Hanover Park, IL (Vocus) November 10, 2010
The federal district court in Rhode Island ruled on October 27, 2010 against BCBSRI over its recoupment practice for over $400,000 against two healthcare providers. Relied upon recent US Supreme Court rulings, the court ruled that BCBSRI’s post-payment overpayment recoupment is an ERISA plan fiduciary conduct governed by federal law ERISA instead of provider PPO contract as asserted by BCBSRI. Coincidentally for self-insured ERISA health plans, this federal court ruling clarified, for the first time, that the billions of dollars, the healthcare industry recouped from healthcare providers in the past decade by all Third-Party Administrators (TPAs), are the ERISA plan assets, rather than PPO contract refund, as traditionally claimed by the TPA industry. Consequently, this court ruling gives green light for all self-insured health plans under ERISA to recover billions of dollars already recouped in the past decades by all TPAs, as ERISA plan assets recovery. ERISAclaim.com announced free webinars on how to identify ERISA plan assets and recover plan assets from traditionally misclassified PPO contract refund, estimated in billions of dollars.
"This federal court ruling provides the unexpected but timeliest and valuable guidance on the plan sponsors’ legal rights to the billions of dollars already recouped or recovered on behalf of more than 60% self-insured health plans for 176 million hard-working Americans, covered under employer-sponsored health plans,” said Dr. Jin Zhou, President of ERISAclaim.com, a national consultant on ERISA compliance and claim appeals.
With about $2.5 trillion health expenditure annually, more than 60% of 176 million Americans are covered under self-insured employer-sponsored plans. The vast majority of self-insured plans paid out healthcare claims from the plan assets, including employer contributions and employee salary withholding, by the third-party claims administrators (TPAs), either a big insurance company or benefits claim processing company. When billions of dollars from the ERISA plan assets were mistakenly paid out initially and recovered subsequently years later for whatever reasons by the plan TPAs, the vast majority of the recouped money may not have been returned to the original plans, as the healthcare industry historically and erroneously claimed the recouped "overpayment" money, the real plan assets on behalf of self-insured plans, as the TPAs’ PPO contract overpayment refund settlement. As most of the billions of dollars recoupment were made retrospectively across the plans, patients and providers, and without access to TPAs recovery database, most self-insured ERISA plan sponsors may not be successful in plan assets recovery, elaborated by Dr. Zhou. The new free webinars from ERISAclaim.com will demystify the billion-dollar overpayment recoupment industry and plan assets recovery in the wake of this new federal court ruling.
According to the court papers, BCBSRI v. Jay Korsen et al, Blue Cross Blue Shield of Rhode Island sued two healthcare providers for $412,952.93, alleging breach of PPO contract and fraud in the state court of Rhode Island. The defendants moved the case to the federal court arguing that Blue Cross' state law claims for breach of contract and fraud (Counts I and II) are completely preempted by the Employee Retirement Income Security Act ("ERISA"). Among other things, the federal court made following ruling in denying BCBSRI’s motion to remand the case to the state court.
In deciding that the overpayment recoupment dispute with fraud claims is not governed by BCBSRI provider contract under state law, but is completely governed and preempted by federal law ERISA, the court explained:
“The Court holds further that there is no independent legal duty controlling Defendants' conduct herein; because, while the Provider Agreements do impose duties on Defendants, these duties are not independent of the terms of the ERISA plans. Consequently, the Court holds that Blue Cross' Count I for breach of contract, alleging that Defendants breached the Provider Agreements by submitting claims using improper CPT codes and submitting claims for services that were inappropriate or not medically necessary, and Count II for fraud are completely preempted by ERISA. The Court converts these claims to a federal ERISA § 502 (a) (3) claim.”
The court case info: BLUE CROSS & BLUE SHIELD OF RHODE ISLAND v. JAY S. KORSEN and IAN D. BARLOW, filed on October 27, 2010, Case#: 1:09-cv-00317-L-LDA, UNITED STATES DISTRICT COURT FOR THE DISTRICT OF RHODE ISLAND
ERISAclaim.com provided compliance assistance and litigation support in administrative appeals and judicial proceedings for defendant in this case.
ERISAclaim.com, located in Chicago suburb in Illinois, is a leading national firm in the past 10 years, providing comprehensive and unique ERISA and PPACA educational and consulting services, Dr. Jin Zhou, President of ERISAclaim.com, regarded as the Godfather of ERISA claims for providers in the industry, published ERISA and PPACA appeals systems and CD Book, ERISAclaim.com website, and hundreds of educational articles and seminars. ERISAclaim.com offers free webinars, basic and advanced educational seminars and on-site claims specialist certification programs should as well as litigation support.
For a complete copy of the court decision: http://www.erisaclaim.com/BCBSRI_V_Korsen.pdf
For registration and scheduling info of the free webinar: http://www.erisaclaim.com/Free_ERISA_Webnars.htm
For more information on ERISA Health Plan Overpayment Recoupment Assets Recovery: http://www.erisaclaim.com/Embezzlement_Recovery.htm
For any questions, please contact Dr. Jin Zhou of http://www.ERISAclaim.com at 630-808-7237.
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