The lawsuit has to do with the provisions of ERISA which is the grounds for the insurance carrier demanding the providers repay what they were given. Here’s a good example of “audit algorithms” and how they are used to get money. The law suit states they are in violation of ERISA and that retroactive payment demands are not part of the game. Remember this news making article relative to Wal Mart with ERISA where they were suing the woman who received care?
“You may have heard the recent story about Wal-Mart suing an employee who suffered severe brain damage when her minivan was hit by a tractor-trailer.
Wal-Mart sought to recover $417,000 it paid for her medical care under its employee health plan. This $417,000 was money the woman desperately needed for life-sustaining nursing care. Due to substantial negative media coverage, Wal-Mart dropped its claim against the woman and dismissed its lawsuit.Under ERISA, an insurance company or HMO can deny coverage without penalty, even if that denial of coverage causes serious harm or even death.”
Healthcare reform has addressed some of these situations but apparently not to the point to where retroactive audits can still be done to demand payments to be returned in this case it’s the doctors they are going after versus the patients. This is just another “loophole” to where extensive business intelligence algorithms were produced to see if it could generate more profits and revenue, not good for consumers and doctors. As the article states Untied is not alone and there are similar lawsuits against other insurers. BD
Once more it’s all about those algorithms for profit.
NEW YORK, Feb. 2, 2011 (GLOBE NEWSWIRE) -- Pomerantz Haudek Grossman & Gross LLP, one of the country's preeminent class action firms and a leader in combating the abuses of the health insurance industry, filed a class action lawsuit against UnitedHealth Group and Health Net of the Northeast, Inc. on behalf of a putative nationwide class of health care providers, as well as the Ohio State Chiropractic Association. United's acquisition of Health Net of the Northeast's health insurance business closed in December 2009, adding to United's status as the nation's largest private health plan by revenue. 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 had previously been paid as health insurance benefits.
The action alleges that the post-payment audit and review process as applied by the Defendants 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 the United and Health Net health care plans, but without proper appeal or other protections otherwise available under ERISA for both self-funded and fully insured health care plans offered through private employers.
"ERISA establishes the procedures that insurance companies must follow when making benefit determinations – whether prior to payment or retroactively," says Plaintiffs' counsel, D. Brian Hufford of Pomerantz. "The Defendants here, as is true for many insurance companies, are violating their ERISA obligations in order to recover funds that simply do not belong to them."
Pomerantz and Buttaci & Leardi have pending actions against a number of Blue Cross and Blue Shield entities, as well as Aetna, Inc., asserting similar claims.