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2012 U.S. Healthcare: ERISA or PPO? Federal Court Ruled For Aetna In Total Denial, PPO Cancellation & SIU Overpayment Disputes

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

Hanover Park, IL (PRWEB) January 01, 2012 Offers Webinars To Examine A New Federal Court Ruling For Aetna In Its ERISA Defense Against A Provider's 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 provider's remand for state PPO claims, when Aetna denied “all provider services for all patients”, canceled the provider's 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 Christie's claims is preempted by ERISA. Complete preemption permits removal to federal court”. 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, 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 Aetna's 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 Christie's 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 Christie's claims is preempted. Giles, 172 F.3d at 337; Cotner, 2008 WL 59174, at *3. Aetna has made that showing. Regardless of Aetna's reasons for terminating the Provider Agreement, this case is properly in federal court.”

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

1.    The court factual and legal analysis and conclusion of Christie v. Aetna on PPO or ERISA.
2.    Other similar or identical court decisions in 2011 on ERISA or PPO for a hospital in a single claim of million dollars.
3.    How to appeal under ERISA and PPO?
4.    New federal health reform laws, PPACA, will be fully enforced in 2012. PPACA adopted ERISA in its entirety for all health group and individual claims, for both ERISA or non-ERISA claims.
5.    Complete PPACA Regulations and Guidance on DOL website:
6.    EBSA News Release: US Department of Labor's EBSA creates new consumer assistance Web page [11/10/2011]
7.    "Federal Department Of Insurance Complaints Website" for Doctors and Patients:
8.    Congressional GAO Reports: 39% to 59% denial reversal with valid appeals, only 0.5% appeals in Ohio -

To find out more about PPACA Claims and Appeals Compliance Services from

Located in a Chicago suburb in Illinois, for over 11 years, is the only ERISA & PPACA consulting, publishing and website resource for healthcare providers in the country. 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. Dr. Jin Zhou is regarded as the industry “Godfather of ERISA claims” for healthcare providers.

For any questions, please contact Dr. Jin Zhou, president of, at 630-808-7237.


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