document.

“These unilateral “offsets” reflect Aetna’s enterprise-level policy with respect to recovery of any payment it believes – without validation by any court or other independent third party – was overpaid by any Aetna Plan. These offsets violate the terms of the Aetna Plans, and Aetna’s application of this policy violates ERISA as well as Aetna’s fiduciary duties as a claims administrator. There is no provision in any Aetna Plan that permits Aetna to withhold benefit payments owed by one Aetna Plan to a medical provider for Covered Services rendered to one of the plan’s insureds simply because Aetna unilaterally alleges that the insured’s provider may owe a debt to a different Aetna Plan with respect to benefits previously paid by that plan for services rendered by the provider to a different Aetna Insured.” according to court document.

The class provider plaintiffs alleged Aetna ERISA violations in part:

“The terms of the plans require the plan actually to pay benefits for Covered Services; they do not provide that this obligation may be satisfied through a unilateral “recovery” that effectively takes benefits owed by one Aetna Plan for Covered Services provided to one of its Aetna Insureds and uses those benefits to offset an alleged and disputed overpayment that Aetna alleges that it caused a different Aetna Plan to make for services provided to a different Aetna Insured.” according to court document.

“Even if Aetna had caused an Aetna Plan to overpay Plaintiffs at some point in the past, recovering such overpayment by unilaterally refusing to pay a new and unrelated claim relating to a different Aetna Insured and a different Aetna Plan is not permitted under ERISA.” according to court document.

The class provider plaintiffs asserted the following cause of actions in part:

“FIRST CAUSE OF ACTION: CLAIM FOR BENEFITS DUE under 29 U.S.C. § 1132(a)(1)(B)…Aetna should be required to pay all such benefits and prevented from engaging in these practices in the future.” according to court document

“SECOND CAUSE OF ACTION: CLAIM FOR INJUNCTIVE AND DECLARATORY RELIEF under 29 U.S.C. § 1132(a)(3)…Aetna should be enjoined from continuing to engage in this illegal conduct and ordered to provide Plaintiffs and members of the Class with other appropriate equitable relief, including disgorgement of profits.” according to court document

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 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

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Jin Zhou, President
ERISAclaim.com
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