On March 30, 2012, Federal Court Denied UnitedHealth’s (UHC) Motion, In Its Entirety As To All Claims, To Dismiss Providers’ ERISA Class Action, Alleging UHC’s Wrongful Overpayment Recoupment In Violation Of ERISA. Avym Offers Webinars To Examine The Legal Impact Of This Decision for All Payers and Providers.
On March 30, 2012, United States District Court of New Jersey denied UnitedHealth’s (UHC) motion, in its entirety as to all claims, to dismiss the providers’ ERISA class action alleging that UHC’s wrongful overpayment recoupment is in violation of federal law, ERISA. Avym now offers executive webinars to examine the profound legal impact for all providers and payers.
The Court case info: Premier Health Center, PC, et al. v. Unitedhealth Group, et al., Case #: 2:11-cv-00425, United States District Court District of New Jersey, Filed 03/30/12.
The insurance practice of overpayment recoupment has been and is becoming a larger legal and financial challenge for health plans, healthcare providers and patients to overcome. Almost all health care providers have been affected by an overpayment dispute over the past few years and according to industry estimates, more than 50% of the $2.6 trillion in annual US healthcare expenditure is subject to overpayment dispute. Additionally, more than 10% of any previous and future reimbursements are subject to overpayment recoupment by the payers in both private and public sectors.
According to the Court document, the healthcare provider and their association plaintiffs are challenging defendants’ practices of improperly recouping previously paid health care benefits from providers without complying with procedural protections under ERISA, “Plaintiffs allege that United “took steps to coerce the Individual Plaintiffs and other Class members to return the alleged overpayments, including by withholding payments from new and unrelated services and applying them to the alleged debt, or by filing invalid lawsuits seeking to compel repayment.” The Defendants seek dismissal of Plaintiffs’ Amended Complaint for lack of standing to sue and for having failed to state a claim upon which relief can be granted pursuant to Fed. R. Civ. P. 12(b)(6). The Court “ORDERED that UnitedHealth Group, UnitedHealthcare Services, Inc., and OptumHealth Care Solutions, Inc.’s motion to dismiss—(D.E. 31)—is hereby DENIED as to all claims”, but granted defendants’ motions to dismiss claims, without prejudice, against two subsidiary companies of UHC.
The case factual background was described in the Court document:
“After performing its services, pursuant to the assignment of benefits form, Premier submits a claim to United who will then make payment to Premier on the claim. Occasionally, United will engage in post-payment audits of benefit payments. Following the post-payment audit process, United determined that they had erroneously made overpayments to the Plaintiffs and demanded repayment. Plaintiffs allege that United “took steps to coerce the Individual Plaintiffs and other Class members to return the alleged overpayments, including by withholding payments from new and unrelated services and applying them to the alleged debt, or by filing invalid lawsuits seeking to compel repayment”.
From the court document: “Plaintiffs further allege that many of the United Plans at issue are governed by ERISA, “which establishes strict rules and procedures that United or other entities that administer ERISA plans must comply with.” Furthermore, “ERISA sets forth specific steps that must be followed when an insurer such as United makes an ‘adverse benefit determination’ by denying or reducing benefits, including by providing a ‘full and fair review’ of the decision.” “By making a retroactive determination that a previously paid benefit was, in fact, paid improperly, an insurer makes an adverse benefit determination under ERISA.” Plaintiff avers that “United has violated ERISA by making its retroactive adverse benefit determinations without complying with ERISA[’s] requirements.”
On January 24, 2011, Plaintiffs filed a complaint in the United States District Court for the District of New Jersey. On April 22, 2011, YF Corporation’s ambulatory surgical center (ASC) client, Beverly Hills Surgical Center (BHSC), as a Named Class Plaintiff, filed a class-action in federal court against UnitedHealth Group for alleged ERISA violations through its abusive overpayment recoupment practice. With assistance from YF Corporation, BHSC, which represents all ambulatory surgical center facilities, is the first ASC facility provider in the nation to combat abusive overpayment recoupment practices by filing an ERISA class action against UnitedHealth Group, the largest health insurer in America.
“On April 22, 2011, Plaintiffs filed an Amended Complaint, which is the subject of Defendants’ United and Health Net motions to dismiss. The parties have submitted their respective briefs and the Defendants’ motions are now ripe for this Court’s adjudication.”
The Court denied the Motion to Dismiss filed by United in its entirety, including denying UHC’s anti-assignment argument and upholding the standing of all providers’ national and state association plaintiffs: “In light of the above, the Court finds that based upon Defendants’ course of conduct with Plaintiffs, Defendants have waived any right to enforce the anti-assignment provision. Therefore, Plaintiffs have met their burden to establish standing to sue under ERISA.”
“Accordingly, the Court finds that the Associations have standing to bring ERISA claims on behalf of their individual members.”
“ORDERED that UnitedHealth Group, UnitedHealthcare Services, Inc., and OptumHealth Care Solutions, Inc.’s motion to dismiss—(D.E. 31)—is hereby DENIED as to all claims.”
If the Court denied each and every legal argument by UHC in this class action for overpayment recoupment, what does this mean to every overpayment request by every payer?
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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.