Aetna must comply with federal law ERISA for all post-payment overpayment demand due to ERISA plan coverage dispute
Hanover Park, IL (PRWEB) December 07, 2012
On November 30, 2012, federal government, DOL (Department of Labor), filed an Amicus Brief in the Court of Appeals for the Third Circuit in support of plaintiff providers in an overpayment ERISA class-action: Aetna must comply with federal law ERISA for all post-payment overpayment demand due to ERISA plan coverage dispute; a healthcare provider with a valid assignment has federal rights to ERISA appeals and lawsuit in federal court; a post-payment, retroactive, overpayment demand is an ERISA adverse benefit determination, triggering full and fair reviews guaranteed under ERISA; and Aetna's hypothetical state law claims of fraud may not short-circuit federal ERISA procedural protections for both in-network and out of network providers and patients. ERISAclaim.com now offers webinars, advanced trainings and litigation support to assess this DOL action for all healthcare providers.
According to the Court document, DOL advised the Court in part: “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. Under the statute and regulations, the beneficiary or participant is entitled to a claims procedure that "afford[s] a reasonable opportunity . . . for a full and fair review by the appropriate named fiduciary of [a] decision denying [a] claim," 29 U.S.C. §1133, and can then appeal the denial in federal or state court.” ….“Application of this term to "any" "reduction" or "termination," and the reference to " any utilization review" with respect to group health plans, makes plain that the claims regulations apply to post-payment, or retroactive, denials of health benefits.”
“This is the first time the federal government completely and clearly clarifies and interprets the federal law ERISA as the primary governing laws for all overpayment disputes due to plan coverage dispute”, said Dr. Jin Zhou, president of ERISAclaim.com, a national expert in ERISA claim appeals and compliance.
“This is extremely importantly significant, as DOL’s action in federal appeals court is only less than two months after a recent federal court decision on October 12, 2012 in Chicago, having reached the same conclusion for plaintiff providers in another provider ERISA overpayment class-action against numerous Blue Cross Blue Shield entities”, added Dr. Zhou.
According to the Court document, the following is the Statement of Fact, in part, from DOL Amicus Brief:
“Tri3 is a provider of medical equipment to, among others, participants and beneficiaries in ERISA health care plans insured by the defendant Aetna.”
“Aetna maintains a Special Investigations Unit ("SIU") to detect and investigate incorrect or fraudulent insurance claims through post-payment audits.”
“Aetna rejected this evidence and concluded that, regardless of the billing code provided and its prior authorization of payment, no pneumatic compressors are covered under the plan and that the two devices at issue are, in any event, excluded from coverage because Aetna considers them to be experimental and/or investigational”, according to the court document.
“Tri3, acting solely as an assignee of the beneficiaries and participants, sued Aetna pursuant to ERISA section 502(a)(1)(B) and for injunctive relief under section 502(a)(3)”, according to the court document.
“Aetna moved to dismiss the claims, arguing that "the actions complained of arise in the context of fraud prevention and recovery" that other circuits have held may be pursued under state law without triggering ERISA preemption”, and “The district court granted the motion to dismiss”, according to the court document.
DOL argued: “TRI3'S CLAIM THAT AETNA'S DEMAND FOR REIMBURSEMENT BASED ON A RETROACTIVE DENIAL OF BENEFITS ON GROUNDS THAT THEY WERE NOT COVERED BY THE PARTICIPANTS' PLANS STATES AN ERISA CAUSE OF ACTION THAT THE DISTRICT COURT SHOULD NOT HAVE DISMISSED”, according to court document.
DOL Amicus Brief info: TRI3 Enterprises, LLC v. Aetna, Inc., Case No. 12-2308, Date Filed: 11/30/2012, in the United States Court Of Appeals for the Third Circuit, On Appeal from the United States District Court for the District of New Jersey.
For a copy of DOL Amicus Brief in TRI3 Enterprises, LLC v. Aetna, Inc.:
The BCBS ERISA overpayment class-action case info: 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.
To find out more about PPACA Claims and Appeals Compliance Services from ERISAclaim.com:
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.