Federal Court Rules against BCBS in Overpayment ERISA Class Action: Providers Entitled to ERISA Appeal Rights

On Oct. 12, 2012, Federal Court rules against BCBS in an overpayment ERISA class action by providers nationwide: 1) overpayment demand due to plan coverage and/or medical necessity are ERISA denials; 2) providers are entitled to ERISA EOB’s, and ERISA appeal rights.

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Among other ERISA protections, within at least 180 days after the initial demand, a plan may not recoup or offset any alleged overpayment, as a provider will have at least 180 days to initiate an ERISA Appeal,” said Dr. Zhou

Hanover Park, Illinois (PRWEB) October 18, 2012

On Oct. 12, 2012, Federal Court rules against BCBS in an overpayment ERISA class action by healthcare providers nationwide: 1) all overpayment demands due to plan coverage and/or medical necessity are ERISA denials; 2) providers are entitled to ERISA EOB’s and ERISA appeal rights. This decision will protect every patient and provider under the federal law ERISA in all overpayment disputes with ERISA plans, as ERISA provides at least 180 days to appeal all denial decisions. In a separate decision on the same day for the same case, the Court denied provider’s motion on class certification, due to the provider’s lack of valid ERISA assignment, among other things.

ERISAclaim.com offers webinars and advanced ERISA claim specialist programs to discuss the profound impact of the Court decision for all healthcare providers, and how to correctly appeal every overpayment demand, under this landmark court decision, with valid ERISA assignment, and in compliance with ERISA claim regulations.

“Now, finally for the first time in U.S. healthcare history, the federal court has provided a clear and definitive legal guidance for the multi-billion dollar overpayment industry: all employer sponsored health plans must comply with federal law ERISA in making all overpayment demand from providers,” said Dr. Jin Zhou, president of ERISAclaim.com, a national expert on PPACA and ERISA appeals and compliance.

“Among other ERISA protections, within at least 180 days after the initial demand, a plan may not recoup or offset any alleged overpayment, as a provider will have at least 180 days to initiate an ERISA Appeal,” said Dr. Zhou.

The case information: PENNSYLVANIA CHIROPRACTIC ASSOCIATION v. BLUE CROSS BLUESHIELD ASSOCIATION, Case: 1:09-cv-05619, United States District Court, N.D. Illinois, decided on October 12, 2012.

The Court made the summary judgment against the Defendants on the following critical issues, among other things, in favor of the plaintiffs:

1.    “Entitlement to ERISA notice and appeal rights”;
2.    “Adverse benefit determination”
3.    “Appeal rights”
4.    “Assignment”
5.    “Authorized representative”

According to the Court document, the following is the case general background:

“Plaintiffs have sued a number of Blue Cross and Blue Shield entities for violations of the Employee Retirement Income Security Act (ERISA) and Florida law…… The defendants are Blue Cross and Blue Shield of America (BCBSA) and individual Blue Cross and Blue Shield entities (BCBS entities). BCBSA is a national umbrella organization that facilitates the activities of individual BCBS entities. Individual BCBS entities insure and administer health care plans to Blue Cross and Blue Shield customers (BCBS insureds) in various regions.”

“Plaintiffs allege that defendants improperly took money belonging to plaintiffs. They allege that defendants would initially reimburse the provider plaintiffs for medical services they provided to BCBS insureds. Sometime afterward, plaintiffs allege, defendants would make a false or fraudulent determination that the payments had been in error. Defendants then would demand that individual plaintiffs repay the supposedly overpaid amounts immediately. If plaintiffs refused to do so, defendants would forcibly recoup the amounts they sought by withholding payment on other, unrelated claims for services plaintiffs provided to other BCBS insureds.” according to the Court document.

“Plaintiffs allege further that when defendants made these repayment demands, they typically did not provide adequate information regarding available review procedures. Plaintiffs allege that defendants sometimes failed to offer any appeal process at all. When an appeal process was available, plaintiffs allege, defendants refused to provide details about which patients, claims, and plans were claimed to be the subject of overpayment or “effectively ignored” plaintiffs’ appeals. Fourth Am. Compl. ¶ 18. Plaintiffs contend that this conduct deprived them of their right to a “full and fair review” under ERISA. 29 U.S.C. § 1133.” according to the Court document.

“Although their complaint indicates otherwise, all four plaintiffs involved in the current motions state that they are not seeking final determination that the defendants' repayment requests and recoupments were improper, but only an order "remanding" the claims to the insurance plans so that the plans can provide ERISA-compliant notice and appeal rights. As part of that remand, however, plaintiffs argue that defendants should be required to return all the money they have received from their repayment demands and recoupments, in order to return the situation to the status quo ante, that is, the situation as it existed before the repayment requests.” according to the Court document.

“ERISA is now the most powerful legal protection for providers in the skyrocketing healthcare overpayment dispute,” said Dr. Zhou.

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 12 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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Attachments

PCA v BCBSA PCA v BCBSA

Overpayment ERISA Class Action