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Hanover Park, IL (PRWEB) January 01, 2012

ERISAclaim.com Offers Webinars To Examine A New Federal Court Ruling For Aetna In Its ERISA Defense Against A Providers State PPO Claims, When Aetna Denied All Provider Services For All Patients, Canceled PPO Contract, With A SIU Demand For $ 59,000 Overpayment Refund.

On Nov. 22, 2011, the federal District Court in Southern District Of Texas ruled, in Christie v. Aetna (Case 4:10-cv-01766), for Aetna in its ERISA removal defense against a providers remand for state PPO claims, when Aetna denied all provider services for all patients, canceled the providers PPO contract, and made a SIU demand for $ 59,000 overpayment refund. Relied upon Supreme Court decisions, the Court concluded that Under the test set forth in Davila, at least one of Christies claims is preempted by ERISA. Complete preemption permits removal to federal court. ERISAclaim.com offers Webinars to examine this court decision and its profound impact in 2012 for all PPO doctors and hospitals faced with similar or identical issues for ERISA compliance.

As vast majority of PPO doctors and hospitals in USA have direct contracts with payers, this Court decision is a wakeup call for provider PPO dreams. Court agreed with Aetna and Aetna is correct this time: PPO is not even triggered unless ERISA is resolved or moot, says Dr. Jin Zhou, president of ERISAclaim.com, a national expert on PPACA and ERISA appeals and compliance.

Medical necessity, proper documentation, SIU audit and overpayment recoupment are the most frequent payment disputes in managed care claim denials. Federal law ERISA compliance must be the No. 1 priority in 2012 for all providers in reimbursement practice, advised Dr. Zhou.

According to the court documents, the provider plaintiff had been a PPO provider for more than 10 years since 1997 with Aetna and was paid by Aetna without issues. In 2007, Aetna SIU audited the plaintiff and made a $ 59,000 overpayment refund demand, and then stopped paying for all Provider Services for all patients which it had routinely and consistently paid in the past. Thereafter, Aetna terminated the Provider Agreement with Christie altogether. The provider sued Aetna for more than $ 119,000 in unpaid claims in the state court. The plaintiff brought this lawsuit in state court against Aetna, alleging breach of contract, quantum meruit, and promissory estoppel based on Aetnas alleged failure to perform in accordance with the terms of the parties Provider Agreement. The case was removed to this Court on the grounds that Christies contract claims raised federal claims in character because they were preempted by the Employee Retirement Income Security Act of 1974 (hereinafter ERISA).

Aetna argued that a PPO contract is not even triggered unless ERISA is resolved or moot. The Court document showed: Aetna filed a Sur-Reply in which it notes that by its terms, the Provider Agreement is not triggered unless Aetna is billed for Covered Services, which the Agreement defines as [t]hose Medically Necessary Services which a member is entitled to receive under the terms and conditions of a Plan. (Doc. No. 35, Sur-Reply to Reply to Response to Mot. Remand 2.) To qualify as adequate, Aetna states, Christie had to show that J.V.s claim was covered by J.V.s ERISA plan. (Id. 7.) In other words, when Aetna refers to lack of documentation, it means that Christie failed to make a showing that J.V.s claim was covered.

After the Court reviewed the facts, and relied upon Supreme Court decision, the Court agreed with Aetna that federal ERISA law governs, even only with just one of the provider ERISA claims. The Court determined:

To prevent remand, Aetna need only show that one of Christies claims is preempted. Giles, 172 F.3d at 337; Cotner, 2008 WL 59174, at *3. Aetna has made that showing. Regardless of Aetnas reasons for terminating the Provider Agreement, this case is properly in federal court.

The ERISAclaim.coms 2012 Webinars start at $ 5,000 per 2-hour session and will cover the following topics:

1.

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Hanover Park, IL (PRWEB) January 01, 2012

ERISAclaim.com Offers Webinars To Examine A New Federal Court Ruling For Aetna In Its ERISA Defense Against A Providers State PPO Claims, When Aetna Denied All Provider Services For All Patients, Canceled PPO Contract, With A SIU Demand For $ 59,000 Overpayment Refund.

On Nov. 22, 2011, the federal District Court in Southern District Of Texas ruled, in Christie v. Aetna (Case 4:10-cv-01766), for Aetna in its ERISA removal defense against a providers remand for state PPO claims, when Aetna denied all provider services for all patients, canceled the providers PPO contract, and made a SIU demand for $ 59,000 overpayment refund. Relied upon Supreme Court decisions, the Court concluded that Under the test set forth in Davila, at least one of Christies claims is preempted by ERISA. Complete preemption permits removal to federal court. ERISAclaim.com offers Webinars to examine this court decision and its profound impact in 2012 for all PPO doctors and hospitals faced with similar or identical issues for ERISA compliance.

As vast majority of PPO doctors and hospitals in USA have direct contracts with payers, this Court decision is a wakeup call for provider PPO dreams. Court agreed with Aetna and Aetna is correct this time: PPO is not even triggered unless ERISA is resolved or moot, says Dr. Jin Zhou, president of ERISAclaim.com, a national expert on PPACA and ERISA appeals and compliance.

Medical necessity, proper documentation, SIU audit and overpayment recoupment are the most frequent payment disputes in managed care claim denials. Federal law ERISA compliance must be the No. 1 priority in 2012 for all providers in reimbursement practice, advised Dr. Zhou.

According to the court documents, the provider plaintiff had been a PPO provider for more than 10 years since 1997 with Aetna and was paid by Aetna without issues. In 2007, Aetna SIU audited the plaintiff and made a $ 59,000 overpayment refund demand, and then stopped paying for all Provider Services for all patients which it had routinely and consistently paid in the past. Thereafter, Aetna terminated the Provider Agreement with Christie altogether. The provider sued Aetna for more than $ 119,000 in unpaid claims in the state court. The plaintiff brought this lawsuit in state court against Aetna, alleging breach of contract, quantum meruit, and promissory estoppel based on Aetnas alleged failure to perform in accordance with the terms of the parties Provider Agreement. The case was removed to this Court on the grounds that Christies contract claims raised federal claims in character because they were preempted by the Employee Retirement Income Security Act of 1974 (hereinafter ERISA).

Aetna argued that a PPO contract is not even triggered unless ERISA is resolved or moot. The Court document showed: Aetna filed a Sur-Reply in which it notes that by its terms, the Provider Agreement is not triggered unless Aetna is billed for Covered Services, which the Agreement defines as [t]hose Medically Necessary Services which a member is entitled to receive under the terms and conditions of a Plan. (Doc. No. 35, Sur-Reply to Reply to Response to Mot. Remand 2.) To qualify as adequate, Aetna states, Christie had to show that J.V.s claim was covered by J.V.s ERISA plan. (Id. 7.) In other words, when Aetna refers to lack of documentation, it means that Christie failed to make a showing that J.V.s claim was covered.

After the Court reviewed the facts, and relied upon Supreme Court decision, the Court agreed with Aetna that federal ERISA law governs, even only with just one of the provider ERISA claims. The Court determined:

To prevent remand, Aetna need only show that one of Christies claims is preempted. Giles, 172 F.3d at 337; Cotner, 2008 WL 59174, at *3. Aetna has made that showing. Regardless of Aetnas reasons for terminating the Provider Agreement, this case is properly in federal court.

The ERISAclaim.coms 2012 Webinars start at $ 5,000 per 2-hour session and will cover the following topics:

1.

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