DOL ERSA FAQs About The Benefit Claims Procedure Regulation

Aetna + CIGNA Settlement
Demystified

 © 2004  Jin Zhou, ERISAclaim.com

Aetna ERISA "Talking Points" (www.aetna.com)

1. ERISA stands for Employee Retirement Income Security Act

2. E. B. = External Boards (of Reviews) (§7.10-7.11): 1) Medical Necessity, 2) Billing & Coding and 3) Policy Coverage

3. Settlements Only for MCO/Provider Contract Disputes

4. Settlements Not for Patient Coverage/ERISA Disputes, (§7.10-7.11)

5. Patient Disputes = ERISA/Coverage/Medical Necessity/Bundling & Down Coding

6. Provider Disputes = PPO Discount/HMO Capitation/Provider Relationship (DOL FAQ A8)

7. Patient Disputes ≠ Provider Disputes, (DOL FAQ A8); Provider/MCO Contract (PPO/HMO) Disputes are not Triggered until Patient ERISA Disputes With the ERISA Plan Are 100% Resolved or Moot (DOL FAQ C12) (PASCACK VALLEY HOSPITAL, INC. v  LOCAL 464A UFCW WELFARE REIMBURSEMENT PLAN (3rd Cir. 11/01/2004), Northeast Hosp. Authority v. Aetna Health Inc., (October 17, 2007)

8. External Reviews (3 E. B.) Are Not Available until Internal Reviews (ERISA) Completed, (GAO)

9. ERISA = Federal Law Mandate; External  Reviews = State Law Mandate, (GAO)

10. No ERISA Compliance = No Rights for Any One

NBC 10 Breaking News:

Overpayment - FBI - Class Action

"Biggest Fraud in US History"

NBC10 Video

Pomerantz Files Class Action Against Blue Cross Blue Shield Association ("BCBSA") and Related BCBSA Entities

Reuters, Thu Sep 10, 2009 6:11pm EDT

CHICAGO--(Business Wire)--

"Pomerantz Haudek Grossman & Gross LLP today announced that it and co-counsel Buttaci & Leardi, LLC filed a class action lawsuit against the Blue Cross Blue Shield Association ("BCBSA") and 22 leading BCBS insurers across the country on behalf of a putative nationwide class of health care providers, as well as the Pennsylvania Chiropractic Association ("PCA"), the New York Chiropractic Council (the "Council"), and the Association of New Jersey Chiropractors ("ANJC"). The suit challenges the Defendants` abusive practices in using post-payment audits and reviews, and improper repayment demands, to pressure providers to repay substantial sums that have previously properly been paid as health insurance benefits for services provided to BCBS subscribers.

 

......In making the appointment, the Court stressed the significant role Pomerantz had played in a $249 million settlement of its UCR class action against Health Net, stating that the Court had "similarly appointed Pomerantz to be Plaintiffs` spokesman to the Court in the Health Net litigation because the Court found D. Brian Hufford, Esq. to be the attorney most capable of presenting Plaintiffs` position in a clear and concise manner." In re Aetna UCR Litig., 2009 Dist. LEXIS 66853, *8 n.4 (D.N.J. July 31, 2009)."

For a copy of the BCBSA Complaint, click here

Pomerantz Files Class Action Against Aetna (News from Pomerantz)

For a Copy of the Official Complaint, click here

Pomerantz Files Class Action Suit Against Aetna On Behalf of Healthcare Providers to Challenge Abusive Post-Payment Audit Practices (GlobeNewsWire, press release)

"NEWARK, N.J., July 29, 2009 (GLOBE NEWSWIRE) -- Pomerantz Haudek Grossman & Gross LLP today announced that it and co-counsel Buttaci & Leardi, LLC, have filed a class action lawsuit against Aetna, Inc., and its various health insurance subsidiaries on behalf of a putative nationwide class of health care providers, the Association of New Jersey Chiropractors ("ANJC") and the New York Chiropractic Council ("NYCC"). The suit challenges Aetna's abusive practices in using post-payment audits, with false allegations of fraud, to pressure providers to repay substantial sums that have previously properly been paid for providing services to Aetna subscribers.

The action alleges that Aetna's post-payment audit process violates the Employee Retirement Income Security Act of 1974 ("ERISA"), in that its repayment demands are retroactive determinations that particular services are not covered under the terms of Aetna's health care plans, but without any of the appeal or other protections otherwise available under ERISA for both self-funded and fully insured health care plans offered through private employers. The complaint further alleges that both the post-payment audit process and the pre-payment claim review process employed by Aetna to strong-arm chiropractors into unfavorable settlements violate the Racketeer Influenced and Corrupt Organizations Act ("RICO"). In addition to challenging the process by which Aetna pursues and applies its audits, the complaint also challenges numerous clinical policy bulletins of Aetna, which are used to deny services retroactively without adequate basis or clinical support."

