On November 5, 2014, only 15 days after the high court’s denial of BCBSM’s appeal, a federal district court in Michigan lifted a previous stay order for one of the more than 50 similar pending cases. The federal district court in Michigan reopened a separate but identical case after the U.S. Supreme Court, on Oct. 20, 2014, rejected BCBSM appeal of a $6.1 million fraud judgment in favor of a self-insured plan.
Pursuant to the HHS, OIG and the National Health Care Anti-Fraud Association’s conservative estimate, at least 3 percent—or more than $60 billion each year—is lost to fraud, in the current $3 trillion annual healthcare expenditure.
Additionally, in accordance with the Supreme Court Hi-Lex decision and the reopening of pending cases, all self-insured health plans nationwide should look to recover at least $30 to $45 billion in refunds from the past 10 years of successful plan assets TPA/ASO anti-fraud recoupments and managed care savings in the private sector.
“Failure to safeguard plan assets is definitely a fiduciary breach under ERISA, and now the Supreme Court has given us a legal formula for plan assets recovery, a timely and true resolution to today’s U.S. healthcare crisis,” says Dr. Jin Zhou, president of ERISAclaim.com, a national expert and the “ERISA Godfather” in ERISA healthcare compliance and medical claim appeals.
As the DOL ramps up audits and enforcement actions in health plan claims and appeals, every ERISA self-insured health plan sponsor or fiduciary should keep in mind that they are required to monitor TPA/ASOs successful overpayment recoveries and managed care savings, in order to determine whether:
- any of the billions of dollars of successful TPA/ASO overpayment recoupments and offsets nationwide each year are ERISA plan assets;
- all TPA/ASOs must refund all ERISA plan assets as ERISA prohibits all self-dealings;
- all self-insured plan administrators are liable for fiduciary breach in failing to safeguard or recover plan assets.
As illustrated by the Supreme Court decisions and the reopening of similar cases, it is extremely critical for all self-insured health plans and TPAs to understand the implications of the Supreme Court decision rejecting BCBSM’s $6.1 million appeals. Moreover, the high court’s decision will likely have a multi-billion dollar impact on all self-insured plans.
Avym Corporation demystifies this high court decision with new 2015 ERISA Fiduciary TPA Auditing & Plan Assets Recovery Programs designed to enable self-insured health plans in the recovery of potentially billions of dollars in similar TPA/ASO hidden fees. These advanced Recovery Programs can assist all self-insured plans recover all hidden fees in TPA/ASO overpayment recoupments and managed care savings and are based on the Supreme Court’s new interpretation of ERISA plan assets, fiduciary and ERISA prohibited transactions and self-dealings with respect to the managed care industry and ASO contracting practices.
On Oct. 20, 2014, the U.S. Supreme Court announced: “Petition DENIED”, and ultimately declined all appeals of BCBSM’s $6.1 million fraud judgment in favor of a self-insured ERISA plan by the U.S. Court Of Appeals for the Six Circuit, upholding the decision by the District Court for the Eastern District of Michigan. (http://www.supremecourt.gov/Search.aspx?FileName=/docketfiles/14-168.htm.)
Supreme Court Case Info: Blue Cross Blue Shield of Michigan, Petitioner v. Hi-Lex Controls, Inc., et al., Case No. 14-168, Docketed: August 14, 2014, Lower Ct: United States Court of Appeals for the Sixth Circuit, Case Nos.: (13-1773, 13-1859), Decision Date: May 14, 2014
The high court announced its decision, without comments, on October 20, 2014 that it will not review a ruling by the U.S. Court of Appeals for the Sixth Circuit in Cincinnati, concluding:
“BCBSM committed fraud by knowingly misrepresenting and omitting information about the Disputed Fees in contract documents”,
after it affirmed a District Court decision, in May 2013, concluding that Michigan’s largest health insurer violated the Employee Retirement Income Security Act (ERISA) in ERISA prohibited transactions and ERISA fraud by concealing BCBSM’s hospital claims markup as much as 20% and pocketed the overcharge for over 20 years, according to the Supreme Court website: (http://www.supremecourt.gov/Search.aspx?FileName=/docketfiles/14-168.htm.)
On November 5, 2014, only 15 days after the high court decision on October 20, 2014, the federal district court in Michigan lifted a previous stay order for one of the more than 50 similar cases pending in the same court. (Fisher & Company, Inc. et al v. Blue Cross and Blue Shield Michigan, U.S. District Court, Eastern District of Michigan (Detroit), CIVIL DOCKET FOR CASE #: 2:13-cv-13221-GER-MAR.)
On November 5, 2014, the district court explained its decision to reopen the pending case:
“On May 14, 2014, the U.S. Court of Appeals for the Sixth Circuit issued its opinion in the Hi-Lex Conrols matter, affirming the district court’s judgment. Hi-Lex Controls, Inc. v. Blue Cross Blue Shield of Mich., 751 F.3d 740 (6th Cir. 2014). BCBSM timely filed a petition for a writ of certiorari to the United States Supreme Court on August 12, 2014, and the Supreme Court denied the petition on October 20, 2014. Blue Cross Blue Shield of Mich. v. Hi-Lex Controls, Inc., cert. denied, 83 U.S.L.W. 3109, 2014 WL 3965217 (U.S. Oct. 20, 2014) (No. 14-168)….Accordingly, IT IS HEREBY ORDERED that Plaintiffs’ Motion to Lift Stay (Dkt. # 19) is GRANTED and that this matter is REOPENED.”,
according to court documents.
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