District Court Rules against BCBSRI on Overpayment Recoupment and Withholding Tactics–Paves way for US Healthcare Overpayment Claim Denial Appeal Process

District Court Rules against BCBSRI on Overpayment Recoupment and Withholding Tactics–Paves way for US Healthcare Overpayment Claim Denial Appeal Process

Federal court rules against BCBSRI in its overpayment recoupment and withholding lawsuit against healthcare providers: BCBSRI cannot recover money from past payments and cannot withhold money from future claims payments.

On May 22, 2013, the United States District Court for The District of Rhode Island ruled against BCBSRI in a landmark lawsuit for overpayment recoupment against two healthcare providers for alleged fraudulent billings.  Furthermore the court ruled in favor of the provider defendant’s counterclaims against BCBSRI for withholding monies from future claims.

In light of this landmark court decision, Avym Corporation offers advanced compliance webinars to examine the federal court’s judicial guidance on the nation’s most onerous healthcare provider claim denials: payor alleged overpayment refund demands from past payments and automatic withholding of future payments from other patients.

The training programs and policies advocated by Avym Corporation are one and the same that provided ERISA appeal compliance as well as fraud and abuse prevention assistance for the two defendant providers in this case.

Case Info: Blue Cross & Blue Shield Of Rhode Island v. Jay S Korsen And Ian D Barlow, Case#: 109-Cv-00317, Filed 05/22/13, United States District Court for The District of Rhode Island.

This case offers clear and authoritative legal guidance when dealing with the issues of overpayment demands to providers.   While relying upon relevant recent Supreme Court decisions, among other things, the court decided the following:

  1. Federal law ERISA is the only mechanism available to BCBSRI regardless of BCBSRI PPO contract;
  2. As a matter of ERISA law, BCBSRI can make no recovery for past payments and can withhold no money from future claims;
  3. Both healthcare providers were absolved of wrong doing as BCBSRI failed to present “clear and convincing evidence” to support fraud, medically unnecessary or mis-coding allegations;
  4. The two providers were not “given any opportunity to appeal or have Blue Cross’s determination reviewed, despite the inclusion of review procedures both under ERISA and the Provider (PPO) Agreements.”
  5. Whatever monies BCBSRI paid to both healthcare providers for alleged fraudulent billing and non-medically necessary treatments, rightfully, equitably, and in good conscience belongs to the providers;
  6. BCBSRI cannot recover the monies already paid out to the providers because those monies are not subject to equitable lien from the BCBSRI PPO contract overpayment provisions.
  7. The court rules for the provider’s counterclaims against BCBSRI for withholding money from future claims and orders BCBSRI to return all monies withheld from future claims with prejudgment interests and attorney fees to be determined by the court.

All employer sponsored health plans must comply with federal ERISA regulations when making demands for overpayment refunds.  According to industry estimates, the amount of money that payors seek to recover from providers through overpayment demands is in the billions of dollars.

A recent DOL court brief filed in federal appeals court for the 3rd Circuit also provides detailed regulatory interpretation of ERISA claim regulation for all overpayment disputes and appeals.  In all overpayment cases, a provider is entitled to insist upon its assigned right to challenge the allegedly wrongful decision to deny benefits through a process that complies with ERISA claims regulation


Avym Corporation offers advanced ERISA Compliance and Appeals training for both participating and non-participating hospitals, ASC’s and all providers, to appeal all overpayment denials, recoupment and withholdings or offseting, under the Court guidance in this case in compliance with ERISA and PPACA regulations.

To find out more about PPACA Claims and Appeals Compliance Services from AVYM please click here.

Located in Los Angeles, CA, AVYM is a leading provider of services focusing entirely on the resolution of denied or disputed medical insurance claims by participating in the nation’s first ERISA PPACA Claims Appeals Certification program.  AVYM also 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.



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