What’s Next: The Plaintiff’s Perspective – Healthcare Insurers Face Explosive New Cause of Action « BulletProofblog.com>>

Authored By: Larry Smith September 16, 2009

"In this regular feature, Bulletproof interviews top plaintiffs' attorneys for their perspective on the crises likely to affect businesses in the near future. Today we talk to D. Brian Hufford, partner in the Columbus, Ohio office of the pioneering class action firm Pomerantz Haudek Grossman & Gross LLP. Mr. Hufford has just filed a class action against the Blue Cross Blue Shield Association and 22 BCBS insurers across the country on behalf of providers and professional chiropractic associations in Pennsylvania, New York, and New Jersey."

ERISAclaim.com - "Overpayment" Refund Request Response & Appeals

BCBSA News, June 30, 2009

Blue Cross And Blue Shield Companies' Anti-Fraud Efforts Recover $350 Million In 2008

"WASHINGTON – Blue Cross and Blue Shield companies' anti-fraud investigations resulted in overall savings and recoveries of nearly $350 million in 2008, an increase of 43 percent from 2007, according to data released today by the Blue Cross and Blue Shield Association (BCBSA) National Anti-fraud Department (NAFD).  From 2007 to 2008, the number of cases opened increased nearly 34 percent, and the closed cases increased about 43 percent."

AMNews: July 6, 2009. Tennessee Medical Assn. sues collections firm
Health Research Insights has contacted physicians in several states this year trying to collect alleged overpayments.

For A Copy of TMA v. HRI Lawsuit, click here
 

AMNews: May 18, 2009. State medical societies strategize against collector
Legal action is one option against Health Research Insights.
 

AMNews: May 11, 2009. Company stops tapping physicians for 'overpayments'
Doctors protested self-insured Georgia-Pacific's attempt to collect refunds of suspected claims upcoding.
 

AMNews: April 13, 2009. Self-insured companies going after doctors to recover 'overpaid' claims
There is no clear time limit on how far back ERISA-protected companies can go to recoup money. One company is turning that into a business.

Overpayment Demand Letter from HRI:

"Dear Health Care Professional,

 

......You must take action as outlined in items (1) or (2) above, in order to ensure compliance with the Employee Retirement Income Security Act of 1974 (ERISA). ERISA is the federal law that, among other things, governs health benefit plans in private industry. Investigation of potential ERISA violations is given to the United States Secretary of Labor pursuant to sections 504 and 506 as amended by the Comprehensive Crime Control Act of 1984 and enforced by the US Department of Labor.

 

In the event HRI is not contacted by you or your designee, a Complaint may be filed with the Employee Benefits Security Administration (EBSA). You may view additional information at (www.dol.gov/ebsa)."

Physicians Strike Back At Employers' Collection Firms ( BNET Healthcare Blog | BNET)

"In the most recent clash, the Tennessee Medical Association has sued Health Research Insights (HRI), a Franklin, TN-based firm that has sent collection letters to physicians in Georgia, Kentucky, Tennessee and Texas. Other defendants in the suit include the Metropolitan Government of Nashville and Davidson County, TN, and Nashville’s Board of Education, which runs a self-insured plan for school employees. Blue Cross and Blue Shield of Tennessee, the plan’s administrator, is also named in the suit, although the insurer disavows any relationship with the collection firm.

 

The suit, which alleges fraud, says that HRI keeps 40 percent of whatever it collects. The TMA wants a court to enjoin HRI from making any further efforts to collect from physicians. An earlier protest by the Georgia Medical Society against HRI’s work on behalf of Georgia Pacific led to a suspension of those activities."

Employment-Based Health Coverage and Health Reform: Selected Legal Considerations (PDF) (U.S. Congressional Research Service)

"It is estimated that nearly 170 million individuals have employer-based health coverage. As part of a comprehensive health care reform effort, there has been support (including from the Obama Administration) in enacting comprehensive health insurance reform that retains the employerbased system. This report presents selected legal considerations inherent in amending two of the primary federal laws governing employer-sponsored health care: the Employee Retirement Income Security Act (ERISA) and the Internal Revenue Code (IRC)."

ERISAclaim.com - "Overpayment" Refund Request Response & Appeals